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SYLLABUS OF THE CONTENTS 
 
 OF 
 
 WOEKS EECENTLY PUBLISHED, 
 
 BY . 
 
 SAMUEL HIGHLEY, 32, FLEET STREET. 
 
 ILLUSTRATED BY NUMEROUS PLATES; 
 
 ON THE 
 
 DISEASES OF THE EYE ; 
 
 BY JOHN MORGAN, F.L.S. 
 
 SUEGEON TO GUY's HOSPITAL. 
 
 THE ANATOMY, PHYSIOLOGY, AND 
 
 DISEASES OF THE TEETH; 
 
 BY THOMAS BELL, F.R.S., &c. 
 
 PROFESSOR OF ZOOLOGY IN KING's COLLEGE, LONDON. 
 
 THE STRUCTURE, ECONOMY, AND 
 
 DISEASES OF THE EAR ; 
 
 BY GEORGE PILCHER, 
 
 LECTURER ON SURGERY AT THE WEBB STREET SCHOOL OF MEDICINE. 
 
LECTURES ON 
 
 DISEASES OF THE EYE; 
 
 BY JOHN MORGAN, F.L.S. 
 
 SUEGEON TO GUY's HOSFITAL, AND LECTUKER ON SUEGEKY AT THAT INSTITUTION. 
 
 Demy 8vo. Price I8s. 
 
 " It is a plain, judicious and practical treatise. It gives the pith of what is known, and of what it 
 is requisite to know, and avoids those minute details, which, however appropriate in systematic works, 
 fail to sustain their claim to utility in the actual practice of Ophthalmic Art." — Johnsons Medico-Chirur- 
 gical Review. 
 
 The Following List comprises a Part of the Plates which are finely executed by Canton, and 
 
 Proper and Injurious Modes of Examining the Eye distinguished. 
 
 Acute Inflammation of the Conjunctiva. Aphthous or Pustular Inflammation of the 
 
 ■ Conjunctiva. Chronic Aphthous Inflammation of the Conjunctiva. 
 Inflammation of the Cornea as seen in Strumous Ophthalmia. Pannus or Vascular 
 Cornea 
 
 Granular State of the Conjunctiva of the upper lid, with the first eff'ects of its pressure 
 
 upon the globe. 
 Hypopion or Unguis with inflamed Conjunctiva or Cornea. 
 Staphyloma of the Cornea. Diffused Staphyloma of the Sclerotic. 
 
 Abscess of the Globe with acute inflammatory Chemosis of the Conjunctiva and disor- 
 ganised Cornea. 
 
 Abscess of the Globe with Slough of the Cornea. Fungus Hsematodes as contrasted with 
 
 ditto. Fungus Hsematodes in its earliest stage. 
 Incipient Retinitis. Incipient Iritis and Iritis in a more advanced stage. Prolapsus of the Iris. 
 Acute diffused Inflammation of the Sclerotic. Haze of the Cornea, with Inflammation of 
 
 the Iris. 
 
 Chronic Sclerotidis. Appearances of Sclerotic and Conjunctival Inflammation, contrasted. 
 Fungus Hsematodes of the Globe of twelve years standing — ditto at its termination after 
 
 sixteen years — appearance of the Orbit on removal of the tumour after Death. 
 Melanosis affecting the Globe and Lids. 
 
 Sections of Malignant Diseases, illustrating Hodgson's discovery of the formation of serous 
 
 Cysts as the origin of Cancerous, Fungoid, and other Diseases. 
 Staphyloma Racemosum. Glaucoma — often mistaken for Cataract. 
 Purulent Ophthalmia. Inflammatory Chemosis. 
 Transparent depression of the Ulcer indicating Ulcer of the Cornea. 
 True Pterygium distinguished from Pterygium Pingue. 
 
 Capsulo- Lenticular Cataract — Soft Cataract — Central and Opaque Capsular Cataract. 
 Progressive Stages of the Operations for Cataract — Operation .for Solution — Operation 
 
 for Depression. 
 Operation for Artiflcial Pupil. 
 
 Instruments used in different Operations on the Eye. 
 
 carefully coloured. 
 
THE ANATOMY, PHYSIOLOGY, AND 
 
 DISEASES OF THE TEETH; 
 
 BY THOMAS BELL, F.R.S., F.L.S., F.G.S. 
 
 LECTUKEE ON ANATOMY AND DISEASES OF THE TEETH, AT GUY's HOSPITAL, AND PROFESSOR 
 OF ZOOLOGY IN KINg'S COLLEGE, LONDON. 
 
 Demy 8vo. Price 145. 
 
 " To the general Practitioner as well as the professed Dentist, we can conscientiously recommend 
 Mr. Bell's Book." — Johnsons Medico-Chirurgical Revieiv. 
 
 PART L— ANATOMY, PHYSIOLOGY, &c. 
 
 The Structure, Organization,"and Vitality, of the Teeth. 
 
 Number, Arrangement, and Uses of the Temporary and Adult Teeth. 
 
 Articulation of the Teeth. 
 
 Of Mastication and the Parts concerned therein. 
 Tormation and Progress of . the Temporary and Permanent Teeth . 
 Diseases resulting from the irritation of Dentition. 
 On temporary irregularity and its prevention. Permanent irregularity. 
 /' Supernumerary Teeth. On the Osseous union of Teeth. 
 On the supposed occurrence of a third set of Teeth. &c. &c. &c. 
 
 PART II.-'DISEASES, &c. 
 
 On Dental Gangrene (commonly called Caries) — Its origin and progress — Its proxi- 
 mate, remote, and exciting causes — Prevention — Method of Treatment—On 
 Excision of the Teeth. 
 
 On total Necrosis — Abscess in the Bony Structure — Exostosis of the Teeth. 
 
 Injuries produced by Mechanical Violence. 
 
 On the loss of Enamel and wearing down of the Teeth. 
 
 On Salivary Calculus — Its formation and effects — Means of prevention and removal. 
 
 Diseases of the internal Membrane. 
 
 Diseases of the Gums and Alveolar Processes. 
 
 Effects of Mercury on the Teeth, Gums, &c. 
 
 Diseases of the Antrum Maxillare. 
 
 On Extraction of the Teeth, and accidents accompanying, or following it. 
 Neuralgia, and Nervous Affections connected with the Teeth. 
 
 THE PLATES, ENGRAVED BY CANTON, EXHIBIT IN UPWARDS OF ONE 
 HUNDRED FIGURES, VIEWS OF— 
 
 The Formation, Growth, and Development of the Teeth in the Foetus and Adult. 
 Natural and Magnified Sections of the Teeth. 
 
 Production of the permanent Teeth, and their connexion with the temporary ones. 
 The upper and lower Alveoli after removal of the Teeth. 
 The upper and lower Teeth, with their Articulations. 
 Gangrene. Abscess. Fungous Growth, &c., of the Teeth. 
 Instruments. — &c., &c., &c. 
 
A TREATISE ON THE 
 
 STRUCTURE, ECONOMY, AND DISEASES 
 OF THE EAR; 
 
 BY GEORGE PILCHER, 
 
 LECTURER ON ANATOMY AND SURGERY, AT THE WEBB STREET SCHOOL OF MEDICINE. 
 
 Demy Siw., Price 10s. 6d. 
 
 " The perusal of this Work has afforded us much pleasure. — A Work was w'^anted to place the 
 whole subject within the grasp of all Surgeons who choose to devote some little exclusive or particular 
 study to the Diseases of the Ear, and their treatment, and this has fairly and well supplied the defi- 
 ciency." — Johnson's Medico-Chirurgical Heview. 
 
 Anatomy of the Ear — External Ear, Tympanum, Labyrinth, Nerves of the Ear. 
 
 Physiology of Hearing. Sound. Influence of Sound upon the Ear. Influence of the 
 External Ear. Influence of the Membrane of the Tympanum. Influence of the 
 Ossicula. Influence of Air on the Tympanum. Influence of the Labyrinth. Influence 
 of the Nerves. 
 
 Of the Abnormal Condition of the Ear — Development and Malformations. 
 
 Of the Diseases of the Ear. — Acute Otitis. External Acute Otitis. Inflammation 
 of the Membrana Tympani. Internal Otitis. Inflammation of the Labyrinth. 
 
 Chronic Diseases. External Otitis. Inflammation of the Auricle. Chronic Diseases of 
 tlie Meatus. Foreign Bodies in the Ear. Chronic Inflammation of the Membrana 
 Tympani — of the Tympanum — of the Eustachian Tube. 
 
 Nervous Diseases. Excited and Torpid Functional Derangements of the. Acoustic Nerve. 
 Functional Derangement of the Tympanic Nerves. Otalgia. &c. &c. &c. 
 
 The Plates shew the Comparative Anatomy of the Ear in the Lobster, Sturgeon, Thornhack, 
 and other Fish; — in the Turkey, Owl, Domestic Fowl, Whale, Porpoise, 8fc. Also the 
 Anatomy, Diseases, Malformations, and appearance after injuries of the Human Ear. 
 British and Continental Instruments, 8fc., Sfc. 
 
 MR. LAWRENCE'S 
 
 ANATOMICO-CHIRURGICAL PLATES, 
 
 THE SIZE OF NATURE, 
 
 I.— THE NOSE, MOUTH, LARYNX, AND FAUCES. 
 
 Anatomico-Chirurgical Views of the Nose, Mouth, Larynx, and Fauces, with explanations 
 and references, and an Anatomical Description of the parts. By W. Lawrence, F.R.S., 
 Surgeon to St. Bartholomew's Hospital. 
 
 Folio, Price 10s. 6d. plain — £1 Is. coloured. 
 
 n.-THE MALE AND FEMALE PELVIS. 
 
 Comprising — ■ 
 
 Front Views of the Male and Female Pelvis, in which the Bones are seen in their natural 
 connection with the principal Ligaments, so as to shew the Construction, Figure, 
 Outlines, Boundaries, and Dimensions of the Cavities in question. 
 
 The External Organs of Generation in the Female. 
 
 Superficial and deeper seated Views of the Muscles of the Male Perineum and Anus. 
 Muscles of the Female Perineum and Anus. 
 
 Lateral Views of the Male and Female Pelvic Viscera in their natural situation. 
 
 The Subjects were selected by Mr, Lawrence, who superintended the Dissections> most 
 of which he executed himself, and furnished the Descriptions and Explanatory References. 
 
 Folio, Price }0s. 6d. plain — £1 Is. coloured. 
 
if 
 
 ' ON THE 
 
 NATURE AND TREATMENT 
 
 OF 
 
 STOMACH AND URINARY DISEASES. 
 
ON THE 
 
 . NATURE AND TREATMENT 
 
 OF 
 
 STOMACH AND URINARY DISEASES: 
 
 BEING AN INQUIRY INTO THE 
 
 \ 
 
 CONNEXION OF DIABETES, CALCULUS, 
 
 AND 
 
 OTHER AFFECTIONS OF THE KIDNEY AND BLADDER, 
 WITH INDIGESTION. 
 
 BY 
 
 WILLIAM PROUT, M.D. F.R.S. 
 
 FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS. 
 
 THE THIRD EDITION, MUCH ENLARGED. 
 
 LONDON: 
 
 JOHN CHURCHILL, PRINCES STREET, SOHO. 
 
 MDCCCXL. 
 
PREFACE 
 
 TO THE FIRST EDITION. 
 
 The author of the present volume has been in the habit for 
 many years of closely attending to the Diseases of the Urine ; 
 and the following pages exhibit an outline of his observations 
 on the subject. With his own observations, the principal facts 
 and opinions of others have been likewise incorporated ; while, 
 on the other hand, to avoid controversy, whatever appeared 
 doubtful has been in general omitted without remark. 
 
 It was his original intention to prefix an historical introduc- 
 tion respecting the urine, with a detailed account of the chemical 
 experiments on which many of his peculiar views are founded ; 
 but, upon reflection, he was induced to relinquish both these 
 objects for the present, and to confine his attention chiefly to 
 practical points. Chemical details could not, indeed, be alto- 
 gether avoided, because chemistry constitutes the very basis 
 on which the whole superstructure is founded. Care, however, 
 ^ has been taken to render them as plain and concise as possible, 
 ^: and thus to present such a view of this part of the inquiry as 
 ^ may be intelligible to the general reader. 
 
 t To establish new views on medical subjects is almost too 
 > much for an individual to hope. The author, therefore, has 
 
vi 
 
 PREFACE. 
 
 chiefly confined himself to illustration ; and, leaving it to the 
 profession at large to establish his conclusions, (if they are 
 capable of being established,) rests, in the mean time, perfectly 
 satisfied that justice will be done to his attempts. 
 
 The author's steady aim throughout his researches has been 
 to arrive at truth ; and whoever will direct him to this object, 
 where he has failed to reach it, will be esteemed a friend. He 
 never aspired to perfection ; but if he has succeeded in throw- 
 ing some light on the pathology of these important diseases — 
 if he has furnished a clue by which their pathology may be 
 still further extended — if he even convinces a single individual 
 that it is impossible to know anything about the diseases of 
 the urine, without repeated and careful examination of that 
 secretion, he will not deem his labours altogether useless. 
 
 Southampton-street, Bloomshury-square, 
 12th December, 1820. 
 
PREFACE 
 
 TO THE SECOND EDITION. 
 
 Organic diseases of the urinary organs are so frequently asso- 
 ciated with derangements of the urine itself, that in a great 
 variety of instances, the former cannot be advantageously 
 treated without taking into consideration the latter. Hence, 
 with the view chiefly of offering some remarks on this part of 
 the subject, the author has been induced, in the present edition, 
 to give a summary sketch of the principal diseases of the kid- 
 ney and bladder.^^ 
 
 In this edition, also, an attempt has been made to recapitulate 
 the practical inferences deducible from the phenomena and pro- 
 perties of the urine. Before he made this attempt, the author was 
 not aware of the difficulties he had to encounter ; and he re- 
 grets to say, that from the utter impossibility of giving an in- 
 telligible description of many of the appearances, he has not 
 been able to render this part of the subject so complete as he 
 had anticipated. The author makes this avowal, lest, on the 
 one hand, he should be accused of concealing what he knows ; 
 while on the other, to obviate the charge of claiming for him- 
 self a knowledge he does not possess, he is equally anxious to 
 
 * For an account of the symptoms of these organic diseases^ (in which, 
 of course, little novelty could be expected,) the author acknowledges his 
 obligations to various well-known treatises, and particularly to M. Soem- 
 mering's useful little work on the diseases of the urinary organs to 
 which old men are more particularly liable. 
 
viii 
 
 PREFACE. 
 
 state, that he has not the least pretensions to a single fact 
 which the commonest observer may not readily learn to dis- 
 crimmaite, provided he will bestow the requisite attention on the 
 subject. 
 
 Lastly, the author expresses his obligation to the President 
 and Curators of the Royal College of Surgeons, for their liberal 
 admission to the Museum of the Royal College ; to the splen- 
 did collection in which, and to the kind assistance of Mr. 
 Clift, he is indebted for much valuable information ; and 
 particularly for many of the specimens of calculi represented 
 in the annexed plates. 
 
 Sackville Street, May, 1 823. 
 
V 
 
 PREFACE 
 
 TO THE THIRD EDITION. 
 
 This edition has been rewritten, and the materials arranged 
 on principles now for some years before the public. As these 
 principles naturally include almost every disease to which or- 
 ganised beings are liable ; with the view of familiarising them, 
 and of rendering the different parts of the volume in some de- 
 gree independent of each other, the leading points have been 
 purposely repeated — a statement thus made at the outset, to 
 obviate the charge of tautology. 
 
 The author, in presenting to the public the results of nearly 
 thirty years observation and experience, has still kept in view, as 
 much as possible, the practical character of his treatise. All 
 chemical and physiological details, therefore, not urgently 
 required, have been avoided. Such details may be given in a 
 future volume. In the mean time, conscious of his fallibility 
 and imperfections, the author invites the candid criticism of 
 the experienced chemical pathologist, who alone is capable of 
 appreciating his labours. 
 
 Sackville Street, September, 1840. 
 
CONTENTS. 
 
 INTRODUCTION. 
 
 COMPRISING AN OUTLINE OP THE GENERAL PHYSIOLOGY AND PATHOLOGY OF ASSIMI- 
 LATION, AND OP THE SECRETION OP THE BILE AND OP THE URINE. 
 
 Section I. Of the ultimate composition and structure of organised bodies ; 
 
 and of their general physical characters as dependent on 
 
 their composition .... Page i 
 Section II. Of alimentary prommate principles . . . vi 
 Section III. Of the primary processes of assimilation . . xviii 
 Section IV. Of the secondary processes of assimilation . . xxxiii 
 Section V. Of the general pathology of the primary and secondary assimi- 
 lating processes .... xlii 
 Section VI. Of the general composition and properties of the hlood . liii 
 Section VII. Of the functions of the liver ; and of the composition and rela- 
 tions of the bile to the assimilating processes . . Ivii 
 Of biliary concretions^ or gall stones . . Ixiv 
 Section VIII. Of the functions of the kidneys; and of the composition and re- 
 lations of the urine to the assimilating processes . Ixvi 
 Of urinary calculi . . . . cv 
 
 DESCRIPTION OF THE PLATES. 
 
 General arrangement and division of the subject into two Parts or Books Page 1 
 
 BOOK I. 
 
 OF FUNCTIONAL DISEASES. 
 Chap. I.— General observations on the pathology of aqueous assimilation 
 
 AND SECRETION . . . . .1 
 
 Of an excess and deficiency of urine considered with reference to 
 disease . . . • .5 
 
Xll 
 
 CONTENTS. 
 
 Chap. II. — General observations on the pathology of saccharine assi- 
 
 milation AND secretion . . , .13 
 
 Section a. Of diabetes . . . .26 
 
 Of the properties of the urine . . . .26 
 
 Of the constitutional symptoms . . . .28 
 
 Of the causes . . . . .34 
 
 Of the diagnosis and prognosis . . . .38 
 
 Of the treatment . . . . .40 
 
 Of diabetic diuresis, as it occurs in young children . 56 
 
 Section 6. Of the oxalic acid diathesis . . . ^9 
 
 Of the properties of the urine . . . .59 
 
 Of the constitutional symptoms . . . .61 
 
 Of the causes . . , . .63 
 
 Of the treatment . . . . .67 
 
 Section c. Of lactic acid, ^c. . . . .70 
 
 Of the developement and consequences of lactic acid in the sto- 
 mach and primae viae . . . .70 
 
 Of the developement and consequences of lactic acid in the 
 system in general . . . .75 
 
 Of the causes of the developement of lactic acid . . 80 
 
 Of the treatment of the diseases connected with the develope- 
 ment of the lactic acid in the system . . .84 
 Chap. III. — General observations on the pathology of albuminous 
 
 assimilation and secretion , . .90 
 
 Section a. Of an excess and deficiency of urea in the urine . 92 
 
 Of an excess of urea . . . .92 
 
 Of the properties of the urine , . . .93 
 
 Of the constitutional symptoms . . . .94 
 
 Of the causeS;, &c. . . . . .95 
 
 Of the treatment . . . . .99 
 
 Of a deficiency of urea . . . .103 
 
 Of the properties of the urine . . . . 1 05 
 
 Of the constitutional symptoms and causes . .106 
 
 Of the treatment . ... 108 
 
 Sections. Of albuminous urine in general . . .111 
 
 Of chylo-serous urine . . . . .112 
 
 Of the properties of the urine . . . .112 
 
 Of the constitutional symptoms, &c. . . .114 
 
 Of the treatment . . . . .117 
 
 Of serous urine in general, with reference to the kidney in a 
 state of health and in a state of degeneration ; and quiescent 
 and inflamed ..... 120 
 
 Species a. Var. 1 . Of serous urine, the kidney in a state of health 
 
 and quiescent . . . .124 
 
 Var. 2. Of serous urine, the kidney in a state of 
 
 health and inflamed . . .128 
 
CONTENTS. 
 
 xiii 
 
 Of the properties of the urine, and constitutional symptoms 
 Of the causes, diagnosis, and prognosis 
 
 Of the treatment ..... 
 Species h. Of serous urine, the kidney in a state of degeneration 
 Division of this species into two Sections, viz. degeneration 
 with ancBmotrophy ; and degeneration with hcemotrophy 
 Species 6. Section I. Of serous urine, kidney in a state of anaemotrophied 
 degeneration ; quiescent 
 
 Subsp. a. State of the urine 
 
 )8. State of the urine 
 
 \ a. State of the kidneys 
 
 /3. State of the kidneys 
 
 a. Constitutional symptoms 
 
 )8. Constitutional symptoms 
 
 . Concomitant diseases 
 
 o and )8 Causes predisposing and exciting 
 
 Species 6. Section II. Of serous urine, kidney in a state of hsemotrophied 
 degeneration; quiescent 
 
 Subsp. 7 State of the urine 
 
 S State of the urine 
 
 7 State of the kidneys 
 
 5 State of the kidneys 
 
 — 7 Constitutional symptoms 
 
 — . S Constitutional symptoms 
 
 ^ 7 and S Causes, predisposing and exciting 
 
 Diagnosis and Prognosis 
 
 c, , i a and )8 
 S^^^P- J 7 and S 
 
 Treatment 
 
 Species h. Sections I and II. Of Serous urine, kidney in a state of 
 motrophied and haemotrophied degeneration ; inflamed 
 Properties of the urine 
 State of the kidneys 
 Constitutional symptoms 
 Treatment 
 
 M. Rayer's arrangement of diseases connected with serous urine 
 Dr. Christison's, ditto 
 Section c. Of lithic acid 
 
 Of amorphous and impalpable sediments 
 Of crystallised sediments ; red gravel 
 Of renal concretions of lithic acid 
 Of the causes, predisposing and exciting, of lithic acid gravel 
 and concretions ..... 
 
 128 
 129 
 131 
 133 
 
 139 
 
 205 
 
xiv CONTENTS. 
 
 Of the diagnosis and prognosis .... 213 
 Of the treatment . . . . .214 
 Section d. Of cystic oxide . . . .231 
 
 Of the treatment, &c. . . . . 239 
 Chap. IV. — General observations on the pathology of oleaginous 
 
 ASSIMILATION AND SECRETION .... 241 
 
 Section a. Of obesity and leanness . . . 242 
 
 Section b. Of cholesterine and its deposites ; gall-stones . 250 
 
 Of the symptoms ..... 252 
 
 Of the causes . . . . . 257 
 
 Diagnosis, prognosis, and treatment . . . 260 
 Chap. V. — General observations on the pathology op the incidental 
 
 MATTERS of ORGANISED BODIES . . . 267 
 
 Subspecies a. Of the diseases connected with the insoluble inci- 
 dental matters, the triple phosphate of magnesia and am- 
 monia, and the phosphate of lime . . . 267 
 Of the symptoms, &c., attending the deposition of the triple 
 
 phosphate ..... 268 
 
 Of the causes, ditto .... 269 
 
 Of the symptoms, &c., attending the deposition of the phosphate 
 of lime . . . . .271 
 
 Of the causes, ditto . . . . .271 
 
 Of the symptoms, &c., attending the deposition of the mixed 
 
 phosphates , . . . . . 274 
 
 Of the causes, &c. ..... 276 
 
 Subspecies b. Of the diseases connected with the soluble inci- 
 dental matters, including potash, soda, and ammonia , 278 
 Symptoms, &c. . . . . . 280 
 
 Causes, diagnosis, and prognosis . . . 280 
 Of the general treatment of the diseases connected with the 
 
 presence of incidental principles . . . 282 
 
 Illustrative cases ..... 288 
 
 Transition from the oxalate of lime to the phosphatic diathesis . 295 
 
 Transition from the lithic acid to the phosphatic diathesis . . 295 
 
 Transition from the cystic oxide to the phosphatic diathesis . 296 
 
 General recapitulation of the first book . . . 297 
 
CONTENTS. 
 
 XV 
 
 BOOK II. 
 
 OF MECHANICAL DISEASES. 
 
 Division of the subject ...... 314 
 
 Chap. I. — Of the origin and increase of calculous deposites in the 
 
 KIDNEYS . . . . . . 316 
 
 Section I. Of the origin and increase of renal concretions . 316 
 Section II. Of the symptoms produced by renal concretions in 
 
 general . . . . . .324 
 
 Of the symptoms produced during the descent of renal concretions 
 
 from the kidney to the bladder . . . 331 
 
 Of the treatment, &c., of renal concretions . . . 335 
 Chap. II. — Of diseases of the kidneys, produced by, and liable to 
 
 BE CONFOUNDED OR ASSOCIATED WITH, CALCULUS IN THOSE 
 
 ORGANS ...... 340 
 
 Of the symptoms of acute inflammation of the kidney . 340 
 
 Of the causes of nephritis .... 344 
 
 Of the symptoms of suppuration and abscess of the kidney . 344 
 Of the symptoms of indurated obliteration and gangrene of the 
 
 kidneys ...... 346 
 
 Of the symptoms of pyelitis .... 346 
 
 Of pains in the back ..... 349 
 
 Of the general diagnosis of the above affections « . 349 
 
 Of the general treatment of the above affections . . 355 
 
 Chap. III. — Of the origin and increase of calculi in the bladder . 358 
 
 Of the symptoms, &c., of calculus in the bladder . . 361 
 
 Of the treatment of calculus in the bladder , . 369 
 
 Chap. IV. — Of diseases in the bladder and its appendages produced 
 
 BY, AND LIABLE TO BE CONFOUNDED OR COMPLICATED WITH, 
 
 VESICAL CALCULI ..... 374 
 
 Of the symptoms, &c., of cystirrhcea, or chronic inflammation of 
 the bladder . . . . .375 
 
 Of the consequences of ditto . , . 375 
 
 Of general or acute inflammation of the bladder . . 379 
 Of the symptoms, &c., of chronic inflammation of the prostate 
 
 gland . . . . . .384 
 
 Of the symptoms, &c., of prostatal concretions . . 386 
 Of the symptoms, &c., of acute inflammation of the prostate gland 388 
 Of the causes of inflammation of the bladder and prostate . 390 
 Of the symptoms, &c., of irritable bladder . . . 391 
 depending on disease in the kidney . 392 
 
XVI 
 
 CONTENTS. 
 
 Of the symptoms, &c., of irritable bladder 
 
 • depending on organic disease of the bladder— 
 
 fungus hcematodes ..... 
 
 depending on cancer, &c., of the bladder 
 
 — — depending on thickening, &c., of the coats of 
 
 the bladder 
 
 of the urethra 
 
 depending on stricture, &c., of the urethra 
 depending on gouty and rheumatic affections 
 
 ■ depending on affections of the nervous system 
 
 depending on spasm of the bladder 
 
 • depending on paralysis of the bladder 
 
 depending on hysteria 
 
 Of the diagnosis of the above forms of irritable bladder 
 
 Of the treatment .... 
 Chap. V. — Of hemorrhage prom the urinary organs in general 
 
 Of the causes of hsematuria 
 
 Of the seat of hsematuria . . 
 
 Of the treatment of hsematuria 
 Chap. VI. — Of suppression, retention, and incontinence of urine 
 
 Of suppression of urine . . 
 
 Of retention of urine . . 
 
 Of incontinence of urine . . 
 Chap. VII. — Observations on the removal op calculi from the blad- 
 der ; comprising remarks on the effects op solvents for 
 
 THE stone, and ON THE OPERATIONS OF LITHOTOMY AND LITHO- 
 TRITY ; WITH A REVIEW OP THE CIRCUMSTANCES WHICH OUGHT 
 TO DETERMINE THE CHOICE OP ONE OF THESE MEANS IN PREFE- 
 RENCE TO THE OTHER, OR WHICH RENDER ALL OF THEM DAN- 
 GEROUS ...... 
 
 Of solvents for the stone, natural and medicinal 
 
 Of the comparative safety of lithotomy and lithotrity . 
 
 400 
 402 
 
 402 
 403 
 
 403 
 
 404 
 405 
 407 
 408 
 411 
 417 
 431 
 431 
 435 
 437 
 441 
 441 
 444 
 446 
 
 451 
 452 
 461 
 
 APPENDIX. 
 
 Containing tables illustrating the number of fatal cases of Diabetes and Calcu- 
 lus, in different districts of England and Wales ; the comparative prevalence 
 and laws of formation and alternation of different calculous deposites ; of 
 the comparative prevalence of calculous affections at different ages and in 
 the different sexes ; and of the rate of mortality from the operation of litho- 
 tomy . . . . . . . 469 
 
INTRODUCTION. 
 
 OUTLINE OF THE GENERAL PHYSIOLOGY AND PATHOLOGY OF 
 ASSIMILATION ; AND OF THE SECRETION OF THE BILE AND 
 OF THE URINE. 
 
 Section I. 
 
 Of the ultimate composition and structure of organised bodies ; 
 and of their general physical characters as dependent on their 
 composition. 
 
 1. The olbjects of nature are divided into the inorganised 
 and the organised. Under the head of inorganised bodies are 
 included all elementary principles and their mineral com- 
 pounds. Under organised substances are included all sub- 
 stances forming a living constituent of vegetables and animals. 
 With the general nature of common chemical or mineral ele- 
 ments and their compounds, we take it for granted the reader 
 is acquainted. We confine our attention, therefore, solely to 
 organised products. 
 
 2. Organised bodies include vegetables and animals ; and in 
 their well-marked forms, no two things can perhaps be con- 
 ceived to offer a stronger contrast than these two great divi- 
 
 b 
 
11 
 
 INTRODUCTION. 
 
 sions of organised bodies. Yet vegetables and animals so 
 gradually approximate, tliat their characters appear to coalesce ; 
 and at, and near, this point of coalescence, it often becomes dif- 
 ficult to discriminate between the two divisions of organised 
 beings, and to pronounce with certainty which is vegetable, 
 and which is animal. Kor does the chemical composition of 
 vegetables and animals assist us in overcoming this difficulty. 
 It is true, indeed, that vegetable substances in general contain 
 essentially no more than three elements, hydrogen, carbon, 
 and oxygen ; while animal substances usually involve a fourth, 
 azote ; yet there are many vegetable matters of whose com- 
 position azote forms a considerable part ; while certain animal 
 substances are entirely wanting in that principle. The chemi- 
 cal composition of a substance, therefore, as already stated, 
 will not enable us to determine whether it belongs to the divi- 
 sion of vegetables or of animals ; and when it happens to be 
 doubtful or unknown, other data must be called into requi- 
 sition, before the point can be determined. 
 
 3. Besides the four constitutional elements mentioned, of 
 which all organised substances are essentially compounds ; 
 other principles generally enter into their composition. These 
 other principles, which are in very minute quantity, are not so 
 essential to the existence of organised substances, as the four 
 constituent elements above mentioned, yet, however minute 
 the quantity, the influence of these other principles seems to 
 be most important ; they are sulphur, phosphorus, chlorine, 
 fluorine, iron, potassium, sodium, calcium, magnesium, and 
 probably more besides. These principles have by most chemists 
 been deemed extraneous, or foreign to organised bodies ; but 
 we have elsewhere attempted to show that there is good reason 
 to believe that the office of such additional principles, though 
 different from that of the four constitutional elements of or- 
 ganised bodies, are nevertheless most remarkable. These four 
 elements, along with the additional principles, are, in the pre- 
 sent state of our knowledge, alike denominated the ultimate 
 elements of organised bodies ; but hydrogen, carbon, oxygen, 
 
GENERAL REMARKS. 
 
 Ill 
 
 and azote, may be termed, for the sake of distinction, the essen- 
 tial elements ; and sulphur, phosphorus, &:c., the incidental 
 elements of such bodies. Finally, the combinations of the 
 ultimate elements, of which all organised bodies are composed, 
 with one another, according to certain laws, produce what are 
 denominated the immediate^ or -proximate elements of organised 
 bodies. Of such proximate elements, sugar, oil, albumen, &;c.,' 
 are familiar examples. 
 
 4. As our inquiry is principally limited to the chemical 
 composition of organised bodies, a minute inquiry into their 
 structure would be foreign to our purpose. We may, however, 
 state, that of the many opinions advanced by physiologists on 
 the subject, the prevailing opinion seems to be, that the ulti- 
 mate structure of organised bodies is vesicular or globular ; 
 that is to say, that organised bodies consist of vesicles or 
 globules, each one of which is, in a certain sense, a complete 
 and independent system or organised molecule ; that these 
 organised molecules coalesce lengthways, and thus form fibres ; 
 and lastly, that these fibres, by adhering to, or interlacing with, 
 each other in various ways, form the different textures of 
 organised bodies. Whether this be a correct representation of 
 the matter or not, we shall not stay to inquire ; it is sufficient 
 for our present purpose to know, that in the ultimate and more 
 elementary condition in which organised molecules are known 
 to us, their composition not only differs altogether from that 
 of mineral bodies, but that they never assume a crystallised or 
 mineral form. Hence the solid aggregates of crystallised 
 molecules are never, like crystals, defined by straight lines and 
 angles, but are always more or less rounded. Even the fluids 
 found in organised bodies are, for the most part, very hetero- 
 geneous in their characters, and consequently uncrystal- 
 lisable ; for though the basis of all organised fluids be usually 
 water, yet many of them contain such a variety of other 
 substances as to completely modify the condition of the 
 water, and prevent the exertion of its properties as a mineral 
 body. 
 
 b 2 
 
INTRODUCTION. 
 
 5. The next important step in our inquiry is the investiga- 
 tion of the causes of organic peculiarities. Why do organised 
 bodies differ so widely in their composition, and structure, and 
 properties, from inorganised bodies ? 
 
 6. The answer to this question in all its bearings is beyond 
 our powers. That there exists, however, in all living organised 
 bodies some power or agency, whose operation is altogether 
 different from the operation of the common agencies of matter, 
 and on which the peculiarities of organised bodies depend, is 
 universally admitted. A variety of opinions have been enter- 
 tained on the subject of these organic agencies by different 
 philosophers, none of which require more than a brief notice 
 here. 
 
 7. The chief opinions, or rather hypotheses, (for they are 
 nothing more than hypotheses,) which have been framed to 
 account for the phenomena of organisation, may be classed 
 under three heads, viz. 1. The hypothesis of independent exist- 
 ing vital principles or " agents," superior to, and capable of 
 controlling and directing, the agents operating in inorganic 
 matters ; on the presence and influence of which the pheno- 
 mena of organisation and of life depend. 2. The hypothesis 
 that vitality or vital agency is a property, not independent of, 
 but superadded to, the common properties or agencies of mat- 
 ter ; and 3. The hypothesis that the lowest kind of vitality, or 
 irritability as it is termed, is the result of certain aggregations 
 of inorganic matters ; and that this lowest kind of vitality or 
 irritability is a " property which, when acted on by appropriate 
 powers, is competent to give rise to that series of actions in 
 which life consists ;" in other words, as more explicitly stated 
 by an advocate of this hypothesis, that " as one specific pro- 
 perty, namely, irritability or vitality, which is common to 
 organised matter in general, qualifies it, when subjected to 
 appropriate stimuli, to manifest those ruder and less elevated 
 actions which constitute life ; so other specific properties, 
 peculiar perhaps to certain forms only of such matters, may 
 qualify them, when properly acted upon, to display those more 
 
GENERAL REMARKS. 
 
 V 
 
 delicate and dignified actions in which sensation and thought 
 respectively consist." 
 
 8. Of these three hypotheses I have always chosen the first ; 
 which is not only the most ancient, but has been generally 
 adopted by physiologists, in various modified forms, to the 
 present time. The other two hypotheses are of more recent 
 origin, and have been more or less exclusively adopted by 
 certain modern physiologists. A detailed statement of my 
 reasons for preferring the hypothesis of " peculiar agents" in 
 preference to the other hypotheses, which appear to me to be 
 not only untenable but absurd, would be quite out of place 
 here ; I shall, therefore, reserve what I have to say on this 
 subject till a future opportunity. 
 
 9. Though differing so greatly and variously in their physi- 
 cal characters, we shall find, if we exclude incidental matters, 
 such as the earthy base of bones, kc, that the stamina or 
 groundwork of organised beings may be considered as consti- 
 tuted of four great classes of proximate principles. Moreover, 
 as animal existence is supported by alimentary substances de- 
 rived from the animal and vegetable kingdoms, these ali- 
 mentary matters must of course be similarly constituted ; and 
 aliments in fact, may be viewed in the same light ; that is, the 
 four great classes of proximate principles may be considered 
 either as staminal principles, composing animal bodies ; or as 
 aliments by which animals are supported. But as the latter 
 view is in some respects most convenient for our purpose, we 
 shall consider these proximate principles in an alimentary 
 point of view. 
 
 * See Rudiments of Physiology, by John Fletcher, M.D. Part i. 
 page 11. 
 
VI 
 
 INTRODUCTION. 
 
 Section II. 
 Of Alimentary Proximate Principles. 
 
 10. For many years past, as just stated, I have been accus- 
 tomed to consider alimentary principles as divided into four 
 great classes or groups — a division now, I believe, generally 
 acquiesced in by physiologists ; at least in this country. These 
 four great classes or groups may be denominated the aqueous^ 
 the saccharine, the albuminous, and the oleaginous ; on each of 
 which we shall proceed to make a few remarks. 
 
 11. Of the aqueous alimentary principle. — ^Water constitutes 
 not only the medium in which most organic operations are 
 performed ; but its elements, either as water or separately, 
 enter into the composition of every living organised being. 
 The subject of water, therefore, in a physiological point of 
 view, may be considered under two heads, as the medium in, 
 or by means of which, all organic operations are performed ; 
 and as an alimentary principle. 
 
 12. The proportion of water entering into the composition 
 of organised beings is so remarkable as to appear almost 
 incredible. Not only does the blood contain four-fifths of its 
 weight of water, but even the parts of the body termed solids, 
 that is the muscular mass of which animal bodies chiefly consist, 
 contain in reality only about one fourth of solid matter. As 
 an instance in illustration, we may mention a fact stated by 
 Blumenbach, viz. that a perfectly dry mummy of an adult 
 Guanche, in his museum, preserved with all the muscles and 
 viscera entire, did not exceed seven pounds and a half in 
 weight."^' 
 
 * The original inhabitants of the island of TenerifFe are called Guanches. 
 See the Introductory Observations to Blumenbach's Physiology. 
 
ALIMENTARY PRINCIPLES. 
 
 Vll 
 
 13. The water thus constituting so large a proportion of 
 living animal bodies is the medium by which all vital agen- 
 cies are performed. In the blood, for instance, the solid 
 organised particles are transported from one place to another ; 
 are arranged in the place desired ; and are again finally 
 removed and expelled from the body, chiefly by the agency of 
 the water present. Water also imparts to the more solid ' 
 constituents of the frame that peculiar flexibility and power 
 of extension so characteristic of animal solids. In short, with- 
 out water, matter in its solid state appears incapable of vitality 
 (or at least of displaying vital properties) in the higher ani- 
 mals, or even in plants ; and in a few of the lower animals 
 vital processes are entirely arrested when water is withdrawn ; 
 though in some instances they may be restored when this 
 fluid is again supplied. 
 
 14. As water constitutes so large a proportion of organised 
 beings, we may naturally suppose that, surrounded as they are 
 by an atmosphere colder and drier than themselves, the quan- 
 tity of water they contain is liable to perpetual change. Ac- 
 cordingly, we find this to be the case, and that aqueous vapour 
 is either freely separated from the skin, from the lungs, and 
 from other organs ; or perhaps, under different circumstances, 
 is as freely absorbed by the same organs from the surrounding 
 atmosphere. In these various modes, much of the water in 
 animal bodies is doubtless liable to be changed ; but the great 
 portion is separated by organs expressly adapted for the pur- 
 pose, viz. the kidneys ; and supplied by fluids taken by the 
 mouth in the form of drinks. 
 
 15. Of water considered as an alimentary principle, that is, 
 as a constituent principle of organised products in the form 
 of water ; or when decomposed, as contributing the elements 
 by which such organised products are elaborated, we can say 
 but little here : for as water and its elements, as just stated, 
 enter into every organic operation, to do justice to the subject, 
 every organic operation should be detailed, — a circumstance, 
 not only for this reason alone, even were the means within 
 
VIU 
 
 INTRODUCTION. 
 
 our power, impracticable; but which is absolutely imprac- 
 ticable in reality, from the very little we know of the subject. 
 A few of the instances in which water plays an important part 
 as a whole, as well as of instances in which this fluid is decom- 
 posed, and its elements appropriated^ will be noticed in subse- 
 quent parts of this volume. 
 
 16. Of saccharine alimentary principles. — Under the de- 
 nomination of saccharine bodies, we include a very large class 
 of substances, the general composition of which appears to be 
 similar ; that is to say, they consist of a combination of carbon 
 and water in various proportions. The analogy among these 
 bodies is further proved by the facts that many of them are 
 easily converted into others ; and that they are all capable of 
 forming the oxalic or some analogous acid, by the action of 
 nitric acid. 
 
 17. The saccharine principles are chiefly derived from the 
 vegetable kingdom, and indeed constitute what may be called, 
 by way of distinction, vegetable aliments. As employed by 
 man, some of them exist nx the crystallised form, which, from 
 the simplicity of their composition, they readily assume ; 
 though, as we have said, in the living plant of which they con- 
 stitute a part, their form is anything but crystalline. Of 
 crystallisable saccharine bodies, the chief are sugar and vinegar ; 
 of uncrystallisable or organised bodies, the most remarkable 
 are the different forms of the amylaceous, or starchy principle ; 
 the different forms of lignin, or the woody principle ; and the 
 different forms of gum,, or the mucilaginous principle. 
 
 18. Of sugar. — Sugar exists in considerable quantity, and but 
 little complicated, in many plants. Moreover, the greater num- 
 ber of the other saccharine principles are capable of being con- 
 verted into crystallised sugar, by artificial processes. Sugar is 
 the only crystallisable product employed in considerable quan- 
 tity as an aliment ; and by the perfectly healthy stomach 
 seems to be readily assimilated. There are, however, certain 
 states of disease in which this organ appears to lose, in a great 
 measure, the power of assimaliting thi^ principle, and in such 
 
ALIMENTARY PRINCIPLES. 
 
 IX 
 
 states of disease, sugar consequently is ill adapted as an ali- 
 ment. Indeed, on the whole, though sugar, as we have said, 
 is capable of being assimilated in large quantity, it is doubtful 
 if mankind have been the gainers, except in convenience, by 
 employing it in a form in which it is the furthest possible 
 removed from organisation and life. 
 
 19. Vinegar or acetic acid, however dissimilar to sugar in 
 its sensible properties, is nevertheless similarly constituted. 
 Moreover, as is well known, most of the forms of the saccharine 
 principle are readily convertible into vinegar, by different 
 artificial processes. Vinegar, either by accident or design, 
 has been employed by mankind, in all ages, in greater or less 
 quantity, as an aliment ; that is, substances naturally con- 
 taining it in small quantity have been employed as ali- 
 ments ; or it has been formed artificially from certain bodies 
 with the view to alimentary purposes. Like sugar, this prin- 
 ciple appears to be more diflicult of assimilation in its pure or 
 crystallisable form, than in that state of mixture or union in 
 which, for the most part, it naturally occurs. 
 
 20. Lactic acid. — Nearly allied to vinegar or the acetic 
 acid, is the peculiar acid which, from its having been first 
 recognised in sour milk, is termed the lactic acid. This acid, 
 like the acetic acid, is probably, under certain circumstances, 
 capable of becoming an aliment ; but as it is often found un- 
 changed and even developed in the stomach, and indeed in 
 almost all parts of the animal system, it is probably less diges- 
 tible, and therefore less adapted as an aliment, than the acetic 
 acid. 
 
 21. The remaining principles of the saccharine group, under 
 no circumstances, natural or artificial, ever assume the crys- 
 tallised form ; and their structure, in the common and strict 
 sense of the term, may be said to be organised. Of these the 
 most important to mankind is, 
 
 22. The amylaceous or starchy principle.— The amylaceous 
 or starchy principle is obtained in slightly modified states from 
 
X 
 
 INTRODUCTION. 
 
 a great variety of vegetables, but principally from the seeds of 
 the Cerealia. Even by the unassisted eye, starch is seen to be 
 composed of minute particles ; and when these particles are 
 examined with a microscope, they are found to be granules 
 more or less rounded, and without the least trace of crystal- 
 lisation. These granules are conceived to be insulated in the 
 cellules of the texture in which they are formed ; for it would 
 appear, that their state, when first secreted and deposited in 
 the cellules, is semi-fluid ; and that the excess of water is sub- 
 sequently removed. Raspail and Dumas have shown that 
 each of these little grains is covered with a smooth integument, 
 not affected by water at the common temperatures ; within 
 which integument is enclosed a substance rather more soluble. 
 According to some chemists, this interior substance has an 
 analogy with gum ; but probably it is only a variety of amy- 
 laceous matter. Berzelius affirms that starch, when burnt, 
 leaves about "23 per cent, of residuum, consisting entirely 
 of the phosphates. But when this residuum is abstracted 
 and allowed for, the essential composition of starch is found 
 to coincide very nearly with the essential composition of 
 sugar ; that is to say, starch is composed of carbon and water : 
 and the proportions of their combination are very nearly the 
 same as in sugar. The starch used as an aliment is principally 
 derived, as we have said, from the seeds of the Cerealia or corn 
 tribe ; but varieties of this principle are found in the roots 
 and other parts of many plants ; as arrow root, from the roots 
 of the maranta tribe ; potato starch, from potatoes ; sago, 
 from the pith of the sago palm, &c. 
 
 23. The amylaceous principle is readily assimilated by the 
 healthy stomach, and directly or indirectly forms a constituent 
 of the food of most of the higher animals, as well as of man. 
 It differs, therefore, from sugar, in being a necessary article of 
 food, without which animals could not exist ; while sugar is 
 not. Hence a much larger quantity of amylaceous matter, 
 than of sugar, can be taken ; and what is a still more decisive 
 
ALIMENTARY PRINCIPLES. 
 
 fact, the use of this larger quantity of amylaceous matter may 
 be persisted in for an unlimited period, which it appears is not 
 the case with a large proportion of sugar. 
 
 24. Lignin, or the woody fibre, though assuming a great 
 variety of appearances in different plants, and including very 
 different incidental matters, has nevertheless, in all the plants 
 in which it has yet been examined, been found to possess very 
 nearly the same composition ; or to consist of equal weights of 
 carbon and water. Such at least is the composition of woods 
 so very different as the box and willow, the oak and the beech ; 
 and these are the chief, if not the whole, of the woods which 
 we believe have yet been analysed. Hence it is perhaps not 
 unreasonable to suppose that every variety of lignin has a 
 similar composition. All woods, when burnt, leave a greater 
 or less quantity of incidental mineral residuum, in the shape 
 of ashes ; the nature of which, as above observed, differs ex- 
 ceedingly in different sorts of woods. 
 
 25. Lignin forms the appropriate food of numerous insects 
 and of some of the lower animals, but of few of the higher 
 classes of animals. The reason of this is probably to be sought 
 for, in their not being furnished with organs proper for com- 
 minuting and reducing it ; for when lignin is comminuted and 
 reduced by artificial processes, it is said to form a substance 
 analogous to the amylaceous principle, and to be highly nu- 
 tritious. 
 
 26. The gummy or mucilaginous principles form a very 
 numerous class of bodies, nearly allied, if not actually belongings 
 to the saccharine group, into which they appear to merge by 
 imperceptible grades. As instances of these principles in their 
 well-marked forms may be mentioned, the sugar of milk^ 
 among crystallised, and gura arahic among the uncrystallised 
 bodies. The mucilaginous principle chiefly differs from sugar 
 
 * See this circumstance, which is stated on the authority of Autenrieth 
 of Tubingen, alluded to in the Fhilos. Trans. ; also in niy Bridge- 
 
 water Treatise. 
 
Xll 
 
 INTRODUCTION. 
 
 by being coiiTerted by nitric acid into an acid called the sac- 
 lactic, instead of the oxalic. 
 
 27. It seems to be generally admitted, that gums and mu- 
 cilaginous matters are nutritious ; and there can be little doubt 
 that in certain proportions, and for a certain time, they are 
 capable of constituting an aliment to man. In some forms of 
 disease also, their peculiar composition and properties may 
 even render them an appropriate aliment. But whether, like 
 the amylaceous principle, they are adapted to constitute a 
 human aliment for an unlimited time, may be questioned ; 
 though I know of no data at present, by which the point can 
 be satisfactorily determined. 
 
 28. Albuminous aliments constitute a very numerous class of 
 bodies, all differing from each other in some slight particulars, 
 but still having certain properties in common, so as to render 
 it probable that their ultimate comjDosition is similar, or at 
 least analogous. Their exact composition cannot be stated ; 
 but they all involve a fourth element, azote; and in this 
 respect are strikingly distinguished from both the other classes 
 of aliments. 
 
 29. Albuminous aliments are principally derived from the 
 animal kingdom. Hence they are not inappropriately termed 
 animal aliments. iN^one of them exist naturally in the crys- 
 tallised state ; nor can they be made to crystallise by artificial 
 means. Yet certain modifications of them readily assume the 
 crystallised form, and in diseased conditions of the animal 
 economy, in which such modifications occasionally exist in 
 large quantity, they often concrete into masses, and prove a 
 source of secondary disease, as will be shown hereafter. The 
 principal luodifications of albumen are, gelatine, albumen 
 strictly so called, jfiZ>ri?i, curd, gluten, and perhaps a few others, 
 which may be rather considered as varieties of some of the 
 preceding matters, than as distinct substances. 
 
 30. Gelatine and albumen. — When any part of an animal body 
 (with the exception, perhaps, of entirely oleaginous matters) 
 is boiled in water, it is separated into two portions — one solu- 
 
ALIMENTARY PRINCIPLES. 
 
 Xlll 
 
 ble in water, and forming with the water a tremulous jelly, or 
 gelatine; the other remaining insoluble, indeed becoming 
 harder the longer it is boiled ; and, from the identity of its 
 properties with those of white of eggs, denominated albumen. 
 Gelatine and albumen exist in very different proportions in the 
 different textures ; some of these textures, as the skin, being 
 almost entirely convertible into gelatine ; while others yield 
 comparatively little gelatine, and consist principally of albumen. 
 In no animal compound does gelatine exist as a fluid ; hence 
 gelatine has been supposed to be produced by boiling ; but 
 the supposition does not appear to be well founded. Gelatine 
 may be considered as the least perfect kind of albuminous 
 matter existing in animal bodies ; intermediate as it were 
 between the saccharine principle of plants, and thoroughly 
 developed albumen. Indeed, gelatine in animals may be said to 
 be the counterpart of the saccharine principles of plants ; it being 
 distinguished from all other animal substances, by its ready 
 convertibility into a sort of sugar, by a process similar to that 
 by which starch may be so converted. Albumen exists in the 
 fluid state as a component part of the blood ; small quantities 
 of fluid albumen are also contained in certain animal secre- 
 tions ; but there is much more of the principle in a solid state ; 
 and forming what is termed coagulated albumen. 
 
 31. another modification of the albuminous principle, 
 is found in the blood ; and in the living body, like albumen, 
 exists in a fluid or at least in a miscible state ; the most frequent 
 condition of fibrin, however, is that of a tough fibrous mass, 
 in which condition, together with albumen, it forms the basis 
 of the muscular or fleshy parts of animals. 
 
 32. Curd is another modification of the albuminous princi- 
 ple, derived from the milk of animals, and principally designed 
 to form the food of animals in the early stages of their exist- 
 ence ; before the digestive and assimilating faculties are com- 
 pletely developed. 
 
 33. Gluten, though chiefly derived from the vegetable king- 
 dom, contains azote, and so far resembles the fleshy parts of 
 
XIV 
 
 INTRODUCTION. 
 
 animals, as to be in like manner capable of separation into 
 two portions, analogous to gelatine and albumen ; it lias, 
 therefore, been usually considered as a modification of the 
 albuminous principle. Gluten exists in different parts of 
 vegetables, but principally in the seeds of the cerealia, and 
 more esjDecially of wheat. Hence the superiority of wheat to 
 all other vegetable products as an aliment. 
 
 34. Of oleaginous aliments. — Oleaginous bodies occur in an 
 infinite variety of forms, some being solid, others fluid ; yet, in 
 every instance, their peculiar properties are so strongly marked 
 that we seldom hesitate about their nature. In this distinct- 
 ness of outward appearance, oily bodies are strongly contrasted 
 with both the other alimentary groups, and particularly with 
 the saccharine group ; many of which group have few apparent 
 and sensible qualities in common. I have analysed many 
 specimens of the more important varieties of this group of 
 bodies, and have found them to be essentially composed of 
 olefiant gas and water in difierent proportions ; or having re- 
 ference to this composition. These analyses have not yet been 
 published. 
 
 35. Oily bodies are naturally separated by their sensible and 
 chemical properties into two great divisions ; viz. fixed and 
 volatile oils. The fixed oils, solid and fluid, are found both in 
 the animal and vegetable kingdoms. The volatile oils are 
 chiefly found in the vegetable kingdom, and in general are 
 little used as aliments ; unless we except alcoJwl, which, though 
 conforming in its composition to the fixed oils, more nearly 
 resembles in its properties the volatile oils. The fixed oils, 
 as they naturally exist in vegetables and animals, are seldom so 
 pure as to be capable of assuming the crystallised form. When 
 they are separated, however, from the extraneous matters with 
 which they are associated, many of them readily crystallise. 
 The principal fixed oils employed by man, and derived from 
 the animal kingdom, are suet, lard, hutter, train oil, kc, while 
 from the vegetable kingdom we have olive oil, nut oil, and a 
 variety of others. Almost all natural oily bodies, as obtained 
 
ALIMENTARY PRINCIPLES. 
 
 from animals and plants, are divisible into two portions, viz. 
 a portion usually more or less solid, and called stearine ; and 
 another portion always remaining fluid, and termed oleine. 
 
 36. Such are the four great alimentary principles, by which 
 all the higher animals are nourished, and of which their bodies 
 are essentially constituted ; and if we regard carbon as the 
 elementary principle by which, cceteris paribus, the nutritive' 
 powers of three of the alimentary principles are measured or re- 
 presented, (which, in a certain point of view, may be considered 
 to be the case,) we shall find them to stand in the order in which 
 they have been above described ; that is, the saccharine 
 principles contain on an average from forty to fifty per cent, 
 of carbon ; the albuminous (including azote) from fifty to 
 seventy-five per cent. ; and the oleaginous about eighty per 
 cent, of this principle. Of these principles it has already been 
 remarked, that without any alteration in their essential com- 
 position, they are capable of assuming an infinite variety of 
 modified forms ; many of which are so peculiar, that from their 
 sensible properties it is very difiicult to recognise their iden- 
 tity. Moreover, these staminal principles, in all their forms, 
 are capable of readily passing into, and of combining with, 
 each other; at least the organic agents, as we shall see 
 hereafter, have the power of effecting such changes. Fur- 
 ther, these staminal principles are all susceptible of trans- 
 mutation into new principles according to certain laws ; thus 
 the saccharine principle is readily convertible into oxalic acid ; 
 or, under other circumstances, into the modification of the 
 oleaginous principle, alcohol. Though an endless variety of 
 these modifications of the staminal principles exist in different 
 organised beings, still the proportion they bear to the staminal 
 principles is very limited ; and they are either confined to 
 glandular secretions ; or are excrementitious ; or extravascular ; 
 that is, these modifications and combinations form no part 
 of the living animal, though they are often attached to it ; 
 as in the case of the shells, &c. of the moluscous tribes. They 
 also exist in many excreted products. 
 
xvi 
 
 INTRODUCTION. 
 
 37. From this essential identity between the alimentary 
 matters by which animals are nourished, and the composition 
 of their own bodies, it not only follows that in the more per- 
 fect animals all the antecedent labour of preparing these com- 
 pounds de novo, is avoided ; but that a diet, to be complete, 
 must contain more or less of all the four staminal principles. 
 Such at least must be the diet of the higher classes of animals, 
 and especially of man. It cannot indeed be doubted that many 
 animals, on an emergency, have the power of forming a chyle 
 from one or two of these classes of aliments ; but that the higher 
 animals can be so nourished for an unlimited time is exceed- 
 ingly improbable. Nay, if we judge according to what is 
 known from universal observation, as well as from experiments 
 which have been actually made by physiologists regarding 
 food ; we are led to the directly opposite conclusion, namely, 
 that the more perfect animals could not exist on one class of 
 aliments ; but that a mixture of three at least, if not of all the 
 four staminal principles, is necessary to form an alimentary 
 compound well adapted to their use. 
 
 38. This view of the nature of aliments is singularly illus- 
 trated and maintained by the familiar instance of the com- 
 position of milk. All other matters appropriated by animals 
 as food, exist for themselves ; or for the use of the vegetable 
 or animal of which they form a constituent part. But milk is 
 designed and prepared by nature expressly as food, and it is 
 the only material throughout the range of organisation that is 
 so prepared. In milk, therefore, we should expect to find a 
 model of what an alimentary substance ought to be — a kind 
 of prototype, as it were, of nutritious matters in general. Now 
 every sort of milk that is known, is a mixture of the four 
 staminal principles we have described ; in other words, milk 
 always contains, besides water, a saccharine principle ; a caseous, 
 or, strictly speaking, an albuminous principle ; and an oily prin- 
 ciple. Though in the milk of different animals, the three latter 
 of these staminal principles exist in endlessly modified forms, 
 and in very different proportions; yet neither of them is 
 
ALIMENTARY PRINCIPLES, 
 
 XVU 
 
 at present known to be entirely wanting in the milk of any 
 animal. 
 
 39. The composition of the substances by which animals are 
 usually nourished, favours the mixture of the primary staminal 
 alimentary principles ; since most of these substances are com- 
 pounds of at least three of the staminal principles. Thus most 
 of the gramineous and herbaceous matters, besides water, contain < 
 the saccharine and the glutinous principles ; while every part of 
 an animal contains at least albumen and oil. Perhaps, therefore^ 
 it is impossible to name a substance constituting the food of 
 the more perfect animals, which is not essentially a natural 
 compound of at least three, if not of all the four great principles 
 of aliment. 
 
 40. In the preceding sketch we have attempted to give a 
 general notion of the groundwork of organised products, and 
 of their relations to, and dependence on, each other, when con- 
 sidered as aliments ; that is, as the means by which such organ- 
 ised products are themselves formed, and their existence main- 
 tained. This sketch, general and simple as it appears, if rightly 
 understood and applied, will be found to remove much of that 
 mysterious character, with which the processes of nutrition have 
 been invested ; and, by lessening the field of our inquiry, to 
 bring us nearer our object. We had previously known that 
 the articles employed as food by animals, are essentially com- 
 posed of three or four elements. But we have now learnt, 
 that all the more perfect of those matters on which animals 
 subsist, are compounds of three or four proximate principles ; 
 the whole of which compounds except one (the saccharine) 
 are, in their essential characters, identical with the materials 
 composing the frame of the animals themselves. We have 
 also learnt, that owing to this identity of composition, many 
 animals are saved the labour of forming these proximate princi- 
 ples from their elements ; and have only to re-arrange them 
 as their exigencies may require. The task of forming the 
 proximate principles is thus left to the inferior animals, or to 
 plants ; which are endowed with the capacity of compounding 
 
xviii 
 
 INTKODDCTION. 
 
 these proximate principles from matters still lower in the scale 
 of organisation than the animals and plants themselves. Hence 
 there is a series, from the lowest being that derives its nourish- 
 ment from carbon and carbonic acid, up to the most perfect 
 animal existing : each individual in the series preferring to 
 assimilate other individuals immediately below itself; bat 
 having on extraordinary occasions the power of assimilating 
 all, not only below but above itself, in the system of organised 
 creation. 
 
 Section III. 
 
 OF THE PROCESSES OF ASSIMILATION. 
 
 41. The processes of assimilation, in the general sense in 
 which we here use the term, include every process directly or 
 indirectly concerned in the assimilation of the alimentary mat- 
 ters above mentioned, into the textures of a living animal body. 
 In this sense of the term, therefore, the processes of assimila* 
 tion may be divided into two great classes, which, from their rela- 
 tions to each other, may be termed the primary and secondary 
 assimilating processes. The primary assimilating processes 
 comprise the process of digestion, and all the intermediate 
 processes up to sanguification, inclusive ; while the secondary 
 assimilating processes comprise the processes by which the 
 different textures of which the living body consists, are first 
 formed from the blood ; and afterwards re- dissolved and re- 
 moved from the system. With these processes, as far as they 
 are at present understood, we shall presume the reader to be 
 acquainted ; our remarks, therefore, on the primary and secon- 
 dary assimilating functions, in this and the following sections, 
 will be principally confined to the mutual relations and sub- 
 serviences of the different processes to each other. 
 
PRIMARY ASSIMILATION. 
 
 xix 
 
 42. In the processes of assimilation, both primary and se- 
 condary, water plays so important a part, that before we pro- 
 ceed, it becomes necessary to make a few remarks on the 
 subject. Water enters into the composition of most organised 
 bodies in two separate forms ; that is, water may constitute an 
 essential element of a substance, as of sugar, starch, albumen, 
 (fee, in their driest states ; in which case the water cannot be 
 separated, without destroying the hydrated compound. Or 
 water may constitute an accidental ingredient of a substance, 
 as of sugar, starch, albumen, &:c., in their 7noist states, in which 
 case, more or less of the water may frequently be removed 
 without destroying the essential properties of the compound. 
 Now a very large proportion of organised bodies (perhaps all 
 those to which our present inquiry relates) contain water in 
 both these forms ; both as an essential element, and as an 
 accidental ingredient ; and in most instances it is impossible 
 to distinguish between the water that is essential, and that 
 which is accidental, though the mode of union in the two cases 
 must be altogether different.* Organised bodies containing 
 small proportions of combined water are usually of a firm and 
 stable character, and in common language are said to be strong 
 or high ; while those containing larger proportions of com- 
 bined water are usually of a delicate and unstable character, 
 and are said to be iveak or low ; thus we read of strong and 
 weak sugars, glues, &c., varieties of these principles which are 
 found to owe their peculiar properties to the less or greater 
 proportions of combined water they contain. The processes of 
 converting strong bodies into weak and vice versa, are with 
 difficulty accomplished artificially ; for instance, though we 
 can in some respects make a strong sugar weak, in no instance 
 do we appear to be able to reverse the process, and to convert a 
 weak into a strong sugar. As these processes, however, con- 
 
 * The reader is referred to the third book of my Bridgewater Treatise, 
 for some further remarks on the subject of assimilation in general ; and 
 particularly on the influence of water in modifying organised com- 
 pounds. 
 
 C 2 
 
XX 
 
 INTRODUCTION. 
 
 stitute some of the most frequent and important of all the 
 processes of a purely chemical character taking place in or- 
 ganised compounds, it becomes necessary to distinguish them 
 by appropriate appellations ; and for this purpose I have been 
 long accustomed to indicate the change of a strong into a weak 
 principle, by the term reduction, and vice versa, the change of 
 a weak into a strong principle, by the term completion — a 
 nomenclature which will be subsequently adopted throughout 
 these pages, and which the reader is desired to bear in mind. 
 
 43. The primary assimilating processes viewed as a whole, 
 and with reference to the chemical influence of water, as above 
 described, may be considered of two kinds, directly opposed to 
 each other. From the stomach to the duodenum inclusive, 
 the operations are all of a reducing kind ; that is to say, the 
 alimentary matters, however strong and firm, are gradually 
 reduced by this first stage of the assimilating processes to the 
 lowest possible condition, — to the tender and delicate state, as it 
 were, of infancy. In this low state, the alimentary principles 
 enter the lacteals as chyle ; and from this moment they again 
 gradually begin to be raised, and to become stronger and 
 firmer in their texture, till they reach the thoracic duct, where 
 their properties are found to be considerably developed. From 
 the thoracic duct they are poured into the general mass of 
 blood, and immediately subjected to the action of the respira- 
 tory function in the lungs. During the respiratory process, 
 they part with the remainder of their combined water, (which, 
 as we have elsewhere attempted to show, is principally ex- 
 pelled from the lungs with the respired air,)^ and thus, being- 
 rendered complete in their properties, and identical in all re- 
 spects with the blood itself, they are finally adapted for incor- 
 poration with that important fluid. 
 
 44. If we attentively consider the reducing portion of 
 the assimilating processes, we shall find them to be of at 
 least three kinds. In other words, the digestive organs, pro- 
 perly so called, exert a threefold function : First, the 
 
 * See Bridge water Treatise, page 530, second edition. 
 
PRIMARY ASSIMILATION. 
 
 xxi 
 
 stomach has the power of dissolving alimentary substances, or 
 of bringing them into a semifluid condition. This opera- 
 tion seems to be altogether chemical, and probably essen- 
 tially consists in the combination of alimentary substances 
 with water ; that is, in reducing the alimentary substances from 
 a high to a low condition. Secondly, the digested aliments, 
 or the chylous portion of the chyme taken up by the lacteals, 
 though the proportions of its different ingredients may vary, 
 is always essentially the same in its composition. The diges- 
 tive organs, therefore, and more especially the stomach, must 
 possess the power, within certain limits, of changing into one 
 another the simple alimentary principles formerly described. 
 This part of the operations of the stomach appears, like the 
 reducing process, to be chemical ; but not so easy of accom- 
 plishment. It may be termed the converting operation of the 
 stomach. Thirdly, the crude and dead aliments undergo 
 changes in the stomach, (fee, which render them fit to be 
 brought into contact and even union with the living animal 
 body; the stomach and assimilating organs, therefore, must 
 possess the power of organising and vitalising the different 
 alimentary substances. It is impossible to imagine that such 
 organising agency of the stomach can be chemical. This 
 agency is vital, and its nature is completely unknown. 
 
 45. Of the solvent or reducing f unction of the stomach. — The 
 different culinary processes, roasting, boiling, baking, &;c., have 
 all a reducing effect, and may, therefore, be considered as pre- 
 paratory to the solvent action of the stomach. Of these ope- 
 rations man avails himself, and they constitute the chief means 
 by which he is enabled to be omnivorous ; for, without such 
 preparation, a very large portion of the matters which he now 
 adopts as food, would be completely indigestible. By different 
 culinary processes, the most refractory substances can be often 
 rendered nutritious.* Thus, by alternate baking and boiling, 
 the woody fibre itself is said to be convertible into a sort of 
 amylaceous principle, not only possessing most of the proper- 
 * Philos. Trans. 1827. 
 
xxil 
 
 INTRODUCTION. 
 
 ties of the amylaceous principle, but capable of being formed 
 into bread. Nay, even the albuminous principle itself, is pro- 
 bably rendered more nutritious, (certainly better adapted to 
 man in a civilised state,) by the judicious application of cookery ; 
 and the same remarks might be applied to almost every other 
 substance. 
 
 46. The solvent and reducing powers of the stomach may 
 be thus illustrated. When a mass of solid albuminous matters- 
 merely triturated by the masticating processes, arrives in the 
 stomach, it speedily undergoes certain changes. The portion 
 of the albumen in contact with the stomach soon begins to 
 change its appearance, that is, it becomes softened, and 
 assumes a sort of gelatinous character ; by degrees, the pecu- 
 liar action of the stomach brings the whole portion of the 
 mass into successive contact with the living organ ; and in this 
 way at length the whole mass becomes softened or dissolved, 
 and forms the compound termed chyme. Through all these 
 apparent changes, however, the albumen has undergone no 
 real change. What was introduced into the stomach as albu- 
 men, is still albumen in the chyme ; at least chemists have 
 so pronounced it. Yet the albumen has assumed an appear- 
 ance altogether different. The albumen of the egg, and of 
 the aliment, may be coagulated by heat into a firm and elastic 
 solid. The albumen of the chyme (or chyle) is indeed 
 coagulable by heat ; but its coagulation is so imperfect, and so 
 wanting in tenacity, as to offer a striking contrast with the 
 coagulated albumen of the egg. Now what could have hap- 
 pened during these changes in the stomach, but the more 
 intimate connexion or combination of the albumen with water, 
 by which the strong and firm albumen ovi has been reduced t^ 
 the weak and delicate albumen ckyli, as formerly explained ? 
 And if this explanation be admitted with regard to albumen, 
 it must be admitted with regard also to the other alimentary 
 principles. 
 
 47. Of the nature of the peculiar agency by which the com- 
 bination of alimentary substances with water^ and consequently 
 
PRIMARY ASSIMILATION. 
 
 XXlll 
 
 their solution, is effected, we cannot be said to possess mucli 
 certain knowledge. The combination appears to be chiefly 
 owing to the agency of a fluid secreted by the stomach, the 
 glands for the formation of which are most numerous about 
 the pyloric orifice. By this secretion, or by some other 
 agency exerted in the stomach, the previously masticated 
 food which has been introduced into that organ, is asso- 
 ciated with water, and thus becomes itself more or less a 
 fluid. Of this important secretion of the stomach, chlorine, 
 in some state or other of combination, is an ingredient — it 
 would seem a necessarij ingredient ; for the secretion in its 
 healthy state always contains more or less of chlorine, the 
 powerful influence of which seems mainly to contribute towards 
 affecting the combination of the aliments with water.* 
 
 48. The chlorine thus so indispensable to the reducing pro- 
 cess of the stomach, is perhaps more frequently the subject of 
 derangement, than anything connected with the assimilation 
 of the food. It often happens, that instead of chlorine or a 
 little free muriatic acid, a large quantity of free muriatic acid 
 is elicited, which not only gives occasion to much secondary 
 uneasiness, but more or less retards the process of reduction 
 itself. The source of this chlorine or muriatic acid must be 
 the common salt which exists in the blood ; to suppose that it 
 is generated, is quite unnecessary. The chlorine, therefore, is 
 separated from the blood, at least in part ; and it may be de- 
 manded what is the nature of the agency capable of separating 
 the chlorine from a fluid so heterogeneous as the blood ? We 
 
 * This was written long before I was aware of the recent experiments 
 of Eberle, Schwann, and Miiller on this subject. Eberle attempted to show 
 that the digestive principle consists of a solution of mucus in an acid. 
 Schwann and Miiller found that Eberle was in error in his statement, — 
 that all mucus in an acid state has the digestive property — and showed that 
 this property is possessed by an organised principle secreted with the gas- 
 tric mucus only. This principle has been termed ^ep^m, and its action on 
 the matters to be dissolved has been supposed to be somewhat analogous 
 to the action of diastase on starch. See Miiller's Physiology, English 
 Translation, page 543. 
 
XXIV 
 
 INTRODUCTION. 
 
 are acquainted with one agent that exerts such a power, namely , 
 electricity ; and some modification of this agent may be sup- 
 posed to be employed by the animal economy for its operations, 
 in the same manner, and on the same principles, as the mate- 
 rials themselves are employed from which the animal body is 
 constructed. Perhaps, therefore, the decomposition of the 
 salt of the blood may be fairly referred to the immediate 
 agency of some modification of this principle, electricity. We- 
 say some modification of electricity ; for we do not believe that 
 electricity, precisely as we are acquainted with it, and as existing 
 and acting in inanimate nature, can be thus employed ; for 
 the very cogent reason, that the products and operations of 
 organised bodies, which are the results of its agency, differ 
 altogether, as we have said, from those of inorganic bodies. 
 Thus we could conceive common electricity to form or to de- 
 compose the crystallisable principles, sugar, or vinegar, or com- 
 mon salt ; but we never could conceive it to form the organised 
 principles, starch, or albumen ; or even the peculiar combination 
 oi chlorine existing in the stomach of animals, on which, 
 as we have said, the solution of the food depends : because the 
 composition of these principles is not only different, but abso- 
 lutely incompatible with the composition of the crystallisable 
 principles formed by the agency, and agreeably to the laws of 
 operation, of common electricity. 
 
 49. Supposing the chlorine or muriatic acid found in the sto- 
 mach to be derived from the common salt existing in the blood 
 and in the stomach, another question arises, — what becomes of 
 the soda from which the muriatic acid has been separated ? 
 The soda remains behind, or is absorbed into the mass of blood, 
 and a portion of it no doubt is requisite to preserve the weak 
 alkaline condition essential to the fluidity of the blood. But 
 the larger part of this soda is probably directed to the liver, 
 and is elicited with the bile in the duodenum ; where it is thus 
 again brought into union with the acid, which had been sepa- 
 rated from the blood in the stomach. These observations, 
 
PRIMARY ASSIMILATION. 
 
 XXV 
 
 illustrating the importance of common salt in the animal 
 economy, seem to explain, in a satisfactory manner, that in- 
 stinctive craving after this substance, which is shown by 
 animals. 
 
 50. Admitting that the decomposition of the salt of the 
 blood, (fee, is owing to the immediate agency of a modification 
 of electricity, we have in the principal digestive organs a kind 
 of galvanic apparatus, of which the mucous membrane of the 
 stomach and intestinal canal, generally, may be considered as 
 the acid or positive pole, while the hepatic system may, on the 
 same view, be considered as the alkaline or negative pole.^ 
 Whether such electrical action be admitted or not, (and the 
 admission is of no very great importance,) what we have above 
 stated may be received as a simple expression of the facts, in 
 so far as they relate to the saline constituents of the blood. 
 Moreover, be the nature of the energies what they may, by 
 which these changes are effected ; along with these changes, 
 and probably by the aid of the same energies, other very im- 
 portant changes or processes are carried on, to some of which 
 we shall have occasion hereafter to allude. 
 
 51. The formation of chlorine or of muriatic acid appears to 
 be necessary to the reducing operation of the stomach in its 
 healthy state ; but other acids, and particularly the lactic acid, 
 are occasionally, if not always, present during the digestive 
 processes. Whether this lactic acid be essential to the 
 digestive processes in man and in other animals in which 
 it exists, does not appear to be clearly ascertained. My own 
 opinion respecting it is, that though frequently present in the 
 
 * This notion or opinion^ which was first advanced by me many years 
 ago, seems to have lately received some confirmation from the experiments 
 of Matteuci, who found that when the liver and stomach of a rabbit 
 were connected with the platinum ends of the wires of a delicate gal- 
 vanometer, a deviation of the needle amounting to fifteen or twenty de- 
 grees took place. This action became very feeble, or entirely ceased, 
 after the death of the animal ; hence he inferred that it depended on the 
 vital action of the organs, and not on the difference of the chemical pro- 
 perties of their secretions. Matteuci, I'lnstitute, No. 75. 
 
xxvi 
 
 INTRODUCTION. 
 
 human stomach, it is rather to he considered as the result of 
 unnatural irritation, produced by disease, indigestible aliments, 
 Sec, than as a healthy product necessary to the digestive pro- 
 cess. The source of the lactic acid, also, is probably different in 
 different instances. Sometimes it may be derived from the food ; 
 at other times, and that most frequently, it seems to be imme- 
 diately derived, like the muriatic acid, from the blood itself. 
 The lactates exist in the blood, and it may in part be derived . 
 from the lactates already formed in that fluid. There is, 
 however, every reason to believe, that when very abundant, it 
 is derived from the decomposition of the blood in the extreme 
 vessels of the stomach, &:c. We shall consider this point more 
 in detail, when we come to speak of the secondary processes of 
 assimilation in the next section. 
 
 52. Another acid occasionally present in the stomach, and 
 the result of unhealthy assimilation, both primary and secon- 
 dary, is the oxalic acid. From the relation of this principle to 
 the saccharine aliments in particular, there is no difficulty in 
 conceiving how it may be occasionally developed in the sto- 
 mach. Moreover, it is occasionally taken into the stomach as 
 an alimentary matter, for instance, in the stalks of rhubarb, 
 sorrel, &:c. Small quantities of oxalic acid thus developed or 
 introduced into the stomach, do not appear to give much un- 
 easiness in that organ ; and when introduced, it may in some 
 instances, like other saccharine derivatives, be assimilated. 
 The effects of the oxalic acid are most severely felt in the 
 subsequent vital process ; and its developement, more especially 
 during the secondary assimilating processes, is commonly at- 
 tended by formidable derangements of the health. 
 
 53. As to the butyric, acetic, carbonic, and other acids occa- 
 sionally met with during the digestive processes in the stomachs 
 of animals ; these are probably in a great degree the results 
 of indigestion, and derived from the mal-assimilation of the 
 alimentary matters. 
 
 54. Of the converting powers of the stomach, Sfc. — Though 
 the proportions of the different ingredients of the chyle, as 
 
PRIMARY ASSIMILATION. 
 
 XXVll 
 
 ultimately formed, are liable to be varied according to the 
 nature of the food ; yet, whatever the nature of the food may 
 be, the general composition and characters of the chyle remain 
 always the same. The stomach, therefore, must be endowed 
 with a power or faculty, the agency of which is to secure this 
 uniform composition of the chyle by appropriate action on 
 such materials as circumstances may bring within its reach. 
 Two indeed, of the chief materials from which chyle is formed, 
 namely, the albuminous and oleaginous principles, may be 
 considered to be already fitted for the purposes of the animal 
 economy without undergoing any essential changes in their 
 composition ; but the saccharine class of aliments which form a 
 very large proportion of the food of all animals, except those 
 entirely subsisting on flesh, are by no means adapted for such 
 speedy assimilation. Indeed, one or more essential changes 
 must take place in saccharine aliments previously to their 
 conversion either into the albuminous or the oleaginous prin- 
 ciples. 
 
 55. Under ordinary circumstances, the essential changes 
 which alimentary matters undergo in the stomach, are most 
 probably altogether chemical. That is, the changes are such 
 as do take place, or rather such as would take place, if the 
 elements of the substances thus changed in the stomach, could 
 out of the body be so collocated as to bring into action the 
 affinities necessary for the changes produced in the stomach. 
 Thus, as we know, the saccharine principle spontaneously be- 
 comes alcohol, which is merely an oleaginous body of a weak 
 kind. When, therefore, in the stomach it is requisite that 
 sugar be converted into oil, it is probable that the sugar passes 
 through precisely the same series of changes it undergoes out 
 of the body during its conversion into alcohol. We cannot 
 trace the conversion of sugar into albumen, because we are 
 ignorant of the relative composition, and of the laws which 
 regulate the composition of these two substances. The origin 
 of the azote in the albumen is likewise at present unknown to 
 us, though in all ordinary cases it seems to be appropriated 
 
XXVm INTRODUCTION. 
 
 from some external source.^ That the oleaginous principle 
 may be converted into most, if not all, the matters necessary 
 for the existence of animal bodies, seems to be proved by the 
 well-known fact, that the life of an animal may be prolonged 
 by the appropriation of the oleaginous and other matters 
 contained within its own body. 
 
 56. Under ordinary circumstances, then, the converting 
 powers of the stomach must essentially consist of the three - 
 kinds mentioned, viz. the conversion of saccharine aliments 
 into albuminous and oleaginous principles ; the conversion of 
 albuminous principles into oleaginous principles ; and the 
 conversion of oleaginous into albuminous principles. These 
 three forms of the same function may in fact be considered as 
 so many subordinate functions, each distinct in its characters, 
 and each liable to be affected by disease, kc, independently of 
 the others. Of these three subordinate functions, the first, 
 viz. the conversion of saccharine into albuminous and oleagi- 
 nous aliments, is by far the most important. And as the ap- 
 propriation of saccharine aliments is not only common to many 
 animals, but even to vegetables, it may perhaps be viewed as 
 the lowest step of alimentary renovation ; in other words, as 
 constituting the immediate act, as it were, by which the stamina 
 or groundwork of organised beings is formed. Hence, though 
 the appropriation of saccharine aliments by animals, must be a 
 very different process from the appropriation of such aliments 
 by plants ; yet it is probable, that in those animals destined to 
 subsist, in a greater or less degree, on saccharine aliments, 
 such power of appropriation is more firmly established, than the 
 appropriation of albuminous and oleaginous principles. In short, 
 
 ♦ The azote may, in some instances, be derived from the air, or gene- 
 rated. But my belief is, that under ordinary circumstances, the azote is 
 principally furnished by a highly azotised substance (organised urea?) 
 secreted from the blood, either into the stomach or duodenum, or into 
 both these localities ; and that the portion of the blood thus deprived of 
 its azote, is separated from the general mass of blood by the liver, as 
 one of the constituents of the bile ; which secretion, as a whole, is re- 
 markably deficient in azote. 
 
PRIMARY ASSIMILATION. 
 
 xxix 
 
 that the power of appropriating the saccharine principle is the 
 last that ceases to exist in an animal ; and thus often remains 
 to a certain extent long* after the power of appropriating albu- 
 men and oil has ceased. The derangement or partial sus- 
 pension of the power of converting the saccharine principle in 
 man, not only constitutes a formidable species of dyspepsia ; 
 but the unassimilated saccharine matter, in passing through the 
 kidneys, gives occasion to the disease termed diabetes. 
 
 57. The reader will have remarked, that we have frequently 
 used the term ordinary circumstances ; and perhaps it may not 
 be amiss to explain the meaning attached to that term. 
 
 58. When an animal is duly fed, according to that diet 
 which is natural to it, and for which its organisation has been 
 adapted ; a regular and ordinary series of changes takes place 
 within the animal, and the alimentary matters are converted 
 into chyle. But one general characteristic of organised beings 
 is, that within certain limits, and for a certain time, animals 
 possess the power of varying their habits and of accommodating 
 themselves to circumstances. Under extraordinary circum- 
 stances, therefore, extraordinary changes must and do take 
 place. In some instances, these changes out of the ordinary 
 course are to an extent altogether astonishing, and such as 
 defy our utmost calculation. The assimilating organs appear 
 even to decompose principles which are still considered as 
 elementary, nay to form azote or carbon ; so that it is impos- 
 sible to define what, on an emergency, these organs are capable 
 of doing. But what is thus done on an emergency, wdll 
 usually be found to constitute an exception to what is 
 done in ordinary ; their ordinary mode of action being always 
 that which is most simple. 
 
 59. Of the organising and vitalising powers of the stomach., 
 Sfc. — In this part of our investigation we meet with the real 
 difficulties we have to overcome in explaining the operations 
 of living beings. The whole of the great and essential changes 
 which alimentary matters undergo, may, and perhaps will be, 
 traced by care and attention ; but all beyond will probably 
 
XXX 
 
 INTRODUCTION. 
 
 for ever remain unknown to iis. Now at least, tliougli we 
 understand in some degree the chemical changes ; of the vital- 
 ising influence, we in truth know absolutely nothing. There 
 is, however, every reason to believe, that vitality is imparted 
 through the agency of the living animal itself. For though, 
 from the natural composition of alimentary substances, they 
 be to a certain extent fitted for the purposes of the animal 
 economy, yet alone they are incapable of uniting themselves ^ 
 with the living animal frame ; and unless the living economy 
 contribute likewise its share by re-arranging or otherwise ad- 
 justing those minute quantities of incidental principles peculiar 
 to organised products, the future work of assimilation will be 
 incomplete or impossible. 
 
 60. To the present head must be referred all those opera- 
 tions of matters incidental to alimentary substances, and of me- 
 dicinal agents, &:c., which cannot be explained on mere common 
 mechanical or chemical principles. These incidental matters, 
 medicinal agents, kc, interfere with the processes of vitality 
 in modes we do not understand, and therefore can neither 
 anticipate nor control. We can form no conception, for in- 
 stance, why mutton should prove a poison to a certain indivi- 
 dual.^' We know that mutton is essentially composed of 
 albuminous and oily matters, like other meats which such 
 individuals take with impunity. The peculiar effects of mutton, 
 therefore, cannot depend on the mere albuminous and oily 
 principles, but must depend on those principles infinitely 
 minute in quantity, incidental to mutton, and on which its 
 
 * I knew an instance of the illustration mentioned in the text. The 
 individual could not eat mutton in any form. The peculiarity was sup- 
 posed to be owing to caprice, and the mutton was repeatedly disguised, 
 and given unknown to the individual ; but uniformly with the same result 
 of producing violent vomiting and diarrhoea. And from the severity of 
 the effects, which were in fact those of a virulent poison, the^e can be 
 little doubt, that if the use of mutton had been persisted in, it would 
 have soon destroyed the life of the individual. Similar effects are well 
 known to be produced in certain instances by many articles used both 
 as food and medicines ; but this is the only instance which has come to 
 my knowledge, in which mutton has so acted. 
 
PRIMARY ASSIMILATION. 
 
 XXXI 
 
 peculiar sensible properties depend. We do not know the 
 exact nature of these incidental principles on which the pecu- 
 liar properties of mutton depend ; and even if we did know 
 their exact nature, we should be probably quite unable to form 
 a notion of their peculiar mode of operation in the production 
 of the effects in question. The nature of these operations, 
 therefore, as well as the nature of the operation of many medi- 
 cinal agents, must for ever remain concealed. 
 
 61. The preceding observations relate more especially to 
 the assimilating operations taking place in the stomach. 
 With respect to the operations which take place in the duo- 
 denum, it may be observed, that though the phenomena vary 
 considerably according to the nature of the food, so far as we 
 can understand these phenomena, under every change of food 
 the essential character which the chyme undergoes in the duo- 
 denum is unaltered. That is, the acid developed in the sto- 
 mach, combines in the duodenum with the alkali of the bile, 
 and is more or less neutralised, (perhaps entirely neutralised 
 in a healthy condition of the organs ;) the albuminous princi- 
 ples, if not before developed in the stomach, make their ap- 
 pearance ; and the matters destined to be excrementitious are 
 more or less perfectly separated. Of the nature of the more 
 recondite and vitalising changes which take place in the 
 duodenum, we are in the same state of complete ignorance, as 
 we are of the similar changes which take place in the stomachs 
 
 62. In the foregoing remarks on the different processes 
 which take place in the stomach and duodenum, and which 
 are necessary for the conversion of the food of an animal into 
 the living materials of its body, we have endeavoured to dis- 
 tinguish between what, to a certain extent, is within our powers 
 of comprehension ; and what is completely beyond them. 
 Moreover, it may be observed, that though the three great 
 and essential processes of digestion, viz. the reducing, the con- 
 verting, and the organising processes are sufficiently distinct 
 from each other ; yet it is not to be understood that they take 
 
xxxn 
 
 INTRODUCTION. 
 
 place in succession, or in the order in which they have been 
 described. The fact is, that all these processes go on at the 
 same time ; and as soon as a portion of food begins to be dis- 
 solved, its future changes seem to be determined. If it be 
 necessary that the portion of food undergo an essential 
 change, that change is accordingly begun. If no such change 
 be required, the organising process itself begins simultaneously 
 with the reducing process. The consequence of this union of- 
 the digestive processes is, that the staminal principles are all 
 developed in the chyle, as soon as the excrementitious matters 
 are separated by the biliary and pancreatic fluids. 
 
 63. It remains to make a few remarks on those changes 
 which take place after the chyle has entered the lacteals. 
 
 64. We have already stated, that the moment the chyle 
 enters the lacteals, it begins to be subjected to a series of 
 processes of a nature totally different from those it had under- 
 gone in the stomach and duodenum. In the stomach and 
 duodenum, the leading processes, generally speaking, had been 
 of a reducing character ; in the lacteals, the leading process is 
 of an opposite or completing character ; and the water which 
 had been associated with the albuminous and oleaginous prin- 
 ciples in the first stages of assimilation, in the second stages 
 is again gradually removed. In other words, the properties 
 of the chyle as it passes through the lacteals, and the glandular 
 apparatus connected with these vessels, gradually approximate 
 to those of the blood. 
 
 65. Whether the converting process takes place in any form 
 or degree in the passage of the chyle through the lacteals, has 
 not been ascertained. As, however, the cast of the chylous 
 principles seems, as formerly stated, to be determined in the 
 early stages of assimilation, the probability is against the sup- 
 position, that, under ordinary circumstances, any chylous prin- 
 ciple is converted into another, during the passage of the chyle 
 through the lacteals. Besides the completing process, therefore, 
 the only other great change to which the chyle is subjected in 
 
SECONDARY ASSIxMILATIOK. 
 
 XXXIU 
 
 the lacteals, is the vitalising or organising process. Now, the 
 chyle, in the minute state of subdivision to which it is subjected 
 in the lacteals, is most favourably circumstanced for undergoing 
 the vitalising processes ; every particle of it being, as it were, 
 brought into immediate contact with the living and exquisitely 
 organised structure of the lacteal apparatus. In proportion,' 
 therefore, as the combined water of the chyle is separated, 
 may vitality be said to be associated with the chylous mole- 
 cules, till they are fitted to become component parts of the 
 living body. 
 
 66. The above being little more than a simple expression of 
 facts as they present themselves to our notice, may be consi- 
 dered as very imperfect and unsatisfactory. The charge must 
 be admitted ; but in reply we must observe, that the little 
 stated, imperfect as it is, constitutes the whole that we can 
 be said to actually know on the subject at present. 
 
 67. Having briefly traced the assimilating processes through 
 their primary stages, and endeavoured to point out the leading 
 changes which the alimentary matters undergo during their 
 conversion into blood ; we have in the next place to consider 
 the changes which the blood itself subsequently undergoes, 
 during its conversion into the living constituent principles of 
 animal bodies. 
 
 Section IV. 
 
 Of the Secondary Assimilating Processes. 
 
 68. As the term secondary assimilation is novel in the sense 
 in which it is employed in the present volume, it may in the 
 first place require a brief explanation. 
 
 d 
 
xxxiv 
 
 INTRODUCTION. 
 
 69. We have already stated, that under the head of secon- 
 dary assimilation, we range all assimilating processes, subse- 
 quent to those of sanguification. The secondary assimilating 
 processes, therefore, include two great divisions, which, for the. 
 sake of distinction, may be termed the foimative and the de- 
 structive. Under the head of the secondary formative assimi- 
 lating processes, are included the different processes by which 
 the principles of the blood are converted into the different 
 tissues composing animal bodies, as well as the different secre- 
 tions designed for ulterior purposes in the economy: while 
 under the head of secondary destructive assimilating processes 
 are included the extinction (secondary digestion) of the different 
 tissues of the body, and their conversion, either into new prin- 
 ciples designed for ulterior purposes ; or into disorganised pro- 
 ducts designed to be removed from the body; or more frequently 
 into products belonging to both these classes of substances. 
 
 70. Before we proceed to make a few remarks in detail on 
 these two divisions of the assimilating processes, it may be 
 proper to explain briefly the general principle on which the 
 different processes are conducted. When a definite substance 
 like the albumen of the blood, for instance, is converted into 
 one or more new principles, either the entire elements compos- 
 ing the albumen must be re-arranged so as to produce a prin- 
 ciple having new and different sensible properties ; or what 
 appears to be infinitely more common, and indeed the rule, 
 the elements of the simple principle must be so arranged as to 
 form two (or more) principles, either of which may be said to 
 be complementary to the others ; that is, the composition of one 
 (or more) of the new principles must be such, as, in conjunction 
 with the remaining principle, will complete the albumen, from 
 which all the new principles were originally formed.^' 
 
 * The part that water plays in complementary decomposition is often 
 very important, and, to prevent misconception, deserves to be noticed. 
 The original substance to be decomposed is often decomposed or — 
 water; that is, the complementary principles into which a substance is 
 decomposed, do not exactly make up the substance as it usually exists. 
 
SECONDARY ASSIMILATION. 
 
 XXXV 
 
 71. Complementary decomposition is at least of two kinds ; 
 a substance may be changed into a new principle designed for 
 ulterior purposes, and another principle designed to be excre- 
 mentitious ; e. g. albumen may be decomposed into gelatine, 
 and hydrated carbon capable of becoming carbonic acid on 
 exposure to air in the lungs. Or a substance may be decom7 
 posed into two principles, both of which may be designed for 
 ulterior, or both for excrementitious purposes. Instances, 
 perhaps innumerable, of these two forms of change are con- 
 stantly taking place in the animal economy ; though the first 
 seems more naturally to belong to healthy action ; the second 
 to disease. Thus albumen and gelatine are converted into 
 principles, one or both of which are applied to further uses in 
 the economy ; whereas, in peculiar states of disease, gelatine 
 in particular appears to be almost wholly converted into some 
 modification of the saccharine principle and urea ; both of 
 which from their properties may be considered as excremen- 
 titious. 
 
 72. We have alluded above to the decomposition of a prin- 
 ciple into three or more complementary principles, and many 
 such decompositions doubtless take place in the animal economy, 
 though they are at present little understood. As an instance, 
 gelatine may be mentioned ; which, instead of being decom- 
 posed into some form of the saccharine principle and urea, 
 may be, and often is, converted into oxalic acid and the 
 carhonate of ammonia. 
 
 73. The above remarks on complementary decomposition 
 are chiefly applicable to the essential elements of which or- 
 ganised bodies consist. How far they are applicable to the 
 mineral elements incidentally present in organised bodies is 
 not known ; and the following may be said to comprise 
 almost the whole of the little at present understood on this 
 part of the subject. 
 
 but the substance, plus or minus, one or more proportions of water. 
 This circumstance is of such frequent occurrence in organic decomposi- 
 tions, as almost to constitute the rule rather than the exception. 
 
 d 2 
 
XXXVl 
 
 I>TRODUCTION. 
 
 74. The incidental mineral matters found in organised 
 bodies, are supposed to be as fixed and definite, both in their 
 nature and quality, as the essential elements of which such 
 bodies consist. Hence, as the geologist is often enabled to 
 identify strata by the similarity of the fossils embedded in 
 them ; so the physiologist is enabled to identify organised 
 tissues, by the similarity of the incidental mineral matters they 
 usually contain. Thus the nervous mass is characterised by 
 the presence of phosphorus ; a peculiar tissue intimately con- 
 nected with the nervous, by the presence of magnesia ; certain 
 submucous tissues, by the presence of lime, ^c."^ 
 
 75. We know little or nothino; of the modes in which 
 mineral incidental matters enter into the composition of or- 
 ganised products ; but I agree with Berzelius in general, that 
 such incidental matters usually exist in their elementary condi- 
 tion in organised products, and not as binary compounds ; and 
 that they assume the form of binary compounds or oxides, in 
 which they commonly appear, during the destruction of the 
 organised principle. On such occasions the oxygen or other 
 essential element of the binary compound, may be derived from 
 the organised principle itself ; from the decomposition of water ; 
 from the atmosphere, Sec. 
 
 76. The important practical inferences we wish to deduce 
 from the preceding remarks are, that when incidental mineral 
 matters appear as binary compounds among organised pro- 
 ducts, the mal-assimilation or destruction of organised tissues 
 is not only indicated ; but the exact nature of the tissue 
 thus mal-assimilated or destroyed, may be predicated from the 
 nature of the binary mineral compound, 
 
 77. In further illustration of these inferences it may be 
 
 * Some imagine that the mineral incidental principles of organised 
 beings are generated during the vital processes ; while others maintain 
 that they are derived ab externo. My belief is, that under certain extra- 
 ordinary circumstances, the vital agents can form what we now consider 
 as elements ; but that^ in ordinary, such elements are chiefly derived 
 ah externo, in conjunction with the alimentary principles. 
 
SECONDARY ASSIMILATION. 
 
 XXXVll 
 
 observed, that as alimentary matters consist in general of or- 
 ganised products, it is probable that the matters incidental to 
 alimentary matters, (at least such as are congenial to the 
 nature of the individual,) are appropriated along with the 
 essential elements in the primary assimilating processes. On 
 the contrary, when the alimentary matters are not congenial 
 to the individual, or when, for some other reason, they are not 
 primarily assimilated, alimentary matters are often converted 
 into cry stalli sable principles; and the incidental mineral matters 
 at the same time are emancipated in binary forms, and some- 
 times make their escape in large quantities, either into the 
 intestines, or through the kidneys, &:c. 
 
 78. The same circumstances may be supposed to take place 
 in a somewhat different manner during derangements of the 
 secondary assimilating processes. Thus in the secondary forma- 
 tive assimilating processes, when the albumen of the blood, 
 instead of being converted into gelatine, &:c., is converted into 
 urea and a saccharine principle, the incidental matters of the 
 albumen are necessarily set free, and make their escape as ex- 
 crementitious matters ; again, during the secondary destructive 
 processes, the gelatinous tissues, instead of being converted into 
 principles adapted for ulterior uses, may be converted into 
 urea and a saccharine principle, and the incidental matters 
 escape, as before, in binary forms among the other excremen- 
 titious principles. 
 
 79. After these general remarks, we proceed to make a few 
 observations on the leading formative and destructive processes 
 of secondary assimilation.* 
 
 80. Gelatification is that process, by which a certain portion 
 of the fluid albuminous principle of the blood is converted or 
 assimilated into the solid gelatinous tissues of living beings. 
 The gelatinous tissues may be considered as the most important 
 tissues of their kind in animal bodies — as the groundwork, or 
 
 * Strictly speaking, the terms here used ought to be gelatinification and 
 alhuminification, but the abbreviated terms in the text have been adopted 
 for their greater convenience. 
 
xxxviii 
 
 INTRODUCTION. 
 
 staminal and fundamental texture on which all the other tissues 
 rest, and from which, perhaps, some of them are elaborated. 
 The process of gelatification takes place in the extreme capillary 
 blood-vessels, and at the moment when the arterial is con- 
 verted into venous blood ; a phenomenon, therefore, intimately 
 connected with, if not in some degree dependent on, the gela- 
 tificating process. This connexion of gelatification with the 
 respiratory process, at once stamps its importance, and shows 
 that the one process cannot be deranged or cease, without the 
 derangement or cessation of the other. We have elsewhere en- 
 deavoured to point out the nature of some of the changes which 
 take place during gelatification, and attempted to show, that 
 when albumen is converted into gelatine, carbon is eliminated, 
 which carbon (partly perhaps in a hydrated, partly in an 
 oxygenated form,) remains associated with the venous blood 
 till its arrival in the lungs ; where, by combining with the oxygen 
 of the atmosphere, it becomes fully oxygenated, and is con- 
 verted into carbonic acid gas, and in this form makes its escape 
 from the body."^ 
 
 81. The next great secondary process, which goes on in the 
 extreme capillary vessels simultaneously with the gelatificating 
 processes, is alhumification ; a term expressive of the process or 
 processes by which the fluid albuminous principles of the 
 blood are converted into the solid albuminous tissues of living 
 bodies. Alhumification, therefore, includes alhumification 
 properly so called ; or that process by which the albumen of 
 the blood is converted into the albuminous textures of the 
 body; and fibriflcation, or that process by which the fluid 
 fibrin of the blood is converted into the solid muscular fibrin 
 of animals. During these processes, water must be eliminated ; 
 but of the nature of the concurrent changes, we are at present 
 ignorant ; though there is every reason to believe that they 
 are of a most important character. 
 
 82. The changes which the oleaginous matters of the blood 
 
 * See Bridgewater Treatise, page 259, second edition. 
 
 t The solidification of the fluid albuminous materials of the blood into 
 
SECONDARY ASSIMILATION. 
 
 xxxix 
 
 undergo during the secondary formative assimilating processes, 
 can hardly be stated ; further, than that before such fatty mat- 
 ters are laid up in their appropriate tissues, they undergo 
 certain depurating processes, among which the separation of 
 water appears to be one of the most important. 
 
 83. Another class of processes of the formative kind, belonging 
 to the secondary assimilation, some of which are connected more 
 especially with gelatification, others with albumification, are 
 the formation of solid matters, as of bones, horns, hair, &:c. &;c. 
 While still another class may be supposed to include the dif- 
 ferent fluid secretions derived from albuminous and oleaginous 
 matters, and destined for ulterior purposes ; such as the saliva, 
 the different gastric secretions, the spermatic fluid, various oily 
 or resinous secretions, &c. With these, however, we have at 
 present nothing to do ; we pass on, therefore, to the considera- 
 tion of the processes belonging to the other general division of 
 the secondary assimilating processes, those namely of the de- 
 structive kind. 
 
 84. By the secondary assimilating processes of the destruc- 
 tive kind, are meant, as before explained, those processes by 
 which the different tissues of the body are unmade, and are 
 either converted into principles of a higher order, designed 
 for ulterior purposes ; or into effete and crystallisable matters 
 designed to become excreted from the system. 
 
 85. Of the ulterior changes of the gelatinous tissues. — Whether 
 the gelatinous tissues ordinarily undergo changes, by which 
 they are converted into materials of a higher kind, is not 
 accurately known ; but my belief is, that in a perfectly 
 healthy condition of the system they do to a certain extent. 
 Into this part of the subject, however, it does not concern us 
 at present to inquire, and I have to chiefly notice the more 
 apparent, as well, perhaps, as the more common, ulterior 
 changes to which these and the other tissues are subjected 
 during their extinction and removal from the economy. 
 
 the gelatinous, albuminous, and fibrinous tissues, in the extreme capillary 
 vessels, is probably one immediate source of animal heat. 
 
xl 
 
 INTRODUCTION. 
 
 86. From observation, and a variety of reasons whicli the 
 practical nature of this treatise prevents me froni entering on, 
 I have long been of the opinion already repeatedly alluded to, 
 that one mode in which the gelatinous tissues become effete, is 
 by their conversion into two classes of complementary principles, 
 of which urea, or its equivalent, constitutes one principle ; and 
 the saccharine principle in some of its forms, (most frequently in 
 the form of lactic acid,) the other. Both these classes of com- 
 plementary principles escape by the kidneys in their crystal- 
 lisable forms, in large quantities ; particularly the urea ; the lactic 
 acid, escapes, also, from the skin, and from other parts of the 
 body. To a certain extent, these secondary destructive assimilat- 
 ing changes, which the gelatinous tissues undergo, appear to be 
 natural ; they only become a source of mischief when they are 
 excessive, or otherwise abnormal or diseased ; e. g. when the 
 urea is converted into the carbonate of ammonia, or the sac- 
 charine principle into oxalic acid, &;c. 
 
 87. Of the ulterior changes of the albuminous principle. — The 
 ulterior changes which the albuminous tissues undergo, are 
 little understood ; I believe them, however, to be equally if 
 not more important than those changes which the gelatinous 
 tissues undergo under similar circumstances. I mean, of 
 course, in part only ; for that certain portions of the albumi- 
 nous tissues are destined, in the healthy subject, to become 
 effete, and to be removed from the system during the se- 
 condary destructive assimilating processes, there cannot be 
 a doubt ; and the question is, in what forms such effete 
 albuminous matters are eliminated from the system? In 
 reply to this question I may observe, that a great many cir- 
 cumstances, which, for the reasons above mentioned, I cannot 
 detail, have led me to the opinion, that one of the crystallis- 
 able principles thus formed from albumen during the secondary 
 destructive assimilating processes, is lithic acid, most usually 
 in the state of lithate of ammonia. The class of substances com- 
 plementary to the lithate of ammonia appear to consist of cer- 
 tain ill-defined principles, to some of which we shall have occa- 
 
SECONDARY ASSIMILATION. 
 
 xli 
 
 sion to allude in a subsequent part of this introduction. When 
 the formation of lithic acid or its compounds becomes excessive, 
 they prove a source of disease. There is reason also to believe 
 that many formidable diseases are occasionally connected with 
 the destructive mal-assimilation of the albuminous principles ; 
 from which principles various matters of a highly deleterious 
 character, and related to the poisonous principle cyanogen, as a 
 basis, may be readily supposed to be eliminated. 
 
 88. Albuminous matters differ in some respects from the gela- 
 tinous, inasmuch as gelatinous matters do not exist during the 
 primary assimilating processes. This observation is made for the 
 sake of stating, — what will be considered in the next section, — 
 that a very large proportion of the lithate of ammonia found 
 in the urine on common occasions, appears to be developed 
 from the imperfect albuminous matters formed during the 
 primary assimilating processes ; and that it is only in deep- 
 seated affections involving the whole system, that the lithate of 
 ammonia is developed during the secondary assimilation of the 
 albuminous tissues. 
 
 89. Of the ulterior changes of the oleaginous principle, we 
 know still less, perhaps, than of either of the other staminal 
 principles. The large proportion of oleaginous matter which 
 enters into the composition of the nervous mass, shows the 
 important part which oleaginous matters perform in the animal 
 economy ; and the disappearance of fat during the process of 
 hybernation, and under many other circumstances, indicates 
 that this principle is most extensively appropriated during the 
 secondary destructive assimilating processes. 
 
 90. We have already alluded to the changes which the 
 incidental mineral matters found in organised beings appear 
 to undergo during the assimilating processes both primary and 
 secondary ; and we have only to remind the reader, that the 
 presence of large quantities of these incidental matters in 
 the urine or elsewhere, must indicate unusual havoc amona; 
 the various tissues to which they respectively belong ; which 
 
xlii 
 
 INTRODUCTION. 
 
 unusual havoc is probably referable, in a great degree, to an 
 increase in the destructive processes peculiar to the secondary 
 assimilation. 
 
 Section V. 
 
 On the general pathology of the primary and secondary 
 assimilating processes. 
 
 91. Much of what we have to say on this part of the subject 
 has been already mentioned or alluded to ; we shall, therefore, 
 confine our remarks to a brief statement, chiefly by way of illus- 
 tration, of the general facts connected with this part of the 
 inquiry. 
 
 92. The reader will bear in mind that the object of the 
 primary assimilating processes is sanguification ; while the 
 object of the secondary assimilating processes is the formation 
 from the blood of the difierent organised tissues composing 
 animal bodies ; we may, therefore, conclude, that the pheno- 
 mena attending the mal-assimilation of the blood, must vary 
 considerably from the phenomena attending the mal-assimila- 
 tion of the difierent organised tissues ; and consequently, that 
 though the mal-assimilation of the blood necessarily leads to 
 the mal-assimilation of the organised tissues, the two classes 
 of affections require a separate consideration. 
 
 93. Of primary mal-assimilation. — Primary mal-assimilation 
 may occur — a. during the digestive processes taking place in the 
 stomach ; h. during the processes taking place in the duo- 
 denum ; and c. during the subsequent processes taking place 
 in the chyliferous system ; or in all these localities simul- 
 taneously. 
 
 94. a. Mal-assimilation during the digestive processes, may 
 more especially belong to the reducing, the converting, or the 
 
PATHOLOGY OF PRIMARY AND SECONDARY ASSIMILATION. xliii 
 
 vitalisiDg functions of the stomach ; and as the circumstances 
 and symptoms attending these different forms of mal-assimilation 
 are often very different, we shall briefly discuss them separately. 
 
 95. Mal-assimilation more frequently commences with de- 
 rangement of the reducing process of the stomach, than perhaps 
 with any other ; and the presence of such derangement, may in 
 general be recognised by symptoms more especially referred to 
 that organ. When any substance incapable of being reduced 
 or dissolved is taken into the stomach, even in its healthy con- 
 dition, one of the first effects produced is the secretion from 
 the stomach, of a large quantity of acid, of which the lactic acid 
 appears to constitute a chief ingredient. The immediate effects 
 of this extrication of acid are felt both locally and remotely, in 
 various ways. As far as the stomach is concerned, acidity is 
 generally indicated by uneasiness or pain, (gastralgia,) more 
 or less severe ; and by flatulence and spasm. After producing 
 more or less of suffering, the acid indigestible matters, in some 
 instances, are rejected by vomiting ; at other times, they pass 
 into the bowels, and derange the whole alimentary canal, 
 by producing diarrhoea, colic, &;c. Derangements of the re- 
 ducing process, necessarily lead to derangements of all the 
 subsequent processes ; for what is not reduced or dissolved, can 
 never be converted, much less vitalised. It becomes, therefore, 
 of the very utmost importance to organised beings, that this 
 important preliminary function should be well performed ; and 
 that aliments should be carefully adjusted to the powers of this 
 function whenever debilitated or otherwise disordered. 
 
 96. Besides being a necessary consequence of derangements 
 of the reducing function above mentioned ; derangements of 
 the converting function occasionally constitute an original 
 disease, the effects of which are still more formidable than 
 those arising from disordered reduction. Thus in diabetic 
 affections, the reducing function of the stomach seems, in some 
 instances, to be almost morbidly active ; and farinaceous (and 
 even other) matters are reduced to the condition of low sac- 
 charine matter, which the converting function of the stomach 
 
xliy 
 
 INTRODUCTION. 
 
 is incapable, as in health, of changing into the elements of chyle 
 or blood. The consequence is, that this reduced or dis- 
 solved saccharine matter is taken up with the little chyle that 
 may be formed ; and after producing various derangements in 
 its transit through the system, is ejected with the urine. 
 Again, the converting process may be wrongly performed ; the 
 saccharine matter, for instance, instead of being converted 
 into chyle, may be converted into oxalic, lactic, or other acid^ 
 and deleterious matters, which may not only produce much 
 local discomfort, but serious disorder in their subsequent pas- 
 sage through the sanguiferous system and kidneys ; or even 
 through the bowels. In these, and a variety of other 
 similar derangements, the vitalising and all subsequent pro- 
 cesses are of course suspended, as far as regards matters which 
 have thus been mal- converted. 
 
 97. But even supposing the reducing and converting func- 
 tions of the stomach to be performed, the third or vitalising 
 function may, in some instances, be suspended or otherwise 
 deranged. Thus, when more food is taken by healthy indivi- 
 duals, than is required for the purposes of the animal economy, 
 there is reason to believe, that however perfectly the super- 
 fluous portion of the aliments may, for the sake of enabling 
 them to pass through the system without producing great dis- 
 order, be dissolved and converted, the vitalising function is 
 withheld ; and that such superfluous matters are finally elicited 
 either with the bile ; or, in the form of lithate of ammonia, in 
 the urine. Of course also, as above mentioned, the vitalising 
 process never takes place in matters which have been imper- 
 fectly reduced, or mal-converted. 
 
 98. h. Primary mal-assimilation in the duodenum appears to 
 be more generally the result of mal-assimilation in the stomach, 
 than an original state of disease. At any rate we may, in the 
 first place, consider those errors taking place in the duodenum, 
 which originate more immediately from stomachic derange- 
 ments. When the reducing process in the stomach has been 
 imperfectly performed, we have stated that a large quantity of 
 
PATHOLOGY OF PRIMARY AT<ID SECONDARY ASSIMILATION. xlv 
 
 acid is not only derived from the decomposition of the salts of 
 the blood, but actually generated. The acid generated is 
 usually the lactic acid, or some other acid of a destructible 
 character, and may be either derived from the blood, or from 
 the food, or from both sources. Bnt from vrhatever source 
 derived, it is obvious, that unlike the muriatic acid derived from 
 the decomposition of common salt, it can have no equivalent of 
 alkali with which it may again combine and become neutralised 
 in the duodenum. The acid contents of the stomach, there- 
 fore, on reaching the duodenum, do not, as in health, become 
 neutral, but remain more or less acid ; which unnatural acidity 
 not only produces great uneasiness in this important part of 
 the alimentary canal ; but often excites derangement through- 
 out its whole course. Nor is this the only result ; there is 
 every reason to believe that a portion of the acid thus deve- 
 loped is absorbed with the chyle, and interferes with the due 
 completion of that important fluid. In slighter cases of a 
 temporary character, the effects pass off, and all becomes right 
 again ; but in severe and protracted cases, arising from de- 
 rangements of the digestive organs, connected with inveterate 
 constitutional diseases, or from long exposure to strong exciting 
 causes, as malaria, &c., the case is different ; and the acid and 
 unnatural matters make their way from the chyliferous system 
 into the abdominal veins ; the blood in which vessels often 
 becomes quite black, and sometimes acid. Now as this unna- 
 tural blood passes through the hepatic system, the functions of 
 the liver become disordered, and the bile, if not actually ren- 
 dered acid, at least loses its neutralising properties ; and thus 
 the mischief becomes perpetuated. An extreme case is here 
 supposed for the sake of illustration ; such, perhaps, as it 
 occurs in the remittent fevers of tropical climates only ; but 
 similar phenomena appear in an infinite variety of forms and 
 grades, as the results of mal-assimilation, in all climates. The 
 reader also is desired to observe, that for the sake of rendering 
 the illustration more distinct, one acid, the lactic acid, only is 
 spoken of ; but in conjunction with the lactic acid, under such 
 
xlvi 
 
 INTRODUCTION. 
 
 circumstances, it is to be understood that a variety of other 
 unnatural matters of a complementary character, many of them 
 of an acid, perhaps of a poisonous character, must likewise be 
 generated, and thus contribute, in various ways and degrees, 
 to aggravate the disorder ; as we shall have occasion to show 
 hereafter. 
 
 99. Of mal-assimilation peculiar to the duodenal function, we 
 do not know much of a positive character ; but if we may judge 
 from the phenomena, instances of such derangements are rare, 
 compared with those originating in the stomach and liver 
 above mentioned-^ in other words, the duodenum appears to 
 be little more than the field or arena in which the results of 
 prior derangements in the stomach, and the subsequent de- 
 rangements of the hepatic system, are conjointly displayed. 
 
 100. c. Of the nature of primary mal-assimilation in the 
 lacteal system, we can say but little ; though I believe 
 its effects are most important ; especially in the earlier 
 periods of life and adolescence, when this part of the assimilat- 
 ing processes seems to be particularly defective. We have 
 already mentioned, that when too much food is taken rela- 
 tively to the assimilating powers of the stomach, or to the 
 wants of the system, that in the healthy states of the assimilat- 
 ing organs, such superfluous matters are often reduced and 
 converted, and even perhaps partially vitalised, so as to pass 
 with the chyle into the sanguiferous system ; from whence, (not 
 having been sufliciently vitalised, or not being required,) they 
 are ejected from the system through the healthy kidney, in the 
 form of lithate of ammonia. Now, in early life, under such 
 circumstances, from some causes which I do not profess to ex- 
 plain ; but probably from causes connected with original weak- 
 ness or deficient action of the assimilating organs and of the kid- 
 neys ; or rather, in short, of the whole system ; the imperfectly 
 assimilated chyle in passing through the lacteal system, 
 either does not undergo the necessary changes by which 
 chyle is converted into blood ; or is mal-converted into 
 the comparatively insoluble pseudo-albuminous matter of 
 
PATHOLOGY OF PRIMARY AND SECONDARY ASSIMILATION. xlvH 
 
 struma; which in passing through the lungs lays the foundation 
 (perhaps at first mechanically) of tuberculous deposition, and 
 future accretion. Whether or not this be admitted, I believe 
 no one will deny who has studied the subject, that about the 
 age we are now considering, the assimilating organs in stru- 
 mous and consumptive habits are peculiarly deranged ; and 
 that great attention to diet, &c., at this age, (when diet is least 
 apt to be attended to, and all sorts of crudities are taken,) will 
 not only sometimes ward off those phthisical attacks, which, 
 when once established, will inevitably run their fatal course ; 
 but prevent many nearly allied diseases in after life.* 
 
 101. After this brief illustrative sketch of the consequences 
 of primary mal-assimilation, we proceed, in like manner, to 
 illustrate the derangements of the secondary assimilating pro- 
 cesses. 
 
 102. The reader will bear in mind that the secondary assi- 
 milating processes differ from the primary, inasmuch as all the 
 principles both produced and operated on, are fixed and limited ; 
 and that the processes are of two kinds, denominated formative 
 and destructive, i. e. consist of processes by which the princi- 
 ples of the blood are formed into the different tissues of the 
 body ; and of processes by which these tissues are again de- 
 stroyed, and either converted into other principles for future 
 purposes, or into excrementitious matters. 
 
 103. The entire suspension of the formation of the gelatinous 
 processes from the blood is probably incompatible with life ; 
 
 * Strumous, lithic acid, and gouty diseases, are all the results of mal- 
 assimilation of the albuminous principle, either primary or secondary ; 
 and often gradually run into each other. Thus gout and struma are fre- 
 quently, if not always, associated ; and the gouty chalkstones of old age 
 may be considered as little more than modifications of the scrofulous 
 tubercle of youth, both being alike formed from mal-assimilation of the al- 
 buminous principle. Moreover, the offspring of those labouring under gout 
 and struma are (other circumstancesbeing favourable) more subject, during 
 the period of adolescence, to tubercular phthisis, than other individuals. 
 Large deposites of the gouty chalkstone, in middle or advanced age, are 
 often accompanied by incipient disease of the kidnej'^s. 
 
xlviii 
 
 INTRODUCTION. 
 
 but the mal-formation and consequent imperfect developeinent 
 of gelatine seems to take place in a variety of degrees and modes. 
 Circumstances also appear to show, that destructive mal-assimi- 
 lation is equally, if not more frequent than the formative mal- 
 assimilation of the gelatinous tissues ; at least as far as regards 
 the class of derangements we are now considering. It is pro- 
 bable, however, that in all instances, both formative and de- 
 structive mal-assimilation not only of the gelatinous, but of all 
 the other tissues, takes place in a greater or less degree simulta- 
 neously. As illustrative of these remarks we may observe, that 
 during the secondary formative assimilating processes, instead 
 of gelatine, various unnatural compounds, as sugar, oxalic acid, 
 (fee, may be produced ; which may not only interfere with the 
 immediate functions of the organs affected, but with the func- 
 tions of remote organs, as the kidneys, &c., destined to remove 
 such unnatural matters. Again, during the secondary destruc- 
 tive assimilation of the gelatinous tissues, not only the same 
 unnatural matters, as well as others, derived from them, may 
 be generated ; but matters of a complementary nature, and 
 of a still more injurious character, may be produced. For in 
 complementary decomposition, it should be borne in mind, that 
 when one unnatural product is generated, another unnatural 
 complementary product must be generated likewise ; so that a 
 single error may give occasion to very complicated and for- 
 midable consequences. 
 
 104. Precisely similar remarks are applicable to secondary 
 mal-assimilation of the albumificating processes. The albu- 
 minous tissues during the secondary formative assimilating 
 processes may be unnaturally developed ; while during the se- 
 condary destructive assimilating processes, the albuminous tis- 
 sues may be imperfectly reduced and converted ; and in both 
 instances, the comj^lementary products formed must be unna- 
 tural likewise, and thus give occasion to various morbid de- 
 rangements. As instances of the unnatural matters developed 
 during the secondary mal-assimilation of the albuminous tissues ; 
 strumous matters, the gouty chalkstone, &c., may be mentioned 
 
PATHOLOGY OF PRIMARY AND SECONDARY ASSIMILATION, xlix 
 
 as developed by formative mal-assimilation ; while instead of 
 the lithate of ammonia, which seems to be naturally developed 
 during the destructive mal-assimilation of these tissues, various 
 poisonous principles having relation to the lithic acid in their 
 composition, such as the different compounds of cyanogen, 
 &c., before alluded to, are in some instances undoubtedly 
 generated, and prove the source of formidable secondary de- 
 rangements, and even of death itself. 
 
 105. With respect to the mal-assimilation, formative and de- 
 structive, of the oleaginous tissues or rather principles, I shall 
 barely remind the reader of what has been already stated, viz. 
 that they appear to be of equal, if not of greater, importance 
 to the animal economy, than even the mal-assimilation of the 
 gelatinous and albuminous tissues. 
 
 106. It remains, in concluding this part of our subject, to 
 take a brief review of the leading phenomena, for the purpose 
 of pointing out the relations and relative importance, of pri- 
 mary and secondary mal-assimilation, as displayed in their effects 
 on the animal economy. 
 
 107. Mal-assimilation, both primary and secondary, may be 
 induced by a variety of external causes, or may be inherent. 
 As an instance of induced affection, we may mention the mal- 
 assimilation resulting from the cause, whatever it may be, of 
 idiopathic fever — a cause so affecting the organic system, and 
 the primary assimilating functions in particular, that for 
 the time, these functions are sometimes entirely suspended 
 or destroyed. On the other hand, the secondary assimilating 
 functions, though perhaps imperfectly performed, nevertheless 
 proceed ; so that the body, supported in a great degree by the 
 materials of its own substance, becomes emaciated. In fevers 
 of the remittent character produced by malaria, the same phe- 
 nomena to a certain extent take place ; but, in addition, re- 
 markable derangements of the secondary assimilating processes 
 are apt to take place ; and unnatural matters, more especially 
 of an acid kind, are generated, which produce, or at least con- 
 
1 
 
 INTRODUCTION. 
 
 tribute to produce, in their turn, a variety of formidable secon- 
 dary affections, as hepatic and kidney derangements ; also 
 rheumatism, neuralgic affections, &c. 
 
 108. Derangements of the assimilating organs may arise 
 from errors in the quantity or quality of diet, and will vary 
 accordingly. When too much food is taken relatively to the 
 constitution of an individual, either the primary or secondary 
 assimilating processes, or both, may more especially suffer. In 
 some instances, the primary assimilating organs are so weak 
 and so easily deranged, that individuals are constrained to be 
 careful, both with respect to the quantity and quality of their 
 food ; and such individuals often escape the more serious and 
 deeper-seated diseases of a secondary kind, arising from excess. 
 On the other hand, there are individuals whose primary organs 
 will permit them to take with impunity enormous quantities 
 of all sorts of matters. In some of these instances, such mat- 
 ters pass off by the bowels very little assimilated ; in others, a 
 large portion of them undergo, more or less perfectly, the pri- 
 mary assimilating processes, and are carried into the mass of 
 blood ; and individuals in whom this takes place, suffer more 
 especially from derangements of the secondary assimilating 
 processes ; as from hepatic congestion, gout, &;c., particularly 
 about the middle periods of life, when the consequences of 
 excesses of all kinds begin to be manifested. With respect 
 to errors in the quality of the diet, these are so numerous and 
 varied, that it is impossible to do more than notice them 
 here, and to observe that many of the most severe and formi- 
 dable diseases, both of a particular and of an epidemic charac- 
 ter, may undoubtedly be traced to this cause. 
 
 109. Errors of the secondary assimilating processes, whether 
 induced by long derangements of the primary, or whether 
 they arise from original weakness, are manifested at different 
 periods of life, and in different individuals, not only in the 
 various modes mentioned, but in various other ways. As 
 instances we may mention, that in early life the conjunction of 
 secondary with primary mal-assimilation is most usually dis- 
 
PATHOLOGY OF PRIMARY AND SECONDARY ASSIMILATION. 11 
 
 played in the various forms of strumous affection or atrophy 
 while in middle life the same combination of derangements 
 more especially assumes the form of local congestions, hyper- 
 trophieSjf gout, &;c. Such is the case when the derange- 
 ments are of a general character, and involve the formation of 
 all the tissues of the body in a moderate degree. When the malr 
 assimilation is chiefly confined to the gelatinous tissues, the de- 
 rangements are more especially displayed in the form of certain 
 cutaneous affections, destructive suppuration, or other disease, 
 of the cellular tissues ; likewise diabetes, oxalic acid affections, 
 &;c. When the developement, &:c., of the albuminous tissues 
 is chiefly deranged, organic diseases of various kinds connected 
 with these tissues, also litliic acid gravel, &c., are usually 
 the result. Finally, when the mal-assimilation is excessive, 
 and involves the oleaginous in conjunction with the other 
 
 * Atrophy may arise from deficient or imperfect assimilation, either 
 primary or secondary, or both ; but in a great many instances it is con- 
 nected with excessive action in the secondary destructive processes, by 
 which the various tissues are removed from the body faster than they 
 are produced. This derangement of the balance between the primary 
 and secondary processes of assimilation, (which usually arises more from 
 affections of the primary than of the secondary organs,) takes place in 
 fevers and many other diseases, as stated in the text. 
 
 t Certain states of hypertrophy and of dropsy, particularly anasarca, 
 appear to be nearly related^ and to have their origin in the same cause, 
 viz. deficient or deranged action of the destructive processes of secondary 
 assimilation. Thus in hypertrophies, (by which I mean unnatural accu- 
 mulations of natural solid matters,) the secondary formative processes 
 go on uninterruptedly, while the secondary destructive processes are 
 imperfectly performed, and accumulation is the necessary consequence ; 
 so in anasarca, the exhalent (formative) process goes on as in health, 
 while the absorbent (destructive) process is imperfectly performed, and 
 accumulation, as before, takes place ; but with this accidental difference, 
 that the one is a solid, the other a fluid, accumulation. Such accumula- 
 tions, particularly of fat and of water, when of an unnatural character, 
 are often connected with deranged action or organic disease of some of 
 the great outlets by which imperfect or effete matters are removed from 
 the system ; as of the liver, kidneys, &c. On the other hand, unnatural ac- 
 cumulations of albuminous or gelatinous tissues are more frequently the 
 result of some local imperfection in the destructive processes of secondary 
 assimilation. 
 
 e 2 
 
lii 
 
 INTRODUCTION. 
 
 tissues, the consequence is usually some form of malignant or 
 incurable organic disease. 
 
 1 1 0. Lastly, in further illustration of the present part of our 
 subject, the reader may be reminded of what has already been 
 incidentally stated, — that secondary diseases depending on pri- 
 mary mal-assimilation, are in general of a much less formi- 
 dable character, than remote or secondary diseases depending 
 on secondary mal-assimilation. Thus, the occasional appear- 
 ance of sugar, oxalic acid, &;c., in the urine, as the result of the 
 introduction or developement of these matters in the stomach, 
 is of an infinitely less serious character, than the appearance of 
 sugar, oxalic acid, &c., in the urine, as the result of the secondary 
 mal-assimilation of the gelatinous tissues. In the first form of 
 these urinary derangements, except when unusually severe, the 
 derangements are confined to the stomach, &c., while the con- 
 stitutional symptoms are generally trifling; on the other hand, 
 when the sugar, oxalic acid, (fee, are produced during the 
 secondary assimilating processes, not only are the constitu- 
 tional symptoms strongly marked, but there is frequently 
 visible disorganisation of the gelatinous tissues, appearing in 
 the form of carbuncles, cutaneous diseases, &;c. Similar re- 
 marks may be made respecting the appearance in the urine of 
 the lithate of ammonia, &:c. The appearance of the lithate of 
 ammonia in the urine, as everybody knows, is one of the most 
 common attendants of slight dyspepsia from errors of diet, &;c. 
 But the lithate of ammonia appears in the urine also, when no 
 food has been taken into the stomach, and when, therefore, its 
 formation can be only referred to secondary mal-assimilation 
 of the albuminous contents of the blood, or albuminous tissues ; 
 as for instance, in certain fevers and other severe constitutional 
 diseases. It would be easy to multiply instances of this kind 
 here ; but as they more naturally fall to be considered else- 
 where, we shall merely observe in conclusion, that the prac- 
 tical utility of these principles is often of the first-rate im- 
 portance ; as, when duly understood and applied, they not only 
 furnish a means of discrimination and diagnosis among dis- 
 
BLOOD. 
 
 liii 
 
 eases, which we look for in vain from any other source ; but 
 often indicate the true principles of treatment. 
 
 Section VI. 
 
 Of the general composition and properties of the blood. 
 
 111. Having briefly described the phenomena of the primary 
 and secondary assimilating processes, we have in the next 
 place to consider their general result, as displayed in the form 
 of the blood — that important fluid by means of which, all the 
 ulterior processes of vitality are exerted, and from which the 
 corporeal frame is fabricated. 
 
 1 12. The blood, as we have seen, is derived from two sources ; 
 from the chyle, the result of the primary assimilating processes ; 
 and from the lymph, the result of the secondary assimilating 
 processes carried on all over the body. The chyle is conveyed 
 by the lacteals, the lymph by the lymphatics, (two orders of the 
 same class of vessels,) to the common thoracic duct, from 
 whence their mixed contents are discharged into the general 
 mass of blood. It would be foreign to our present purpose to 
 enter here on a formal description either of the chyle or the 
 lymph; but we shall merely observe, that the lymph has 
 usually been considered by physiologists as excrementitious, 
 an opinion to which we cannot accede. That some of the 
 materials of the lymph, as well as of the chyle, are excremen- 
 titious, we have no doubt. Very strong arguments, however, 
 may be adduced in favour of the opinion expressed in the pre- 
 ceding sections, namely, that many of the principles formed 
 during the secondary assimilating processes carried on all over 
 the body and contained in the lymph, are designed for ulterior 
 purposes of a higher order in the animal economy, than the 
 
liv 
 
 INTRODUCTION. 
 
 cruder principles conveyed by the chyle ; for which their more 
 perfectly elaborated character may be supposed to fit them. 
 The nature of this treatise, however, will not permit us to 
 detail the arguments in favour of this opinion at present ; and 
 we must refer the reader who is interested in the matter, to 
 what we have elsewhere said on the subject.* 
 
 113. Ofthehlood, — The chief constituent principles of the 
 blood, as already observed, are of an albuminous nature. The 
 albuminous matters exist principally in three forms, viz. in the 
 form of albumen, properly so called, oi fibrin, and of hcemato- 
 sine, or the red colouring- principle of the blood. Besides these 
 albuminous matters, the blood also contains minute quantities 
 of oleaginous, saline, and other principles. The proportions 
 of these ingredients are liable to variations ; their general 
 proportions are shown in the following table, which contains 
 the results, and mean, of two analyses of the blood by M. 
 
 One thousand parts of blood contain 
 
 Water 
 
 Fibrin 
 
 Albumen 
 
 Colouring- matter 
 
 T? i-i. ^ 4.* f Crystalline 
 Fatty matter j^.j^ 
 
 Extractive matter soluble in alcohol 
 Albuminate of soda 
 Muriate of soda 
 Muriate of potash 
 Carbonate 1 
 Phosphate > of soda 
 Sulphate J 
 Carbonate of lime 
 Carbonate of magnesia 
 Phosphate of lime 
 Phosphate of magnesia 
 Phosphate of iron 
 Loss 
 
 Expt. 1. 
 
 Expt. 2. 
 
 Mean of 
 two results. 
 
 780'145 
 
 785-590 
 
 782-87 
 
 2-100 
 
 3-565 
 
 2-S3 
 
 65-090 
 
 69-415 
 
 67-25 
 
 133000 
 
 119-626 
 
 126-31 
 
 2-430 
 
 4-300 
 
 3-37 
 
 1-310 
 
 2-270 
 
 1-79 
 
 1-790 
 
 1-920 
 
 1-86 
 
 1-265 
 
 2-010 
 
 1-64 
 
 8-370 
 
 7-304 
 
 7-84 
 
 2-100 
 
 1-414 
 
 1-75 
 
 2-400 
 
 2-586 
 
 2-49 
 
 1000-000 
 
 1000-000 
 
 1000-000 
 
 * Bridgewater Treatise, Book III. See also Miiller's Physiology, p. 
 155, second edition, where an attempt is made to show that the organised 
 globules found in the lymph are the globules of the blood in an incipient 
 state. 
 
BLOOD. 
 
 Iv 
 
 Lecanu, one of the most recent and accurate writers on the 
 subject.^ 
 
 114. The mean of the two results, given in the third column 
 of the preceding table, probably represents nearly the average 
 proportions of the different ingredients of the blood, in the 
 healthy state. Of these different ingredients, it may be stated^ 
 that the red particles are held in suspension only, while all the 
 other ingredients exist in solution in the watery portion of the 
 blood ;t and that several of the saline matters mentioned in 
 the table do not naturally exist in the blood at all, but are the 
 results of the analytic processes. The existence of these saline 
 matters among the analytic results, may be thus explained. 
 
 115. It has been stated, that albumen contains minute 
 quantities of sulphur, phosphorus, and other matters in inci- 
 dental union with the hydrogen, carbon, oxygen, and azote, of 
 which it is essentially composed ; and besides these incidental 
 ingredients, the hsematosine or red colouring matter of the 
 blood has also been found to contain iron. Hence Berzelius 
 thinks, with great probability, that the sulphates and phos- 
 phates obtained by incinerating the albuminous principles of 
 the blood are formed by oxidation from the sulphur, phos- 
 phorus, calcium, magnesium, and iron, which he supposes to 
 have originally existed in incidental union with the essential 
 elements of the albuminous principles, as above stated. 
 
 116. The specific gravity of human blood varies from about 
 
 * Beitrage zur Anat. Zool. und Physiol. Gott. 1831. I believe more re- 
 cent analyses of the blood have been published ; but I am not aware 
 that they materially affect the results drawn by Lecanu from his laborious 
 and valuable investigation of the blood. Those who are more particu- 
 larly interestedj are referred to Miiller's Physiology,, vol. i. p. 107, et seq. 
 (second edition ;) where everything known on the subject has been given 
 by the learned author, or by his able translator. 
 
 t I do not know whether the mode in which the fatty matter contained 
 in the blood has yet been satisfactorily ascertained. Most probably, on 
 ordinary occasions, it is associated with some of the organised principles. 
 When in great excess, it appears to be simply diffused through, and sus- 
 pended in the blood, like oil in an emulsion. 
 
Ivi 
 
 INTRODUCTION. 
 
 1-053 to 1-057. The specific gravity of the serum of the blood, 
 usually varies between 1*027 and 1*029. Hence the specific 
 gravity of the fibrin and of the red particles must considerably 
 exceed the specific gravity of the serum. The specific gravity 
 of neither of these two ingredients of the blood is accurately 
 known; but that of the red particles is undoubtedly the 
 greater of the two. 
 
 117. The little we have to say on the chemical properties of 
 the constituent principles of the blood, will be given in a future 
 section ; and the two or three physiological points more im- 
 mediately connected with the blood, may, in illustration of our 
 present inquiry, be thus briefly stated. 
 
 1 18. On looking over the preceding table, one of the most 
 obvious facts that first strikes our attention, is the conspicuous 
 place, among the constituent principles of the blood, occupied 
 by two of the great alimentary principles formerly described, viz. 
 the albuminous and the oleaginous principles ; while the third, 
 the saccharine principle, is entirely absent. Even the animal 
 (saccharine) principle gelatine, though existing abundantly in 
 various structures, is never found in the blood, nor in any product 
 of glandular secretion. The only constituent of the blood we 
 can suppose to immediately represent the saccharine alimentary 
 principle, is perhaps the lactic acid, w^hich Berzelius places 
 among the constituent principles of the blood, and of most animal 
 products soluble in alcohol. M. Lecanu, however, has not spe- 
 cified the lactic acid among the results of his analysis ; although 
 there can be little doubt that this acid, if not always present, 
 is at least very rarely absent from the blood. The lactic 
 acid in the blood may be either derived from the primary or 
 from the secondary processes of assimilation, as we have already 
 explained. 
 
 119. With reference to the present subject, it remains, in con- 
 clusion, to remind the reader of two points we have elsewhere 
 attempted to illustrate, viz. 1st, the formation of gelatine dur- 
 ing the conversion of the arterial into venous blood, and the 
 relations of the carbon, supposed to be liberated during such 
 
/ 
 
 FUNCTIONS OF THE LIVER. Ivii 
 
 conversion, to the respiratory process : and 2nclly, the dimor- 
 flious relations of albumen and fibrin ; which we suppose to 
 depend, in a certain degree, on the presence of different propor- 
 tions of combined water in these two principles — a supposition 
 which, taken in conjunction with a presumed self-repulsive 
 action among the molecules of the living fibrin, may be so> 
 applied as to offer a plausible explanation of many of the pheno- 
 mena presented by the blood ; and particularly of the pheno- 
 mena connected with its spontaneous coagulation, &c.* 
 
 Section VII. 
 
 Of the functions of the liver, and of the relation of the bile to the 
 assimilating processes. Of the composition of the bile ; and of 
 biliary concretions. 
 
 120. We have shown in the preceding sections, that the 
 conversion of the crude and dead alimentary matters into the 
 living blood during the primary assimilating processes is ac- 
 complished by a succession of important changes, some of which 
 are intelligible to us, while the nature of others is unknown. 
 What we see and know, however, are quite sufficient to show 
 us, that all these processes are conducted by, and at the ex- 
 pense of, the living animal body in which they take place ; that 
 is to say, not only the material but the immaterial agents re- 
 quired in the important processes carried on in the stomach, 
 &;c., are derived from the blood. It follows, therefore, that 
 the blood which has thus been robbed of many of its materials, 
 as well as of a portion of its vitality, becomes ill adapted for the 
 future operations of life, till it has undergone important depu- 
 
 * See Bridgewater Treatise. 
 
\ 
 
 Iviii INTRODUCTION. 
 
 ratory processes in the hepatic system. Accordingly, we find, 
 that by a peculiar arrangement, the greater portion of the 
 venous blood from the assimilating organs, before it is again 
 mixed with the arterial blood, passes through the liver, where 
 the unnatural and deteriorated matters, complementary to 
 those which had been separated in the stomach, &;c., are in 
 their turn eliminated, in conjunction with other matters, as 
 hile. In this point of view, the functions of the liver may be 
 considered as excretory only ; but that this important organ 
 performs a positive as well as a negative or excreting function, 
 there can be no doubt. In a former section, we alluded to 
 one of these functions, viz. the obvious secondary function of 
 neutralising the acid products of digestion ; but this, though 
 important, is perhaps subordinate to other secondary functions 
 performed at the same time, of which we know but little; 
 there is reason, however, to believe, that certain other biliary 
 matters are absorbed with the chyle, and perform various 
 offices, one of the most important of which seems to be more 
 especially connected with the elimination of the colouring 
 principle of the blood. With this part of the subject, how- 
 ever, we have nothing to do at present. It is sufficient for 
 our present purpose, to state that the bile, as discharged by the 
 liver, consists of principles partaking of a twofold character ; 
 viz. of principles of an assimilated and secreted kind designed 
 for ulterior purposes ; and of products of an effete and excre- 
 mentitio us character, destined for expulsion from the economy. 
 
 121. With the exact composition and nature of the bile, as 
 discharged from the liver during the digestive processes, we 
 are but imperfectly acquainted ; for the bile collected from the 
 gall-bladder and other sources, for examination, has probably 
 lost some of its im^ovtd^ni positive or active principles, and 
 consists of little more than matters destined to be excreted. 
 The composition, however, of this important fluid, even as we 
 know it, when taken in conjunction with the phenomena de- 
 tailed in the preceding sections, sufficiently bears us out in 
 what we have above advanced ; as the following statement will 
 show. 
 
BILE. 
 
 lix 
 
 122. Of the properties and composition of the bile. — The bile, 
 as we are acquainted with it, is a yellow or greenish yellow 
 fluid of a peculiar sickly odour, which has been compared to 
 that of melted fat. Its taste is bitter, and at the same time 
 sweetish, and excessively nauseous. Bile is heavier than 
 water; the specific gravity of ox bile for instance, varying ^ 
 from r026 to 1*030. Its consistence, like its specific gravity, is 
 variable, being sometimes limpid, but more commonly viscid 
 and ropy. It is generally understood to have a slight alkaline 
 reaction ; but the effects of bile on test papers are difl&cult to 
 distinguish, on account of its colour. 
 
 123. The composition of bile has been variously stated by 
 different chemists ; but they all agree in the points more 
 immediately connected with our present inquiry, viz. that the 
 essential principle (or principles) of bile contains a very large 
 proportion of carbon, and little or no azote ; and that there is 
 also present a considerable proportion of soda in some very 
 loose state of combination. The most celebrated analyses are 
 those of Thenard, Berzelius, and Tiedemann and Gmelin. We 
 shall follow Tiedemann and Gmelin's description and analysis, 
 as being on the whole, perhaps, the most satisfactory, as well 
 as one of the most recent ;^ but the results of Thenardf and 
 Berzelius, J will be incidentally mentioned. 
 
 124. The number of ingredients in the bile, according to 
 the observations of Tiedemann and Gmelin is very great. Of 
 these, several seem to be clearly allied in their properties, and 
 are, probably, only modifications of the same substance. Others 
 may be the results of the processes employed to separate them. 
 The following is an enumeration of the different ingredients 
 which, according to these chemists, exist in the bile of the ox. 
 
 125. One hundred parts of ox bile contain a variable pro- 
 
 * See Recherches experimentales, physiologiques, et chimiqiieSj, sur la 
 digestion. Par Fred. Tiedemann et Leop. Gmelin. Traduites de I'Alle- 
 mand par A. J. L. Jourdan. A Paris, 1826. Vol. i. p. 42. 
 
 t Mem. d'Arcueil, vol. i. pp. 23 and 46. 
 
 X Med. Chirurg. Transactions, vol. iii. 
 
Ix 
 
 INTRODUCTION. 
 
 portion of water : the specimen analysed contained 91*5 parts 
 of water ; the other 8'5 parts consisted of the following animal 
 matters : 
 
 Biliary resin ; cholesterine ; colouring matter ; picro- 
 mel ; biliary asparagine ; a highly azotised substance 
 little soluble in water ; an animal matter (gliadine ?) 
 insoluble in water ; a substance giving off an urinous 
 odour when burnt ; an albuminous matter, mixed 
 probably with some caseous matter ; mucus. 
 And the following saline matters : 
 
 Bicarbonate of ammonia ; margarate, oleate, acetate, 
 cholate, bicarbonate, phosphate, and sulphate of soda, 
 (with a little potash) ; muriate of soda ; phosphate of 
 lime.* 
 
 126. The proportions of these different ingredients were not 
 ascertained, and they are probably variable. The biliary resin 
 and the picromel are stated to be by far the most abundant. 
 
 127. Of the hiliary resin, cholesterine, and colouring matters. — 
 On the biliary resin seems to depend, in a great degree, the 
 sensible properties of the bile ; that is, its peculiar smell, its 
 bitter taste, and perhaps some of its colour. When pure, ac- 
 cording to Tiedemann and Gmelin, it has a pale brown colour, 
 is transparent, and is brittle and easily broken when cold. At 
 a moderate heat it softens, and may be drawn out into threads. 
 It fuses completely a little above the boiling point of water. 
 If the heat be increased, it swells up and burns with a vivid 
 flame, and yields much smoke, giving off an aromatic odour. 
 When distilled in close vessels, it yields an empyreumatic oily 
 and a very acid fluid containing barely a trace of ammonia. 
 The cholesterine (and oleic acids) may be separated from the 
 healthy bile of man and of most animals, by the action of 
 alcohol and ether, in which they are soluble. Cholesterine, 
 when pure, is a white brittle solid of a crystalline lamellated 
 structure and brilliant lustre, very much resembling sperma- 
 
 * Lecann and Casasecu have lately stated that they have detected the 
 stearic and oleic acids in human bile. Journal de Pharmacie, 12. 
 
BILE. 
 
 Ixi 
 
 ceti ; but it is distinguished from spermaceti by requiring a 
 higher temperature for its fusion, and by its not forming a soap 
 with potash. The state in which cholesterine exists in the bile is 
 not known ; but in a perfectly healthy condition of the secretion, 
 it probably exists in solution. Cholesterine forms the chief ingre- 
 dient in biliary concretions ; and is also said to be found in parts 
 unconnected with the hepatic circulation, as in various abscesses, 
 encysted tumours, &c. The colouring matter o^ the bile differs some- 
 what in different animals, but it always possesses more or less of 
 a yellow or brown tint. It is insoluble in water and alcohol, but 
 is readily dissolved by a solution of potash. The solution is at 
 first of a yellowish brown colour, but gradually acquires a green 
 tint, and the colouring matter is precipitated in green flocks by 
 muriatic acid. According to the observations of Tiedemann and 
 Gmelin, the colouring matter is influenced by the presence of 
 oxygen. The yellowish precipitate occasioned by adding mu- 
 riatic acid to bile, absorbs oxygen by exposure to air, and its 
 colour changes to green. The action of nitric acid is still more 
 remarkable. By successive additions of this acid, the tint of 
 the colouring matter may be converted into green, blue, violet, 
 and red, in the course of a few seconds. The yellow concre- 
 tions found in the gall-bladder of the ox, and so much prized 
 by painters for the beauty of their tint, is said to be composed 
 almost entirely of the colouring matter of the bile. 
 
 128. These three principles, viz. the resin of the bile, the cho- 
 lesterine, and the colouring matter, seem in some degree to be 
 allied to each other ; at least, there is reason to believe that their 
 ultimate composition is so far alike, that they contain an excess 
 of carbon relatively to their other ingredients. Of the three in- 
 gredients, however, cholesterine is the only one which, as far as 
 I know, has been examined. This I analysed many years ago, and 
 found to contain upwards of 80 per cent, of carbon. The 
 colouring matter of bile is said to contain azote, which is not 
 found either in the biliary resin or in the cholesterine. 
 
 129. Picromel. — This name was first given by Thenard to a 
 substance he separated from bile ; the taste of which, as the 
 
Ixii 
 
 INTRODUCTION. 
 
 name expresses, seems to be a compound of bitter and sweet. 
 Tiedemann and Gmelin have shown, that the bitter part of 
 the flavour is derived from a portion of adhering biliary resin 
 which Thenard had not separated ; and that when quite pure, 
 the taste of picromel is sweet, without any bitterness. Picro- 
 mel, when pure, occurs in opaque, rounded, crystalline particles, 
 and is soluble both in water and in alcohol. It contains azote ; 
 and from this and other circumstances, it seems to resemble 
 the saccharine principle formed from gelatine by sulphuric 
 acid, rather than common sugar. Picromel combines with 
 the biliary principle, and the compound is soluble in water. 
 It is found in considerable quantity in the bile of the ox ; and 
 has more recently been detected in human bile, as well as in 
 the bile of other animals. 
 
 130. Biliary asparagine was found by Tiedemann and Gmelin 
 in the bile of the ox ; but I believe it has not been found in the 
 bile of any other animal. 
 
 131. The remaining organised substances exist in bile in 
 very small quantity, and are too ill-defined to enable us to 
 form any definite notion of their properties ; that is to say, 
 whether they are necessary or accidental ingredients in its 
 composition. They probably depend upon, or at least are 
 liable to be much modified by, the food of the animal. They 
 are said to contain azote ; and one of them seems to be 
 nearly allied to the ill-defined principle termed osmazome, 
 found in all animal fluids. 
 
 132. Mucus is a constant ingredient in bile in a greater or 
 less degree, and is derived from the mucous membrane of the 
 gall-bladder, &c. 
 
 133. Of the salts of the bile. — These may be classed under 
 the heads of organised and inorganised. The organised, con- 
 sisting of acids of animal origin chiefly united to soda, are the 
 margarate, oleate, cholate, and lactate ? of soda ; of these, the 
 first three acids are probably intimately connected with the 
 cholesterine and resinous principles of the bile. The other 
 salts are of mineral origin, and are such as are usually found 
 
BILE. 
 
 Ixiii 
 
 in all excreted fluids. They will be considered more minutely 
 when we speak of the urine. The phosphate of lime was ob- 
 tained by incinerating the bile. 
 
 134. Berzelius takes a totally different view of the constitu- 
 tion of the bile from that above given. He denies that bile 
 contains any resinous principle, and regards the resin, yellow 
 matter, and picromel, of Thenard, as one and the same sub- 
 stance, to which he applies the name of biliary matter.* This 
 biliary matter is, according to him, precipitable by acids. 
 When sulphuric acid is used, and heat applied, a green mat- 
 ter is obtained, consisting of a compound of biliary matter and 
 sulphuric acid, and which somewhat resembles resin. The 
 acid may be separated by the carbonate of barytes, and the 
 biliary matter thus obtained becomes soluble in water, to which 
 it imparts its own colour and bitterness. The biliary matter, 
 according to Berzelius, contains no azote. He states that one 
 hundred parts of bile contain, 
 
 Water . _ - _ _ 90-74. 
 
 Biliary matter - 8 00 
 
 Mucus of the gall-bladder _ - _ -30 
 
 Alkalies and salts common to all animal fluids -96 
 
 100-00 
 
 135. This view of the composition of bile appears to be as 
 much too simple, as that previously given is too complicated. 
 The truth probably lies between. The experiments of Tiede- 
 mann and Gmelin, as we have seen, prove beyond a doubt that 
 the principle termed biliary matter by Berzelius, and existing 
 in different forms and degrees in the bile of all animals, is com- 
 posed at least of three ingredients, first distinctly defined by 
 Thenard, viz. biliary resin, colouring matter, and picromel, to 
 which may be added a small portion of cholesterine. The 
 other organised products stated to exist in bile by these che- 
 mists, are probably either the results of the analytic processes, 
 
 * Med. Chirurg. Trans, vol. iii. 
 
Ixiv 
 
 INTRODUCTION. 
 
 or accidentally present, and cannot, therefore, be considered as 
 essential to the bile like the above-named ingredients. 
 
 136. The general results of all the analyses of the bile, then, 
 as already stated, are — that the chief organic ingredients, in 
 their general character and composition partake of the oily 
 character, and contain, probably, at least 80 per cent, of carbon ; 
 and — that the saline contents of bile consist principally of 
 soda, which, if not in actual combination with the biliary 
 ingredients, is at least in some other very loose state of com- 
 bination. 
 
 Of hiliar^y concretions. 
 
 137. In particular states of the system connected with de- 
 rangements of the assimilating processes, and more especially 
 affecting the assimilation of the oleaginous principle, certain of 
 the biliary ingredients are either formed in excess, or in some 
 unnatural and detached condition, so that they concrete to- 
 gether into masses which often prove a secondary source of 
 excruciating suffering under the name of gall-stones. The fol- 
 lowing remarks comprise a brief description of the princi- 
 pal forms, and composition, of such biliary concretions. 
 
 138. The most frequent form of biliary concretions, consists 
 of cholesterine in different states of purity.* Concretions 
 
 * Cholesterine may be distinguished from spermaceti and most of the 
 other oleaginous products resembling it, by its high fusing point, which 
 is 278° ; and by its not being converted into a soap by caustic potash. It 
 is free from taste and odour, and insoluble in water ; but dissolves readily 
 in boiling alcohol, from which it is deposited on cooling, in white pearly 
 crystalline scales. The yellow colouring matter of bile is insoluble in alco- 
 hol, sparingly soluble in water, but readily soluble by digestion in a dilute 
 solution of potash. Hence these two most frequently associated princi- 
 ples, cholesterine and colouring matter, may be separated, either by alco- 
 hol, which dissolves the cholesterine and leaves the colouring matter; or 
 vice versa, by a solution of potash, which dissolves the colouring matter, 
 and leaves the cholesterine. 
 
GALLSTONES. 
 
 Ixv 
 
 consisting of cholesterine, unless containing an unusually large 
 proportion of colouring matters, &;c., are commonly of a yellowish 
 white or greenish colour; have a greasy, saponaceous feel, and are 
 lighter than water. When broken, they usually present more 
 or less of a crystallised, shining, and lamellated structure ; and, 
 on exposure to a candle, readily melt and burn with a brilliant 
 flame. Biliary concretions composed essentially of cholesterine 
 vary from tho size of a mustard-seed, or less, to that of 
 an egg ; and they generally contain an obvious nucleus of 
 inspissated bile or some other matters. The larger specimens 
 usually occupy the gall-bladder alone ; while in other cases, 
 instead of being collected into one or two masses, the choles- 
 terine arranges itself around innumerable centres, and forms 
 polygonal concretions of all sizes and shapes ; and this latter, 
 perhaps, is the most frequent occurrence. 
 
 139. Gallstones consisting of inspissated bile, &c., are gene- 
 rally of a dark colour, irregular shape, and free from all crys- 
 tallised appearance. They are also heavier than water ; do 
 not melt, and are not readily combustible ; and when burnt, 
 sometimes leave a considerable quantity of carbonate and phos- 
 phate of lime. This species of biliary concretion appears to be 
 subject to considerable variety in different instances. 
 
 140. Biliary concretions composed almost entirely of the 
 colouring matter of the bile are exceedingly rare in the human 
 subject. I have seen one small specimen, for which I was 
 indebted to Mr. Hutchins. The concretions found occasionally 
 in the gall-bladder of the ox are usually composed almost 
 entirely of biliary colouring matter, and have, as before stated, 
 been long in use among artists as a pigment. 
 
 141. Lastly, Mr. Taylor has recently described an unique 
 concretion, supposed to be biliary, which he found among the 
 
 The other forms of biliary concretions may be distinguished in general 
 by the properties stated. It may be remarked, however, that they are 
 seldom entirely free from the colouring matter of the bile, or even from 
 cholesterine ; and^from these circumstances their biliary origin^ in general, 
 can be readily identified and established. 
 
 / 
 
Ixvi 
 
 INTRODUCTION. 
 
 collection in the museum of the Royal College of Surgeons, 
 consisting essentially of the stearate of lime. This concretion 
 " was externally of a dirty white colour, and had the greasy 
 feel of cholesterine calculi ; it floated in water, and when ap- 
 plied to the tongue left an impression of bitterness. It was of 
 an oval figure, slightly flattened, one inch and a half in length, 
 rather better than an inch in thickness, and about an inch and 
 a quarter in breadth ; but, being broken in this direction, its 
 exact measurement could not be ascertained. It readily 
 yielded to the knife, and the cut surface presented a polished 
 appearance. Its structure was lamellar ; being composed of 
 white and reddish yellow layers, arranged concentrically, and 
 alternating with each other. The layers were easily separable. 
 At its centre there was a small vacuity. When heated before 
 the blowpipe, it readily fused, then caught fire, burning with a 
 clear flame, and giving out the smell of animal matter, but 
 nothing of a urinous character." For the details of the ana- 
 lysis we must refer to Mr. Taylor's paper.* 
 
 Section VIII. 
 
 Of the functions of the kidneys ; and of the relation of the urine 
 to the assimilating processes. Of the composition of the 
 urine ; and of urinary calculi, 
 
 142. The urine, like all the other products formed from the 
 blood, except the bile, is separated from arterial blood. The 
 renal or emulgent arteries are given off from the aorta in its 
 descent through the abdominal region, and, after comparatively 
 a very short course, enter the kidneys. In the kidneys, the 
 arteries become abruptly divided, and from their minute rami- 
 
 * London and Edinburgh Philosophical Magazme, 1840. 
 
I'UNCTIONS OF THE KIDNEYS. 
 
 Ixvii 
 
 fications on the ultimate glandular structure of the kidneys, the 
 urine is separated from the blood. The depurated blood returns 
 to the system as venous blood, by the emulgent veins ; while the 
 urine separated in different parts of the kidney is brought 
 together by an appropriate and very beautiful structure, adapted 
 for the purpose, into the common cavity or pelvis of the kid- 
 ney.* From the kidney the urine passes to the bladder, and, 
 
 * A formal description of the anatomical structure of the kidneys 
 would be misplaced here but the following results of an extensive exa- 
 mination by M. Rayer, of the varieties in the weight and si:se of the organs 
 in the two sexes^ and at different ages, &c., are not only interesting, but 
 important, as regards some of the subjects discussed in the following 
 pages. 
 
 1. That the kidneys of individuals of the same age are never exactly 
 of the same weight. 
 
 2. That immediately after birth, the developement of the kidneys, though 
 progressive, offers such differences, that in one case the weight of a kidney 
 of an infant of seventeen days old, may be strikingly less than the kidney 
 of another infant of two days old. 
 
 3. That in infancy, adult age, and in manhood, the same differences in 
 the weight of the kidney at the same age, are equally observable ; so that the 
 determination of atrophy or hypertrophy of the kidneys is not possible, 
 unless the difference in the weight of the kidneys be very remarkable. 
 
 4. That the weight of the kidneys in women, particularly in old age, is 
 less than in men. 
 
 6. That the left kidney generally weighs more than the right, at all ages.. 
 
 6. That in old age the kidneys are generally as heavy as in the prime of 
 life. 
 
 7. That when the kidney of an adult or old man, without any remark- 
 able alteration of structure, varies much from three ounces {French 
 weight,) it ought to be regarded as having a morbid or an anomalous 
 tendency ; that is, a tendency to atrophy or hypertrophy congenital or 
 accidental. 
 
 The size of the kidneys is not always proportional to their weight; 
 but, generally speaking, the kidneys attain their largest size in adult age. 
 As age advances, they usually become less in bulk, but firmer in con- 
 sistence ; so that, as above mentioned, the weight of the kidneys, at this 
 age, does not diminish in proportion to their bulk. 
 
 M. Rayer has found the size of the kidney to vary in males, between 
 eighteen and forty-five years of age, from three inches ten lines long, one 
 inch one line wide, and one inch one line in thickness; to four inches ten lines 
 long, two inches six lines wide, and one inch and nine lines in thickness, 
 {French measure.) On the contrary, in males between fifty-five and eighty 
 
 /2 
 
Ixviii 
 
 INTRODUCTION. 
 
 after a greater or less delay in this receptacle, is discharged 
 from the system, without being applied to any secondary pur- 
 pose, like the bile. The circumstances thus connected with 
 the separation of the urine from the blood have given occasion 
 to the opinion that the urine is to be viewed as an excretion ; 
 that is, as a noxious fluid, the removal of which from the system 
 is necessary to the due performance of the animal functions ; 
 nor does the accuracy of this opinion seem to admit of doubt.^ 
 
 143. The few remarks we have to offer on the functions of 
 the kidneys, and the relations of the urinary secretion to the 
 assimilating processes, will more naturally fall to be considered 
 after we have briefly described the sensible and chemical 
 properties of that secretion. 
 
 144. Description and composition of the urine. — Healthy 
 human urine, when recently voided and still warm, is a trans- 
 parent fluid of a light amber colour. At this time, it reddens 
 litmus paper ; and its odour is slightly aromatic, and somewhat 
 resembles that of violets ; but the taste is bitter and disagree- 
 able. As it cools, the aromatic odour leaves it, and gradually 
 gives place to another which is peculiar, and well known by 
 the name of urinous. In a few days the urinous odour is suc- 
 ceeded by another, which has been compared to sour milk. 
 At length, this also disappears, and is finally succeeded by a 
 fetid alkaline odour. The sensible qualities of the urine, 
 however, as well as the changes it undergoes, are subject to 
 great varieties from many causes ; such as different articles of 
 food, different diseases, &;c., as will be subsequently shown. 
 
 years of age, the variations have been between three inches six Hnes long, 
 one inch six lines wide, and one inch thick ; and four inches two lines long, 
 two inches four lines wide, and one inch and five lines thick. In females, 
 the variations have been less remarkable. — M. Rayer, Traite des Maladies 
 des Reins, vol. i. page 5, et seq. 
 
 Meckel supposed the weight of the kidney in an adult male to lie between 
 three and four ounces ; and its size to be about four inches long, two 
 inches wide, and one inch thick at its internal, and somewhat less than 
 an inch in its external part. — Meckel, J. F., Manuel d'Anatomie, general 
 et descriptive. Vol. iii. page 553. Paris, 1825. 
 
URINE. 
 
 Ixix 
 
 145. The standard quantity of urine voided by a healthy 
 individual in a given time, has been variously estimated. 
 Generally speaking, more urine is passed in winter and in 
 cold climates, than in summer and in warm climates. Besides 
 mere change of temperature, however, the quantity is liable to 
 be influenced by a variety of causes ; so that it is perhaps im- 
 possible to fix a standard universally applicable ; and every 
 individual must, to a certain extent, be measured by his own 
 standard. Haller supposed the quantity voided in twenty-four 
 hours to be as high as 49 ounces. Dr. Bostock thinks the 
 estimate of Rye more correct, who fixed the standard quantity 
 at 40 ounces. In the last edition of this work, I assumed 32 
 ounces as a fair average, taking the whole year together. If 
 we allow a little more latitude, and suppose that the quantity 
 varies in this country from 30 ounces in the summer to 40 
 ounces in the winter, we shall be probably very near the 
 truth, as regards a person in good health, and who does not 
 drink more than the simple wants of nature require. 
 
 146. Like the quantity of urine, the specific gravity^ also, is 
 liable to great variety, and has in consequence been variously 
 estimated. In the former editions of this work, the specific 
 gravity of healthy urine was stated to be between 1*010 and 
 r015. This estimate has been considered too low, and it is 
 undoubtedly lower than the specific gravity in many instances ; 
 particularly in the over-fed and dyspeptic inhabitants of large 
 towns. The late Dr. James Crawford Gregory found the 
 mean specific gravity of the urine in fifty apparently healthy 
 individuals in Edinburgh, during the months of September, 
 October, and November, at two o'clock in the day, to be 
 1-02246.^' This is probably a little too high ; and, after long 
 and repeated attention to the subject, I am of opinion that the 
 standard specific gravity of a healthy person in the prime of 
 life,, during the whole year in this country, scarcely reaches 
 r020. If, therefore, we estimate the average specific gravity 
 to range from 1*015 in the winter to 1*025 in the summer, we 
 
 * Edinburgh Medical Journal, Nos. 109 and 110. 
 
Ixx 
 
 INTRODUCTION. 
 
 shall be probably very near the truth as regards the generality 
 of well-fed individuals, who are ordinarily reputed to be in 
 good health. 
 
 147. The urine is one of the most heterogeneous fluids 
 known ; as the following elaborate analysis of Berzelius will 
 show. According to this eminent chemist — one thousand parts 
 of healthy human urine consist of 
 
 :3 . 
 
 S3 
 < 
 
 CO 
 
 a» 
 n3 
 
 a. Water 
 h. Urea 
 
 G. Lithic acid - - 
 
 ^ < Free lactic acid, lactate of ammonia, and ani-\ 
 ( mal matters not separable from them j 
 
 e. Mucus of the bladder - - - - 
 
 ^ f Sulphate of potash - - - - 
 
 \ — of soda - - _ 
 
 Phosphate of soda 
 
 of ammonia 
 
 ^ |Pho£ 
 
 f Muriate of soda 
 
 of ammonia 
 
 r Earthy phosphates, with a trace of fluate of 
 i. lime - , - . 
 
 (Silex - - 
 
 933-00 
 3010 
 100 
 
 17.14, 
 
 0- 32 
 
 3-71 
 
 3- 16 
 
 2-94 
 
 1- 65 
 
 4- 45 
 1-50 
 
 l-OO 
 •03 
 
 1000-00 
 
 148. Besides these ingredients, which appear to be essential 
 to healthy urine^ this excretion, in different diseases, has been 
 found to contain the following additional matters : 
 
 /Albumen "t^ 
 ... Fibrin > of the chyle and blood. 
 
 (^Red particles 3 
 
 r Various acids, colouring matters, &c., formed from, or accom- 
 /. -J panying the lithic acid. 
 (Nitric acid. 
 
 m. Xanthic oxide. 
 
 n. Cystic oxide. 
 
 r Sugar. 
 0. < Oxalic acid. 
 
 (^Carbonic acid. 
 
 p. Hippuric acid ? Benzoic acid ? 
 
URINE. 
 
 Ixxi 
 
 q, Prussian blue ; cyanourine. Indigo. 
 r. Bile. Cholesterine. 
 s. Secretion of the prostate gland, &c. 
 t. Pus ; and perhaps other matters. 
 
 149. On each of these principles we shall proceed to make 
 a few remarks ; and at the same time point out the relations 
 of each principle to the constituent tissues of the body, &c.,' 
 and their general pathology. 
 
 150. a. Water, as we have stated, forms the base of the 
 blood and urine, as well as of all animal fluids. When the 
 quantity of water, however, is raised or depressed above a certain 
 standard, it becomes a source of disease ; especially in the urine. 
 Thus there is sometimes a simple increase of the watery portion 
 of the urine, while the other principles remain the same, or 
 become much diminished ; as in hysteria, and in various nervous 
 affections. Sometimes, the increased flow of urine is accom- 
 panied by an increased proportion of a natural ingredient, as 
 of urea ; or of unnatural ingredients, as of albumen or sugar. 
 On the other hand, the proportion of water in the urine is not 
 unfrequently very much diminished below the natural standard, 
 as in the various forms of urinary suppression. Sometimes, 
 when the cause of this suppression is mechanical, the urine is 
 simply diminished in quantity, while its composition and other 
 qualities remain the same ; at other times, the suppression is 
 connected with deranged action of the kidneys ; and in these 
 cases, while the proportion of water is diminished, the propor- 
 tions of the other ingredients are relatively increased ; as hap- 
 pens in various forms of gravel and calculus. These opposite 
 states of the urine may be readily distinguished by the differ- 
 ences in its specific gravity. 
 
 151. h. Urea was long considered to be peculiar to the 
 urine ; but recent observations have shown that the kidney is 
 not necessary to its existence ; and that it is formed from the 
 constituents of the blood, without the agency of that organ. 
 The colour and other sensible qualities of the urine were for- 
 merly also ascribed to this principle. But Berzelius observed 
 
Ixxii 
 
 INTRODUCTION. 
 
 many years ago, that urea was colourless ;^ and in 1817 a paper 
 was published by me,t in which it was further shown that this 
 principle is not only colourless, but has no remarkable smell nor 
 taste. The following is a summary of the properties of urea : 
 
 152. Urea most commonly assumes the form of a four-sided 
 prism. Its crystals are transparent and colourless, and have 
 a slight pearly lustre. It leaves a sensation of coldness on the 
 tongue, like nitre. Its smell is faint and peculiar, hut not 
 urinous. It is neither sensibly acid nor alkaline. Urea under- 
 goes no apparent change on exposure to the air ; except in 
 very damp weather, when it slightly deliquesces ; but does not 
 seem to be decomposed. The specific gravity of its crystals 
 is about r35. It fuses at 250° into a colourless fluid ; and at 
 a higher temperature is converted into ammonia, eyanate of 
 ammonia, and dry solid cyanuric acid.J 
 
 153. Urea is soluble in its own weight of cold water; in 
 every proportion in hot water ; in 4*5 parts of cold, and in 
 about 2 parts of boiling, alcohol. From the boiling alcoholic 
 solution, as it cools, the urea separates in the crystallised form. 
 It is very sparingly, if at all, soluble in sulphuric ether, or in 
 oil of turpentine, though these fluids are rendered opake by it. 
 Urea unites with several acids, but does not neutralise them. 
 The most remarkable of these compounds are the nitrate, the 
 oxalate, the lactate, and the lithate ? of urea ; § the two first, 
 of which readily crystallise. Alkalies scarcely effect urea 
 
 * View of the Progress and present State of Animal Chemistry, p. 101. 
 t Med. Chirurg. Trans, viii. p. 529. The sentences quoted are from 
 ray paper. 
 
 [j: Turner's Elements of Chemistry, part III. page 758, edited by J. 
 Liebig and W. G. Turner ; to which work, as containing the most recent 
 expei inients of this distinguished chemist, I refer the reader. 
 
 § The nitrate of urea has been long known. The oxalate was first, I 
 believe, mentioned by myself. The lactate of urea has been recently 
 described by MM. Cap and Henry, though I long suspected its existence ; 
 but before the existence of lactic acid was fairly determined, considered 
 it as the acetate of urea. The lactate of urea is a very important com- 
 pound, as will be presently shown. 
 
URINE. 
 
 Ixxiii 
 
 at low temperatures, but, when assisted by heat, they rapidly 
 convert it (together with water) into the carbonate of ammonia. 
 
 154. Urea was first analysed by myself, about twenty-five 
 years ago ; and from its composition I was satisfied that it 
 might be formed artificially. I made numerous attempts to 
 form it, but did not succeed ; and the honour of forming the first 
 organic product artificially, is due to Wohler.* Urea is sup- 
 posed to be generated during the destructive assimilation of the 
 gelatinous tissues, and probably always exists in the blood in 
 minute quantity. In certain diseases, of the kidney, however, 
 urea exists in the blood in considerable proportions ; a fact es- 
 tablished by Dr. Christison,t and confirmed by many others. 
 
 155. There are diseases connected both with an excess and 
 a deficiency of urea in the urine, as we shall have occasion to 
 point out hereafter.J 
 
 153. c. Lithic acid, and /. its derivatives, kc. — Lithic, or 
 uric acid, as some choose to call it, is not found in the blood, 
 or, if it ever exists in that fluid, it is in very minute quantity 
 only ; but it is an invariable ingredient of healthy urine, in 
 which secretion it exists in solution at all ordinary tempera- 
 
 * See Turner's Elements of Chemistry^ above referred to. I do not 
 know where the original paper was published. 
 
 t Edinburgh Medical and Surgical Journal, 1829. When engaged in 
 examining the blood, in the year 1816, 1 found urea (or a substance having 
 most of its properties) in that fluid ; but not crediting the fact, and think- 
 ing it might be accidental, did not pursue the inquiry ; though I made a 
 memorandum of the circumstance. I also found, in 1826, a substance very 
 analogous to urea, in the blood of a person who had suffered for three days 
 from suppression of urine ; and which had been sent to me by Dr. Bright. 
 
 % For practical purposes, an excess of urea may be shown by putting 
 a little of the urine into a watch-glass, and adding to it carefully about 
 an equal quantity of pure nitric acid, in such a manner that the acid shall 
 subside to the bottom of the glass. The mixture must be kept as cool 
 as possible ; and if under these circumstances a crystallised deposite be 
 formed, an excess of urea is indicated. The degree of excess may be 
 inferred, near enough for practical purposes, by the length of time which 
 elapses before crystallisation takes place ; which may be from a few 
 minutes to two or three hours. The detection of a deficiency of urea 
 requires a more elaborate process, which will be found detailed in most 
 recent chemical treatises. 
 
Ixxiv 
 
 INTRODUCTION. 
 
 tures. In a physiological, and particularly in a pathological 
 point of view, lithic acid is, perhaps, of more importance than 
 any other principle. I shall, therefore, enter rather minutely 
 into its history under the two following heads, viz. the mode in 
 which lithic acid exists in healthy urine ; and the modifications 
 which lithic acid is capable of undergoing. 
 
 157. Of the mode in which lithic acid is held in solution in 
 healthy urine. — It has been stated that fresh human urine 
 reddens litmus paper ; and that, in consequence, this secretion 
 has been supposed to contain a free acid. With respect to 
 the nature of this presumed acid Berzelius remarks, " As by 
 the laws of chemical affinity the acids of the urine will unite 
 with any alkali that may be present and saturate themselves 
 with it in the order of the force of their respective affinities ; 
 it must follow, that when the quantity of alkali is insufficient 
 to saturate all the acids present, the weakest acids must be those 
 that will remain uncombined, and will give the urine its acid 
 properties. These, therefore, must be the lactic and the uric."^ 
 Thus it appears to be the opinion of this eminent chemist, 
 that the lithic acid exists in solution (at least in part) in 
 a free state ; and such, I believe, was formerly the general 
 opinion. This opinion, however, long ago seemed to me to be 
 very improbable, for the following reasons : First, according to 
 the analysis of Berzelius, one thousand parts of healthy urine 
 contain, in solution, one part of lithic acid ; but Dr. Henry 
 states, that one part of lithic acid requires at 60° at least 1720 
 parts of water to dissolve it. How then are we to reconcile 
 these two statements, on the supposition that lithic acid exists 
 in the urine in a free state ? Secondly, the addition of any 
 acid, even the carbonic acid, to the urine, as is well known, 
 throws down the lithic acid. How is it possible to explain 
 this fact, except on the supposition that the new acid combines 
 with something retaining the lithic acid in solution ; and that 
 the liberated lithic acid, incapable of remaining in solution, is 
 precipitated in the solid form. Thirdly, there is no instance 
 known, in which lithic acid is secreted in a free state. Birds, 
 * Med. Chirurg. Trans, iii. p. 257. 
 
URINE. 
 
 Ixxv 
 
 serpents, (fee, always secrete it in combination with ammonia ; 
 in the gouty chalkstone, lithic acid is secreted in combination 
 with soda, Sec. To suppose, therefore, that the human kidney 
 secretes lithic acid in a free state, is to suppose an exception 
 to a law which appears to be very general. Lastly, the lithate of 
 ammonia exists in large proportion in human urine ; for many 
 of the amorphous sediments consist chiefly of that compound. 
 Eeflecting on these circumstances, I was induced to make 
 some experiments which appeared to confirm the supposition 
 that healthy urine contains no uncombined lithic acid. 
 
 158. Thus with respect to the solubility of lithic acid in 
 water, I found that, when pure, about six times more water is 
 required to dissolve it than has been stated by Dr. Henry ; or 
 at least 10 "000 its own weight at 60^ ; a fact which adds much 
 to the improbability of the common opinion. On the contrary, 
 the lithate of ammonia requires only about 480 times its weight 
 at the same temperature ; and if to the solution any acid be 
 added, the lithate is immediately decomposed, and the lithic acid 
 precipitated in the solid state ; just as happens when the urine 
 is similarly treated. Further, the lithate of ammonia in a state of 
 solution reddens litmus paper ; and what is singular, and scarcely 
 would have been expected, the lithate of ammonia is likewise ca- 
 pable of existing in the same solution with the superphosphate 
 of ammonia ; which, as is well known, has likewise the property 
 of reddening litmus paper. Now, as the phosphate, or rather 
 super-phosphate of ammonia exists in healthy urine, this fact, 
 taken in conjunction with the others, enables us to account 
 very satisfactorily for the two important properties in question, 
 viz. the property of reddening litmus paper possessed by the 
 urine ; and the permanent state of solution in which the lithic 
 acid is held in solution in that secretion ; both of which proper- 
 ties appear inexplicable on the common opinion. Further, if 
 we evaporate healthy urine slowly, (as, for example, under the 
 receiver of an air-pump, with sulphuric acid,) the lithate of 
 ammonia is deposited on the sides of the vessel in abundance, 
 in the form of an amorphous sediment ; whereas, if the lithic 
 
Ixxvi INTRODUCTION. 
 
 acid existed in the urine in a free state, it should be deposited 
 in a pure crystallised form. Lastly, the supposition that the 
 lithic acid exists in the urine in the state of lithate of ammonia, 
 will enable us to throw considerable light on the phenomena 
 presented by the urine in different diseases, as will be shown 
 hereafter.^' 
 
 159. On the changes which the lithic acid is capahle of under- 
 going. — The changes which lithic acid is capable of undergoing, 
 and its analogies and relations, have been lately investigated 
 with great address by Liebig and Wohler ; and though I by 
 no means subscribe to all they have said, or think they have 
 completed the inquiry, I readily admit that they have made 
 great advances on the subject. Many of the observations of 
 these excellent chemists, respecting lithic acid, do not concern 
 us at present ; at least they cannot yet be satisfactorily applied 
 to the explanation of urinary phenomena. Those more im- 
 mediately connected with our subject are the following. 
 
 160. The phenomena to be first briefly noticed, are those 
 
 * In general I avoid all controversial points ; but it may be well to 
 notice briefly one or two other opinions regarding the solubility of lithic 
 acid in the urine. Duvernoy of Stuttgardt maintains that the lithic acid 
 is retained in solution in the urine by the colouring matter, and not by 
 ammonia ; while Wetzlar^ long before_, found that ammonia precipitates 
 the lithic acid from the urine. In answer to the first of these opinions, I 
 may say, that the lithate of ammonia, as voided by serpents, &c., is per- 
 fectly white, and nearly, if not quite, as soluble as the lithate of ammonia 
 in human urine ; the colouring matter, therefore, can have nothing to do 
 in this case with the solubility of the lithic acid. As to the observation 
 of Wetzlar, which is correct to a certain extent, those who are conversant 
 with the properties of the urine, and particularly with the relations of 
 urea, lithic acid, and the salts of ammonia, will find no difficulty in offer- 
 ing an explanation. Everybody will, I presume, admit that lithic acid 
 can combine with ammonia — in short, that there is such a compound 
 as the lithate of ammonia ; what then must be the inference with regard 
 to the experiment in question? That the colouring matters, in conjunc- 
 tion with the other principles of the urhie, exert some influence in retain- 
 ing the lithic acid in solution, I do not doubt ; but that they are the sole 
 cause of the retention of this principle in solution, I can by no means 
 admit. Some further observations will be made on this subject, when we 
 speak of the colouring matter of the urine. 
 
URINE. 
 
 Ix7vvii 
 
 produced by the action of nitric acid on lithic acid ; and, for 
 the sake of distinctness, I shall follow Liebig and Wohler. 
 When one part of dry lithic acid is added in successive por- 
 tions to four parts of nitric acid of specific gravity 1*45 to 1'5, 
 it is dissolved with effervescence, aud the production of heat. 
 The heat should be obviated, as much as possible, by placing , 
 the vessel in ice, and by adding the lithic acid slowly. Small 
 granular crystals of a strong lustre are thus formed, and 
 gradually the whole liquid is converted into a solid mass. By 
 carefully drying and re-dissolving these crystals, it will be 
 found that from a warm but not perfectly saturated solution of 
 them in water, large colourless transparent crystals containing 
 much combined water will be obtained ; or that if a hot satu- 
 rated solution be allowed to crystallise in a warm place, crystals 
 of a different shape will be formed. These last crystals, how- 
 ever differ in no respect from those previously obtained, except 
 in being anhydrous ; and they constitute the substance called 
 Erythric acid by their discoverer Brugnatelli. 
 
 161. When one part of lithic acid is added to thirty- two 
 parts of water, and to the boiling mixture dilute nitric acid is 
 added in successive portions, the lithic acid will become dissolved. 
 On evaporating the solution to two-thirds of its bulk, and per- 
 mitting the solution to stand for twenty-four hours, crystals will 
 be deposited ; which, on being purified by re-solution, will be 
 found to be nearly colourless, or of a slight yellow tint, and of quite 
 a different form and character from the erythric acid formed by 
 strong nitric acid above mentioned. Thus the erythric acid is 
 very soluble in water, has a disagreeable odour, and stains the 
 skin of a purple colour. The new crystals, on the contrary, 
 are sparingly soluble in cold water. Both the solutions, how- 
 ever, redden litmus, and have an acid reaction. The erythric 
 acid is called, by Liebig, alloxan ; the crystals formed by dilute 
 nitric acid alloxantin, for what reason I am unable to assign. 
 The alio xantin,^ according to the same chemist, differs from the 
 erythric acid by containing one more proportion of hydrogen. 
 With respect to these changes, I may remark, that I was ac- 
 
Ixxviii 
 
 INTRODUCTION. 
 
 quainted with some of them, and particularly with the different 
 forms of the crystals of erythric acid ; which I considered to de- 
 pend on the different portions of water they contained. But 
 I was not aware that two distinct substances were generaed 
 under these circumstances ; both of which were neces- 
 sary to the formation of what I termed the purp urate of am- 
 monia. The observations, however, which I have to offer on 
 these and other points connected with the present subject, would 
 be quite misplaced here ; and I shall reserve what I have to 
 say till another opportunity. It remains, therefore, only to 
 make a few remarks on the purpurate of ammonia^ (the murexid 
 of Liebig,) on account of the influence it has been supposed to 
 exert on the colours of urinary deposites. 
 
 162. The purpurate of ammonia may be formed in a variety 
 of ways pointed out by Liebig, several of which were known to 
 me ; I shall only, however, give that process which, according 
 to this chemist, illustrates its immediate composition. Liebig 
 asserts that two equivalents of purpurate of ammonia, and 
 fourteen equivalents of water, contain the elements of one 
 equivalent of erythric acid, two equivalents of alloxantin, and 
 four equivalents of ammonia. When, therefore, erythric acid, 
 alloxantin, and ammonia, are mixed together in solution in 
 these proportions, with due precautions, the purpurate of am- 
 monia is formed directly, without any excess or deficiency. 
 The following are the properties of this remarkable principle : 
 
 163. The purpurate of ammonia crystallises in short four-sided 
 prisms, two faces of which reflect a beautiful green metallic 
 lustre. They are transparent, and by transmitted light are of a 
 garnet red colour. The purpurate of ammonia is sparingly solu- 
 ble in cold, but more readily soluble in boiling water, from which 
 it is deposited in the crystallised form unchanged. The solution 
 does not possess acid or alkaline properties. As the name 
 implies, I considered this substance to be a compound of an 
 acid (purpuric acid) and ammonia.* Liebig, however, asserts 
 
 * See Philos. Trans. 1818, page 420^ where I first described this com- 
 pound. Since Liebig's opinion was published, a late writer, M. Fritzche, has 
 
URINE. 
 
 Ixxix 
 
 that it is a distinct substance, and that the principle I termed 
 purpuric acid, (which he calls murexan^ is not an acid. For a 
 very long time I have been aware that it was not the acid, as 
 it exists in the purpurate of ammonia — a circumstance that first 
 attracted my notice from observing some remarkable changes 
 it undergoes on exposure to air and moisture. For the reasons, 
 however, so often stated, I cannot enter further on the subject 
 here, and proceed to consider the pathological relations of the 
 purpurate of ammonia, — a name which for the present I 
 retain.* 
 
 endeavoured to show, that the purpurate of ammonia is really a saline 
 compound. See London and Edin. Philos. Mag. vol. xv. 491, (1839.) 
 
 * Besides the preceding substances formed from the lithic acid, M. 
 Liebig has described a variety of others, under the following extraordinary 
 names ; Alantoin, cyanuric acid, cyamelid, (or insoluble cyanuric acid) ; 
 AUoxanic acid, Mesoxalic acid, Mykomelinic acid, Parahanic acid, Oxaluric 
 acid, Thionuric acid, (containing sulphur,) Uramil, Uramilic acid, &c. 
 Some of these deserve a brief notice, as they apparently influence the 
 phenomena presented by the urine in many instances. The alantoin of 
 Liebig is the allantoic acid of Vauquelin and Buniva. It may be formed 
 artificially, together with urea and oxalic acid, by boiling lithic acid 
 with the peroxide of lead in water. It occurs naturally in the al- 
 lantoic fluid of the cow. "When urea is submitted to heat, or lithic acid 
 to the destructive distillation, the acid principle formerly termed pyr our ic 
 acid by Scheele, is formed, to which Liebig has given the name of cyanuric 
 acid. Besides cyanuric acid, there are also formed, under these circum- 
 stances, urea, cyamelid, (or insoluble of cyanuric acid,) also hydrocyanic 
 acid, a little carbonate of ammonia, and as a residue, a brown carbonace- 
 ous substance, rich in azote. These observations are quoted — first, with 
 the view of pointing out the relation between urea, lithic acid, and oxalic 
 acid, and their compounds, and which doubtless depend on the still re- 
 moter analogies between the gelatine and albumen from which they are 
 formed ; and secondly, for the sake of showing the possibility, as well as 
 the probability, that in various diseases, urea, lithic acid and oxalic acid 
 may be converted into each other. I consider, however, that such conver- 
 sions, even supposing them to exist, are to be viewed as exceptions^ rather 
 than the rule ; and that urea, lithic acid and oxalic acid are usually 
 formed, in the modes we have attempted to point out in this introduction. 
 I may remark, that as far as I can judge from their description, I was 
 previously acquainted with some of the substances above mentioned, as 
 well as others not described by Liebig; and that before I subscribe to the 
 
IXXX INTRODUCTION. 
 
 164. d. The compounds of lithic acid usually denominated 
 lateritious and pink sediments were supposed by Proust to 
 constitute a peculiar acid which he named the rosacic acid. 
 These well-known sediments have been usually found to con- 
 sist essentially of the litliate of ammonia, and sometimes of the 
 lithates of soda and of lime, in small proportions. They owe 
 their colour partly to the colouring matter of the urine, and 
 partly to the purpurate of ammonia. As this latter point, 
 however, has been controverted by Berzelius, it remains to 
 make a few remarks on the subject. 
 
 165. It is, I believe, generally admitted, that the urine 
 occasionally contains nitric acid in some unknown state of 
 combination, and I have myself found it in combination with 
 pink and lateritious sediments.* The effects of nitric acid on 
 lithic acid have been already stated ; and we have now to 
 make a few remarks on the supposed effects of nitric acid with 
 reference to the colouring matters of the urine. 
 
 166. In the last edition of this volume, I remarked that the 
 colouring matters of the urine appeared to be of two kinds, 
 one having a great affinity for the lithate of ammonia and 
 lithic acid, and imparting to them their yellow colour ; the 
 other of a less distinct or well-marked character, yet apparently 
 closely connected with the preceding in its nature and pro- 
 perties. I also remarked, that these colouring principles of 
 the urine seemed in some way to be intimately connected 
 with the formation of lithic acid ; as they were apparently 
 absent in those forms of disease in which the lithic acid was also 
 either deficient or absent ; as in serous and phosphatic urine, 
 &c. Kow, in consequence of the assertion of Berzelius and 
 othersjf that the pink and lateritious sediments of the urine do 
 
 accuracy of their analyses, such analyses must be better authenticated 
 than they are at present. I must protest also against the barbarism of 
 the terms ; particularly as I am by no means satisfied that the doctrines 
 on which they are founded, are satisfactorily established. 
 
 * Med. Ohirurg. Trans, ix. p. 481. 
 
 t See Medical Gazette, 1834. 
 
URINE. 
 
 Ixxxi 
 
 not owe their red colour to the purpurate of ammonia, I have 
 been induced to examine a little more closely into the proper- 
 ties and phenomena presented by the yellow colouring matters 
 of the urine above mentioned ; and have found that nitric acid 
 produces nearly the same effects, as regards colour, on them, 
 as it does on lithic acid itself ; at least on one of the two forms 
 of the colouring principle above mentioned, (for I still believe 
 that there are two, if not more distinct forms or modifications of 
 the yellow colouring principle of the urine, intimately related 
 to each other.) These yellow colouring principles I have 
 never been able to isolate so completely as to obtain them in 
 a state of purity ; but their properties appear to indicate that 
 they are most intimately related to lithic acid on the one hand, 
 and to some modified condition of the colouring matter of the 
 bile on the other.* Now it is remarkable, as we have stated, 
 that the colouring matter of the bile so far resembles lithic acid, 
 as to assume a purple tint by the action of nitric acid.f The 
 inference therefore is, that the red colour of the urinary sedi- 
 ments is sometimes partially due to the action of the nitric acid 
 on the yellow colouring matters of the urine — in short, that the 
 
 * Some of the yellow colouring matters of the urine appear to be so 
 intimately connected with lithic acid, that one is almost induced to be- 
 lieve that the two substances gradually run into each other. This inter- 
 mediate kind of principle seems either to possess or to exert peculiar 
 effects on the lithic acid^ so as to apparently render it more soluble in 
 the urine. Has the xanthic or lithic oxide, to be presently described, 
 anything to do with the matter ? Another colouring principle, apparently 
 connected with lithic acid, has been found in one instance by Dr. Marcet 
 in a specimen of hlack urine, and for which, from its properties, the term 
 melanic acid has been proposed. See Med. Chirurg. Trans, xii. 37. In- 
 stances oi hlack urine have been frequently alluded to by authors j and 
 indeed, a condition of the urine which would be vulgarly called hlack, is 
 not very uncommon in hysteria, as well as in other affections. I have 
 often seen the common lithate oi' ammonia sediments so deeply tinged, as 
 to appear to the eye almost black, when viewed in an opake vessel. 
 
 + See p. Ixi. Berzelius supposes the colouring and other indefinite 
 matters associated with the lactic acid to be the result of the secondary 
 destructive assimilation ; in short, that they constitute the effete debris 
 of the body. 
 
 9 
 
Ixxxii INTRODUCTION. 
 
 lateritious and pink sediments of the urine partly depend on the 
 purpurate of ammonia, or some modification of this compound, 
 and partly on the altered yellow principle of the urine ; that in 
 different instances, and in different diseases, the two red colour- 
 ing matters thus produced, are mixed in various proportions ; 
 and finally, that the one or the other colouring matter predomi- 
 nates, according to the nature of the disease.* 
 
 168. The next, and perhaps the most important, form in 
 which lithic acid appears in the urine, is that of lithic acid 
 gravel. The reader is referred to the future parts of this 
 volume for the pathology of this important form of lithic acid 
 deposite, and it only remains here, to make a few remarks on 
 the cause of the deposition of lithic acid in the free state. We 
 have already stated, that the addition of any acid, even the 
 carbonic acid, to healthy urine, will cause a deposition of the 
 lithic acid in the crystallised form — a fact clearly proving that 
 healthy urine, though it possesses an acid reaction, contains in 
 reality no uncombined acid. When, therefore, the lithic acid 
 is deposited from the urine in the crystallised form, the in- 
 ference must be, that a free acid exists in the urine ; and the 
 question is, what is the nature of this acid ? The answer, I 
 believe, to this question is, that in the great majority of in- 
 stances, the immediate cause of the precipitation of lithic acid 
 gravel is the lactic acid. In some instances, the mineral or 
 other acids may be the remote cause of the precipitation ; that 
 is, such acids may, from their stronger afiinities for the bases 
 
 » I have supposed, for the sake of distinctness, that the nitric acid is 
 the cause of the developement of the red colour ; but the red colour may 
 probably be de\^eloped both from lithic acid, and from the yellow colouring 
 matter of the urine, by other agencies acting on the same principle 
 of oxygenation, which seems in some way to be necessary to the 
 change. I may point out also another analogy between the yellow 
 colouring matter of the urine and that of the bile, namely, its property 
 of acquiring a green tint. Thus the greenish tint often exhibited by muU 
 berry calculi, and by the urine during the oxalate of lime diathesis, is 
 nothing but another form of the common yellow colouring matter of the 
 urine ; and such greenish urine will often, like certain modifications of yel- 
 low urine, immediately acquire 3 purple tint on the addition of nitric acid. 
 
URINE. 
 
 ixxxiii 
 
 present, combine with them and separate the lactic acid, which 
 may thus act immediately as the precipitant, as just stated. 
 In the greater number of instances of lithic acid gravel, how- 
 ever, the lactic acid seems to be actually secreted in excess ; 
 either separately, which is comparatively rare ; or in a state of 
 combination with urea, which seems to be the rule. Now, as 
 urea has little or no neutralising power, the lactic acid in the 
 lactate of urea exerts its acid powers, and by detaching the 
 lithic acid from its natural state of combination with ammonia, 
 precipitates it in the form of crystallised gravel. As corrobo- 
 rative of this opinion, it may be stated, that the lactate of urea 
 may be sometimes obtained in large quantities from urine de- 
 positing lithic acid gravel. This explanation also leads to the 
 explanation of another pathological fact, viz. the frequent 
 presence of sugar in urine depositing lithic acid gravel ; and 
 vice versa, the frequent appearance of lithic acid gravel in 
 slight forms of diabetic disease. The lactate of urea, and the 
 saccharate of urea, are in fact but modifications of the same sub- 
 stance, and may both be considered as the representatives of ge- 
 latine ; the lactic acid being, as we have said, only a modification 
 of the saccharine principle. Hence, by very slight variations in 
 the action of the vital affinities, the acid or the sugar may 
 predominate and give occasion to the phenomena in question. 
 These remarks are also further interesting, since they illustrate 
 certain facts mentioned in other parts of the volume, viz. that 
 the appearance of sugar in lithic acid deposites, is an unfavour- 
 able symptom ; while, on the other hand, the deposition of lithic 
 acid gravel and of the lithate of ammonia in diabetic urine may 
 be considered as favourable. In the first of these cases, a natural 
 product, the lactate of urea, has given way to an unnatural 
 product, the saccharate of urea ; while in the second, the unna- 
 tural saccharate of urea, has given way to the natural products, 
 the. lactate of urea and the lithate of ammonia, — facts showing 
 that both the gelatinous (saccharine) and albuminous matters 
 are at least partly assimilated. 
 
 169. It only remains, in concluding what we have to say 
 
 ff 2 
 
Ixxxiv 
 
 INTROD^CTIO^^ . 
 
 on lithic acid, that this principle is of albuminous origin, and 
 may be readily distinguished by the developement of the pur- 
 purate of ammonia by the action of nitric acid and heat. 
 
 170. Of the other sensible qualities of the urine arising from 
 its constituent principles, we shall only notice the peculiar smell 
 of the secretion. This has never been satisfactorily explained ; 
 but it is probably connected with some indefinable compound, 
 into which sulphur, phosphorus, and azote, largely enter. The 
 smell of the urine also, as is well known, is liable to be much 
 affected by various articles taken into the stomach, as aspara- 
 gus, turpentine, &;c. 
 
 17 1 . e. Mucus. The last substance of organic origin usually 
 existing in healthy urine, is the mucus, derived from the differ- 
 ent urinary passages, and particularly from the bladder. Mu- 
 cus, from different sources, and as modified by disease, differs 
 very considerably in its properties ; and even in its healthy 
 state and most perfect form, it must be considered as a very 
 ill-defined principle ; at least in a chemical point of view. 
 Generally speaking, mucus is insoluble in water ; though it 
 possesses the property of absorbing a large proportion of that 
 fluid ; which renders it transparent, and causes it to assume a 
 glairy appearance. Mucus also is imperfectly soluble in acetic 
 acid ; and is not coagulated by boiling. These properties suf- 
 ficiently distinguish mucus from albuminous matters. In dis- 
 eased states of the bladder, enormous quantities of mucus are 
 sometimes separated ; and in this case, the properties of the 
 secretion differ considerably from those of healthy mucus ; 
 though I am not aware at present of any chemical tests that 
 will give us much assistance in distinguishing the various 
 diseased states of mucus from each other. Mucus indeed, in 
 some forms of disease, either contains albumen, or resembles 
 the albuminous principle in its properties ; and in this case, it 
 not only becomes more soluble in acetic acid, but exhibits 
 phenomena with other tests, more or less analogous to those 
 of albumen. The appearances presented by mucus in various 
 forms of disease are such that they hardly admit of descrip- 
 
URINE. IXXXV 
 
 tion, and can be only learnt by experience. Those, however, 
 who will take the pains to study the phenomena presented 
 by mucus under different circumstances, will find the forms 
 assumed by this principle of great use in diagnosis.^* Some 
 further remarks will be made on mucus, when we come to 
 speak of pus. 
 
 172. We have next to consider the mineral incidental prin- 
 ciples and their compounds, found in the urine. 
 
 173. y. Sulphur. Sulphuric acid. Sulphates. — Sulphur exists 
 in the blood in small quantities apparently as an incidental ele- 
 ment of the albuminous principle. Sulphur appears also to 
 exist in some peculiar state of combination in the urine ; but by 
 far the greatest proportion of this principle exists in the urine 
 as sulphuric acid in combination, of course, with the alkaline 
 matter present. Sulphur formerly was not known to enter 
 into any morbid product of urinary origin ; but it has recently 
 been ascertained to form a constituent of the rare concretion 
 termed cystic oxide; to be presently described. The urine 
 seems to contain sulphur in some other form than that of sul- 
 phuric acid, in which state the greater part of the sulphur 
 exists ; but the exact nature of this state of combination is 
 unknown. The relative quantity of sulphuric acid in the urine 
 does not appear to vary so much as some of the other princi- 
 ples ; and hence it is probably but seldom the remote cause of 
 lithic acid deposites. The presence of sulphuric acid in the 
 urine, may be shown by its yielding a precipitate insoluble in 
 nitric acid, on the addition of the nitrate of barytes. 
 
 * Mixed or associated with the mucus in the urine, there may be 
 generally seen portions of the Epithelium lining- the mucous passages. 
 In certain forms of disease, this epithelium is not only much increased in 
 its quantity, but modified in its appearances, so as to present various 
 instructive phenomena. See M. Rayer, Traite des Maladies des Reins, 
 i. p. 114. The reader is also referred to the same work (1. c.) for some 
 interesting and important microscopic observations on the phenomena 
 presented by mucous and purulent matter in the urine. See plate III. of 
 this work, where the appearances assumed by the epithelium and mu- 
 cous globules are represented. 
 
Ixxxvi 
 
 INTRODUCTION. 
 
 174. g. Phosphorus. Phosphoric acid. Phosphates. — Phos- 
 phorus, like sulphur, exists in minute quantity both in the 
 blood and in the urine ; and like that substance also, is an 
 incidental element of some of the constituent principles of these 
 fluids.* Phosphoric acid exists in very small quantity in the 
 blood, if at all ; but in healthy urine it is met with, according 
 to the best analyses, in about the same proportion as sulphuric 
 acid. In a pathological point of view, phosphorus and its 
 compounds claim our attention. I am not acquainted with 
 any state of disease distinguished by the positive absence of 
 phosphorus or its compounds with oxygen ; but an apparent 
 excess of this principle, or at least of its acids, is present in 
 certain forms of disease. The acids of phosphorus, however, 
 only become formidabloj when the earthy bases, lime and mag- 
 nesia, are secreted in greater abundance than natural ; which, 
 by combining with the acid, form insoluble salts, and thus give 
 occasion to one of the most distressing species of gravel and 
 calculus. 
 
 175. In healthy urine the phosphoric, like the sulphuric 
 acid, appears to exists principally in union with soda, potash, 
 and ammonia ; and partly with magnesia and lime. From 
 
 * Phosphorus exists in singularly large proportion in the nervous mass^ 
 which of course is formed from the blood. The exact state, however, in 
 which phosphorus exists in the blood, is not known ; though its presence 
 in that fluid cannot be doubted ; unless we suppose the phosphorus to 
 be generated during the secondary formative assimilating processes. My 
 belief, however, is, that this supposition is unnecessary, and that phospho- 
 rus is derived ah externOj and exists as an incidental element in one or more 
 of the ulterior principles elaborated during the secondary formative assi- 
 milating processes ; which ulterior principles, from the relatively small 
 quantity in which they are formed, and from the circumstance of their 
 being appropriated almost as soon as produced, have hitherto escaped 
 observation. Much yet remains to be done with respect to the blood, 
 which can be only successfully accomplished by one who is thoroughly 
 versed in physiology as well as in chemistry. 
 
 Instances are on record, in which the urine has contained so much 
 phosphorus, as to render objects dipped in it luminous in the dark. See 
 Ephem. Nat. Cur. Dec. 1. Ann. vi., and vii. Obs. 193. Also Ann. de 
 Chimie, Feb. 1814. 
 
URINE. 
 
 Ixxxvii 
 
 the excess of acid generally present, however, all the salts 
 usually exist in the state of super-phosphates. Phosphoric 
 acid may be shown to exist in the urine, by its yielding, with 
 the nitrate of barytes, a precipitate soluble in nitric acid ; and 
 again precipitable from its state of solution in that acid by 
 ammonia, without decomposition. 
 
 176. Ji. Muriatic acid. Muriates, — The muriatic acid occurs' 
 both in the blood and in the urine, in combination with soda 
 and potash, which salts, therefore, appear to pass through the 
 kidneys unchanged. In combination with ammonia, muriatic 
 acid exists only in the urine. The muriatic acid and its com- 
 pounds appeared formerly to be of less importance in a patho- 
 logical point of view, than any other similar principles existing 
 in the urine ; but since it has been shown that free muriatic 
 acid exists abundantly in the stomach in certain conditions of 
 that organ, it has been inferred that this acid may occasionally 
 cause the precipitation of lithic acid in the urine. I do not 
 mean to say that the muriatic acid is ever the immediate cause 
 of the precipitation of the lithic acid. In most instances, it 
 probably acts like the sulphuric acid, &c., above mentioned, 
 viz. by liberating the weaker acids ; which are thus enabled 
 to act in their turn, and separate those having still weaker 
 affinities than themselves. Thus, in the present instance, the 
 muriatic acid may be supposed to separate the lactic, and the 
 lactic to precipitate the lithic acid, &c. 
 
 177. There is another circumstance of a negative character 
 connected with muriatic acid, which, as it seems to be important 
 as well as curious, may be here mentioned. In several instances, 
 indeed in all instances in which I formerly made the experiment, 
 I found the quantity of muriatic acid exceedingly diminished, 
 and sometimes even almost entirely wanting in the urine of 
 persons at the point of death. Now, though this circumstance 
 might unquestionably be partly referred to the diminished 
 quantity of common salt taken for some time previously, there 
 can be no doubt that the absence of muriatic acid was refer- 
 
Ixxxviii 
 
 INTRODUCTION. 
 
 able in a much greater degree to the total inactivity or anni- 
 hilation of the functions of the assimilating organs. 
 
 178. The muriatic acid may be shown to exist in the urine, 
 by the white curdy precipitate, insoluble in nitric acid, occa- 
 sioned by the addition of the nitrate of silver to the urine ; 
 after the sulphuric and phosphoric acids have been removed by 
 the nitrate of barytes or of lead. ^ 
 
 179. Soda. Potash. Ammonia. — The two fixed alkalies, as 
 before stated, exist both in the blood and in the urine. In the 
 blood they appear to occur in combination with albuminous 
 and other matters, and with lactic acid ; in the urine with the 
 sulphuric, phosphoric, muriatic, and, according to Berzelius, 
 the lactic acids. Ammonia exists only in the urine in com- 
 bination with the muriatic, phosphoric, and lithic acids. I am 
 not aware of any disease connected with a positive deficiency 
 of the alkalies in the urine ; but an excess, both of the fixed 
 and volatile alkalies is often present in that secretion. An 
 excess of the fixed alkalies, or at least of their combinations, is 
 occasionally present in the urine in certain severe organic 
 affections of the bladder, &c., and such an excess of the fixed 
 carbonated alkalies is always accompanied by an excess of the 
 carbonate of ammonia. An excess of the carbonate of ammonia 
 alone is frequently present in the urine ; and in both these 
 cases, but particularly when the fixed alkaline carbonates are 
 also in excess, the urine has an alkaline reaction at the moment 
 it is passed. This excess of the carbonated alkalies, both fixed 
 and volatile, is often connected with an excess of the earthy 
 phosphates, to be described in the next paragraph; but in 
 some severe forms of disease, the alkaline carbonates exist alone, 
 or at least without any excess of the earthy phosphatic salts. 
 The carbonate of ammonia in the urine is only another form 
 of urea, from which it is derived, either from the action of the 
 fixed alkalies, or from other causes. 
 
 * The fluoric acid has been said to exist in the urine, by Berzelius, in 
 minute quantity combined with lime ; but as far as I know, this obser- 
 vation has not been verified by any other chemist. 
 
URINE. 
 
 Ixxxix 
 
 180. i. Lime. Magnesia. Silex. — Lime and magnesia exist 
 both in the blood and in the urine ; but in very different 
 states. In the blood, they appear to enter, as incidental ele- 
 ments, into the composition of the albuminous principles ; and 
 hence cannot be obtained without combustion. In the urine, 
 they occur in the saline state, chiefly, as before observed, 
 in union with the phosphoric acid, and, according to Ber- 
 zelius, with a little fluoric acid. I am not acquainted with 
 any disease characterised by a deficiency of earthy matters in 
 the urine ; but the most distressing and dangerous form of cal- 
 culous complaints is connected with, and indeed immediately 
 arises from, their excess ; namely, the deposition of the earthy 
 phosphates. In this form of calculous disease, the earthy 
 bases seem to be deposited in much greater quantity than 
 usual ; a circumstance indicating, as we have elsewhere stated, 
 the extraordinary mal-formation or destruction of the tissues 
 to which they are incidental. At the same time, the quantity 
 of phosphoric acid seems to be relatively diminished, a circum- 
 stance not depending on a deficiency of phosphorus ; which 
 appears, like the earthy bases, to be even separated in greater 
 quantity than natural ; but on some defect in the oxygenating 
 operation of the kidneys, by which that principle is permitted 
 to pass through them unchanged. When the earthy bases 
 and phosphorus are in excess, urea is commonly at the same 
 time present in the urine in abundance, but in some unusual 
 state which renders it exceedingly prone to decomposition ; so 
 that either spontaneously, or by the reaction of the alkaline 
 and earthy matters present, it is converted into the carbonate 
 of ammonia. The ammonia precipitates the phosphate of 
 lime, and at the same time combines with the phosphate of 
 magnesia, and forms the insoluble triple phosphate. 
 
 181. Urine containing the phosphates in solution, often 
 becomes turbid on the application of heat, a circumstance with 
 which I was long acquainted, before it was publicly pointed 
 out by Mr. Brett.^ This phenomenon, before its nature was 
 
 See Med. Gazette, xvii. p. 793, &c. 
 
xc 
 
 INTRODUCTION. 
 
 ascertained, often led to mistakes ; the turbidity being ascribed 
 to the presence of albumen in the urine. 
 
 182. The phosphates of lime and magnesia may be shown to 
 exist in the urine, by the addition of ammonia. This alkali 
 precipitates the two salts together ; and in order to separate them 
 they must be removed and redissolved in dilute nitric acid ; from 
 which solution (provided the acid be not in great excess) the 
 lime may be precipitated by the addition of oxalate of am- 
 monia ; and the triple phosphate by the subsequent addition of 
 pure ammonia. The same purposes may be accomplished in 
 other modes. 
 
 183. Silex has been stated to exist in the urine, and even to 
 form urinary sediments and concretions, in some instances. I 
 have many times had silicious sand and concretions brought to 
 me as urinary products ; which, on minute examination and 
 inquiry, I have found to be distinctly of mineral origin. This 
 for a long time made me sceptical on the point ; but Dr. 
 Venables"^ and Dr. Yellowlyf have described concretions 
 containing silex. Berzelius supposes that the small quantity 
 of silex which he found in the urine was derived from the 
 water drunk. This earth may be detected by its well-known 
 refractory qualities. 
 
 184. We have, in the next place, to consider briefly the 
 unnatural and foreign substances which are occasionally found 
 in the urine. 
 
 185. k. Albumen, fibrin, and the red particles, or hcematosine, 
 which constitute the great bulk of the matters existing in the 
 blood, are never met with in healthy urine. But in various 
 diseases, the urine not only contains the serum of the blood, 
 but the fibrin and red particles likewise pass through the 
 kidneys, or are derived from other sources, so as to make their 
 appearance in the urine. In certain diseases, the albuminous 
 matters found in the urine more nearly approach those be- 
 longing to the chyle, than the blood ; as we shall have occa- 
 
 * Quarterly Journal of Science, N. S. 1829. 
 t Brande's Manual of Chemistry, ii. 645. 
 
URINE. XCi 
 
 sion to notice hereafter. In this case, the urine contains a 
 considerable quantity of the oily principles, as well as of the 
 imperfectly developed albuminous principles of the chyle. 
 These imperfect albuminous matters have been sometimes 
 confounded with casein or curd — a principle, of the existence 
 of which in the urine, I never could entirely satisfy myself.^ 
 
 186. Albuminous urine on being exposed to a temperature 
 of about 150^ becomes opake, and deposits this principle in 
 a coagulated state. The precipitated albumen varies consider- 
 ably in its appearance, in different instances. Sometimes it 
 is of a firmer and more decided character, and similar to the 
 precipitate formed by the serum of the blood more or less 
 diluted. At other times, the precipitate is very delicate and 
 fragile in its texture, and somewhat resembles curd ; in which 
 case it may be supposed to be of chylous origin. In estimating 
 these different appearances, however, the quantity of the serum 
 (i. e. the degree of dilution,) must be taken into account. In 
 most instances, particularly when the urine is alkalescent, the 
 effects of heat on albuminous urine are increased by the addition 
 of nitric acid. Indeed, for this reason, and from the phenomena 
 sometimes presented by the phosphates, which, as above ob- 
 served, are likewise precipitated by the application of heat to 
 the urine, the effect of heat should never be trusted to alone, 
 when we wish to judge of the presence of albuminous matter 
 in the urine. 
 
 187. I. Nitric acid^ and various acid and other principles de- 
 rived from the lithic acid, have been already alluded to, when 
 speaking of lithic acid ; see page Ixxx. 
 
 188. m. Xanthic oxide, (the uric, or lithic oxide, of Liebig,) was 
 first described by the late Dr. Marcet, who obtained it from a 
 small calculus consisting of this substance nearly pure. This 
 small specimen I saw and examined .with Dr. Marcet ; but 
 have never met with another specimen. Some late writers 
 
 * Some have asserted, that the albuminous principle termed Caseine oc- 
 casionally exists in the urine ; but, as stated in the text, like M. Rayer, 
 I have seen no instance of the presence of this principle in the urine. 
 
xcii 
 
 INTRODUCTION. 
 
 assert, that xanthic oxide forms a constituent of certain lithic 
 acid calculi, of a light or bright brown colour ; and which 
 exhibit a scaly shining fracture of a brown or deep flesh colour, 
 and yield a resinous lustre by friction. I cannot confirm or 
 deny this statement. 
 
 189. To obtain xanthic oxide from an urinary calculus con- 
 taining it, we are directed to dissolve it in a solution of caustic 
 potash ; and to saturate the solution with carbonic acid. The 
 xanthic oxide is precipitated white ; but, on drying, forms a 
 pale yellow mass, which acquires a waxy lustre by friction. 
 It is soluble in the pure and carbonated alkalies ; and spar- 
 ingly soluble in hot water, muriatic and oxalic acids. It forms 
 a deep yellow solution with strong sulphuric acid, and the 
 addition of water does not cause a re-precipitation. Nitric 
 acid dissolves it without effervescence, and on evaporation there 
 is left a residuum, which, instead of possessing the purple 
 colour yielded by lithic acid under similar treatment, is of a 
 lemon yellow colour — a property from which it derives its 
 name. Xanthic oxide is said by Liebig to differ from lithic 
 acid, by containing one proportion less of oxygen.* 
 
 1 90. n. Cystic oxide. — This substance is peculiar to the urine, 
 and sometimes forms whole calculi. In the form of calculus it 
 may be said to be rare ; but I have reason to believe that its 
 
 * Elements of Chemistry, by Turner and Liebig, p. 822. I feel much 
 interest in seeing the experimental results on which this assertion rests. 
 I know at present of no apparatus or means of operating, capable, when 
 azote is concerned, of unequivocally deciding about the presence or 
 absence of one proportion of hydrogen or even of oxygen in a complicated 
 body. Liebig's analytic apparatus was in effect tried by me nearly twenty 
 years ago, and for rude approximations it answers very well ; but it is not, 
 in my opinion, at all adapted for obtaining very accurate results. There 
 is another circumstance also, which makes me hesitate to receive these 
 results with confidence. I long ago settled, to my own satisfaction, by 
 numerous most careful experiments, that the combining weight of carbon 
 is neither more nor less than six ; whereas, most foreign chemists, follow- 
 ing Berzelius, make the combining weight considerably higher. Since 
 the above was in type, I observe that Dumas has proved, by a very ela- 
 borate series of experiments, that the combining weight of carbon is really 
 six, hydrogen being unity. See Comptes rendus, 17 Aout, 1840. 
 
URINE. 
 
 XClll 
 
 existence in the urine, in certain states of disease, is not a very 
 uncommon occurrence. Cystic oxide may be distinguished by 
 its solubility in alkalies and most acids ; and by the charac- 
 teristic odour it yields when burnt. It is, however, very little 
 soluble in acetic acid ; hence, when cystic oxide exists in the 
 urine, it may be readily precipitated from that fluid by vinegar.^ 
 I analysed this substance many years ago, and the analysis has 
 been lately confirmed in all respects, except that one half of 
 the matters which I estimated to he oxygen, has been proved to 
 be sulphur. I had long suspected that this curious substance 
 contained another principle besides the four usual constituents 
 of organic products ; and was about to verify my conjecture, 
 when I heard of the above discovery. I suspected the presence 
 of phosphorus rather than of sulphur. The cystic and xanthic 
 oxides are doubtless of albuminous origin. 
 
 191. 0. Sugar is not found in the blood in a state of health, 
 but has been many times distinctly recognised in the blood of 
 diabetic individuals ; where it probably always exists in a 
 greater or less degree. Sugar, also, is not a natural ingredient 
 of the urine, but is found in large quantities in that fluid, in 
 the disease just mentioned. I am not aware that sugar has 
 been ever found in the blood, or even in the urine, of any in- 
 ferior animal ; which may be considered a remarkable circum- 
 stance. The sugar of diabetic urine differs in its appearance 
 from common sugar, and approaches in its properties more 
 nearly to the low sugar of grapes. The presence of a large 
 quantity of sugar in the urine may, for the most part, be readily 
 discovered by the sweet taste it imparts to the urine ; but when 
 in small quantity, the presence of sugar is with difficulty de- 
 tected. Urine containing sugar is generally pale-coloured; 
 has a specific gravity above 1'030, and its natural ingredients 
 are often relatively much diminished in quantity. 
 
 192. Oxalic acid is neither found in the blood nor in the 
 urine in a state of health ; but in certain forms of disease 
 probably exists in both fluids. Oxalic acid is usually found as 
 
xciv 
 
 INTRODUCTION. 
 
 a urinary product in conjunction with lime, and forming the 
 oxalate of lime or mulberry concretion. The affinity of oxalic 
 acid for lime is such, that it takes this earth from all its forms 
 of solution. Hence the exact state in which the oxalic acid 
 exists in the blood, and at the first moment of its separation 
 from that fluid, is little known ; though most probably it is in 
 a state of combination either with urea or with ammonia.* 
 The oxalate of lime appears in some rare instances as gravel ; 
 sometimes as an amorphous sediment ; but most generally, as 
 above mentioned, in the form of concretions. Oxalate of lime, 
 when burnt, yields quick lime ; or if the salt be boiled with 
 an excess of sulphuric acid, the oxalic acid may be separated, 
 and thus readily distinguished by its properties. The oxalate 
 of lime also, even when newly precipitated, is insoluble in 
 acetic acid, by which property it may be readily distinguished 
 and separated from the earthy phosphates. 
 
 193. Carbonic acid was long ago stated to exist in the urine, 
 but the circumstance was called in question by Berzelius. 
 Some experiments, however, of Dr. Marcet rendered it pro- 
 bable that under certain circumstances carbonic acid exists in 
 that fluid ; and I have myself very frequently met with this 
 acid in the urine. Moreover, we stated, that the earthy 
 phosphates are sometimes held in solution by carbonic acid ; 
 and that small calculi composed of the carbonate of lime are 
 occasionally voided from the bladder. The carbonic acid in 
 the urine is probably most frequently derived from the de- 
 composition of urea, which with water, as we have stated, is 
 readily converted into the carbonate of ammonia. According 
 to some also, though others have denied the circumstance, car- 
 bonic acid occasionally passes through the system, and may be de- 
 tected in the urine of many individuals who drink freely of soda 
 
 * Oxalic acid is said to pass through the system unchanged, and to 
 occasionally appear in the urine of those who have taken freely of sorrel, 
 rhubarb, tomatoes, &c., which contain this substance. I have reason to 
 believe also, that the free use of the liquor potassce occasions the develope- 
 ment of oxalic acid in some individuals 
 
URINE. 
 
 XCV 
 
 water, &c. The existence of free carbonic acid may be sbown 
 by placing the urine under the receiver of an air-pump, with 
 lime-water, in the manner described by Dr. Marcet.^ 
 
 194. Benzoic acid, Hippuric acid. — Benzoic acid was for- 
 merly stated by Scheele to exist in the urine of children ; but 
 this statement is doubted by Berzelius ; and I think with great, 
 reason ; as I have never met with an instance of its occur- 
 rence. Liebig, moreover, has rendered it probable, that what 
 was formerly considered as benzoic acid, is in reality a new 
 acid, to which he has given the name of hippuric acid ; from its 
 abounding in the urine of the horse. The hippuric acid, how- 
 ever, is not confined to the urine of the horse, but is found in 
 the urine of many herbivorous animals, in combination with 
 soda.f Except hippuric acid exists in the urine of young 
 children, of which there is very great doubt, I am not aware 
 that it has been detected in human urine ; at least in its healthy 
 state.;}: Hippuric acid may be obtained from the urine in 
 which it exists, by adding muriatic acid to the urine after it 
 has been concentrated by evaporation. The hippuric acid is 
 separated in the form of long transparent four-sided prisms, 
 more soluble in warm water than in cold, and soluble in 
 alcohol. 
 
 195. q. Prussian blue ; Cyanourine. Indigo. — A substance 
 supposed to be Prussian blue has, in some rare instances, been 
 met with in the urine.§ Braconnot has also described a sub- 
 stance, under the name of cyanourine^ occasionally found in 
 the urine, and which sometimes tinges it blue. From its pro- 
 perties, this substance appears to be nearly allied to cer- 
 
 • Essay on Calculous Disorders, page 159, first edition, 
 t Ann. de CMmie et de Physique, xliii. page 188. 
 
 t M. Wittstock is said to have found hippuric acid in diabetic urine. 
 Has not the hippuric acid in this, as well as in the instance of children's 
 urine, been sometimes confounded with the lactate of urea, before the 
 properties of the latter compound were ascertained ? Wohler, Berze- 
 lius's Jahresb. vi. 283. 
 
 § See Nov. act. Nat. Cur. viii. obs. 21. Also Archives Gen., Mai, 1823. 
 
xcvi 
 
 INTRODUCTION. 
 
 tain vegetable blues ; and hence it may, as Mr. Rees lias ob- 
 served, be probably derived from some vegetable sulDstance 
 taken as food.* I once met with an instance in which indigo 
 vras occasionally voided in the urine, in considerable quantity. 
 The patient was a middle-aged man of a nervous temperament. 
 He was in the habit of taking Seidlitz powders ; and the indigo 
 most generally appeared in the urine, in the form of a dark 
 blue sediment, after taking one of these powders. The quan- 
 tity was so considerable on one occasion, as to allow of its 
 being collected and examined ; when it was found to possess all 
 the properties of indigo, and was obtained in a state of purity 
 by sublimation. I had expected to find it consist of Prussian 
 blue. 
 
 196. r. Bile. Cholesterine. — In certain diseases, and parti- 
 cularly in jaundice, the bile makes its way, not only into 
 the blood, but into the urine. Urine containing bile is 
 generally of a deep brownish-red colour, when in consi- 
 derable quantity, and viewed by transmitted light. But when 
 examined in small quantity, it has sometimes a yellowish- 
 green appearance. A piece of white linen is well known to 
 be stained yellow by bilious urine ; and the addition of muriatic 
 acid renders it green. This green colour sometimes appears 
 almost immediately ; sometimes not for many hours ; and in a 
 few instances, not at all. If the green precipitate occasionally 
 formed by the addition of muriatic acid ; and the yellow preci- 
 pitate sometimes occurring naturally in bilious urine, be 
 soluble in potash ; or, on being treated with nitric acid, passes 
 through the various shades of blue, violet, and pink, formerly 
 mentioned as displayed by the colouring matter of the bile, 
 the presence of that fluid in the urine is distinctly indicated. 
 In organic affections of the kidney and liver, I have oc- 
 casionally seen in the urine a crystallised fatty substance, 
 similar to that frequently met with in encysted tumours, and 
 various malignant affections, and which has been considered 
 * Rees on the Analysis of the Blood and Urine^ p. 81. 
 
URINE. 
 
 XCVll 
 
 as cliolesterine by Caventou, Breschet, Dr. Christison, and 
 others.^' Some modern chemists have asserted, that the 
 urine always contains a little oily matter, but of this I am 
 not satisfied. 
 
 197. s. Secretion of the Prostate Gland. — In certain diseases 
 of the prostate gland, or when that gland has, from any cause?' 
 been irritated, large quantities of its peculiar secretion are 
 occasionally formed and appear in the urine. This secretion 
 is sometimes but little changed ; at other times its properties 
 are considerably modified. In general, this secretion may be 
 distinguished from mucus, by its marked albuminous proper- 
 ties ; and by its peculiar appearance. This appearance, how- 
 ever, can hardly be so described as to be made intelligible to 
 those who have not attended to urinary phenomena. 
 
 198. t. Pus. — Pus occasionally appears in the urine in great 
 abundance, so as to render its presence unequivocal. When 
 present in the urine in large quantity, and unaccompanied by 
 mucus ; or when mixed with blood, pus in general may be 
 supposed to be derived from an abscess. Most frequently, 
 however, pus is accompanied by mucus. Indeed mucus and pus 
 (or something so like pus as to be with difficulty distinguished 
 from it) seem to be nearly related, and to run into each other 
 by imperceptible grades ; and when the mucus is in excess, or 
 has preceded the pus, we may almost always conclude that 
 some portion of the mucous membrane lining the urinary 
 organs is the common source of both deposites. A great deal 
 of pains has been taken to point out some chemical test which 
 may enable us to distinguish mucus from pus ; but I am not 
 acquainted with any entirely free from objection. Pus, how- 
 ever, when well marked, may be distinguished from mucus by 
 being essentially composed of particles.f Hence, when difi'used 
 
 * M. Breschet in the article " Calcul," of the Nouveau Dictionnaire de 
 Medecine. 
 
 t The subject of pus has been recently much elucidated by Mr. Gulli- 
 ver, to whose papers the reader is referred for further information on the 
 subject. 
 
 h 
 
xcviii 
 
 INTRODUCTION. 
 
 througli the urine, which it readily may be, pus, after a time, 
 again subsides to the bottom of the vessel, in the form of a 
 pale greenish-yellow pulverulent deposite ; and the urine 
 assumes its transparent character; properties by which pus 
 are strikingly contrasted with mucus. Urine containing pus 
 is also almost invariably albuminous; another property by 
 which purulent urine is contrasted with urine merely contain- 
 ing mucus. A third circumstance by which pus and mucus 
 are strongly opposed, consists in the character of the urine. 
 Urine containing pus, particularly when of low or moderate 
 specific gravity, is very often acid, and has little tendency to 
 become alkaline ; on the contrary, urine containing much 
 mucus, if not alkaline when passed, speedily becomes alkaline 
 and putrescent. Lastly, pus usually contains a little oily mat- 
 ter, which mucus does not. 
 
 199. The effects of alkalies on pus were, I believe, first 
 pointed out by Mr. Cruickshanks,"^ and these effects are occa- 
 sionally of considerable importance in a pathological point of 
 view. Thus urine containing both pus and mucus, sometimes 
 becomes alkalescent ; and the ammonia evolved converts the 
 pus into a peculiar glairy substance, which imparts to the 
 urine a ropy consistence. This phenomenon, which is not very 
 common, always denotes the presence of a purulent secretion, 
 as well as disease of a mucous membrane ; as has been recently 
 noticed by Dr. Babington.f I have, however, been acquainted 
 with the fact for many years ; which, as above stated, seems to 
 have been first pointed out by Mr. Cruickshanks. 
 
 200. Lastly, minute hairs have occasionally been found in 
 the urine. These, in many instances, have probably been de- 
 rived from some external source ; though I have repeatedly 
 seen hairs in the urine, where it was difficult to account for 
 their presence in this manner ; and once I met with detached 
 hairs in the pelvis of the kidney after death. 
 
 * Thomson's Chemistry, iv. p. 584, sixth edition, 
 t Guy's Hospital Reports, vol. iii. 
 
URINE. 
 
 XCIX 
 
 201. Besides the preceding* substances, a great many others 
 have been occasionally found in the urine, and consisting of 
 matters which had been taken by the mouth, and passed through 
 the system but little changed. Such, for instance, is the 
 hydriodate of potash, which may be detected in a very short 
 time, in the urine of those who have taken it, by the aid of a 
 solution of starch, and a few drops of nitric acid. Other saline 
 matters said to pass through the urine but little changed, are 
 the borate of soda, the alkaline carbonates, the chlorate of 
 potash, the prussiate of potash, the nitrate of potash, the 
 muriate of barytes, &c. &c. On the contrary, the mineral 
 acids, the preparations of bismuth and lead, the oxide of iron, 
 (fee, are said by Berzelius and Wohler not to pass through the 
 kidneys. Among substances of an organic origin, some pass 
 through the system readily, and appear in the urine, while others 
 are decomposed. Of substances passing more or less readily 
 through the system, may be mentioned, the gallic acid, (as in the 
 uva ursi, &c.,) also the succinic acid, the carbonic acid ? &:c. 
 According to some, the citric, malic, and tartaric acids, pass 
 through the kidneys ; but this is denied by others, and I think 
 with good reason. When combined with alkalies at least, these 
 acids are invariably decomposed in their transit through the 
 system. To the list of substances passing through the system 
 so far as to impart to the urine their peculiar odour, more or 
 less modified, may be added various essential oils and balsams, 
 as turpentine, copaiba, and many others of this class ; also the 
 aromatic and colouring principles of coffee, onions, asparagus, 
 kc. With respect to this last class of substances it may be re- 
 marked, that the phenomena take place much more readily in 
 dyspeptic, than in healthy individuals. Indeed the odour of 
 almost everything taken may be detected in the urine of 
 dyspeptic and sedentary persons ; and the circumstance may 
 be considered as invariably denoting imperfect assimilation. 
 
 202. To facilitate the recapitulation of the preceding details, 
 they may be represented in the following tabular form : 
 
 h 2 
 
c 
 
 INTRODUCTION. 
 
 TABLE, 
 
 Exhibiting a contrasted view of the relations between the prin- 
 ciples of the blood and the principles of the bile and of the 
 urine, formed either mediately or immediately from the 
 blood. 
 
 = o s .g 
 
 ><! O OQ &H PLl M o ffio 
 
 4? 5 
 
 2 S 
 
 'S c3 
 
URINE. 
 
 ci 
 
 203. Before we proceed, the reader is once more requested to 
 bear in mind, that the preceding tabular view (like the observa- 
 tions of which it is to be understood as an epitome) is intended 
 to represent the phenomena as they most generally take place ; 
 and not as they may, and perhaps do, in some instances, take 
 place — in other words, the law and not the exception. We 
 have seen that the analogical relations in composition among 
 albumen, gelatine, urea, lithic acid, lactic acid, sugar, oxalic 
 acid, (fee, are such, that sugar and oxalic acid, for instance, may 
 be formed from lithic acid as well as from urea. There is 
 greater difficulty in supposing that sugar or lactic acid may be 
 directly formed from albumen, or that lithic acid may be directly 
 formed from gela'tine ; yet these, as well as a great many other 
 anomalous conversions, may take place ; and it is to be re- 
 membered, that when such anomalous occurrences do take 
 place, the complementary principles formed must he anomalous 
 likewise, and consist of various unusual and perhaps non- 
 descript substances ; of which I think I have seen instances 
 in different diseases. There is no end, however, to exceptions ; 
 and our business here is chiefly to point out the law, from 
 which, in a great many instances, the exceptions and their 
 analogies may be easily deduced and explained. 
 
 204. The principal facts in the above tabular view may be 
 thus briefly stated. 
 
 205. The blood contains two different forms of the albu- 
 minous principle, one of which, the albumen, properly so called, 
 is converted by the secondary assimilating processes into the 
 gelatinous (or saccharine) and albuminous tissues', the other, 
 the fibrin, into the muscular tissues.* The blood also contains 
 an oleaginous principle. The other animal matters present 
 in the blood are ill-defined, and considered by Berzelius to 
 consist chiefly of the debris of the various tissues formed during 
 the secondary assimilating processes. The albuminous princi- 
 
 * There is reason to beUve, that the colouring principle of haematosine, 
 another modification of the albuminous principle, is intimately related to 
 the colouring principles both of the bile and urine. 
 
Cll 
 
 INTRODUCTION. 
 
 pies of the blood, besides the hydrogen, carbon, oxygen, and 
 azote, of which they essentially consist, contain also inciden- 
 tally, various mineral matters, of which sulphur, phosphorus, 
 iron, calcium, and magnesium, are the chief. The oleaginous 
 matters consist of carbon in large proportion, with hydrogen 
 and oxygen, but no azote. The saline matters in the blood 
 consist chiefly of common salt, with soda in some loose state 
 of combination, either with albumen, or other animal matters. 
 
 206. The hile contains very little azote ; and no principle 
 distinctly known to be analogous to albumen. The peculiar 
 biliary principles (the colouring matter, the biliary resin, and 
 the cholesterine,) contain a large proportion of carbon, and 
 consequently resemble the oleaginous principles of the blood, 
 which, therefore, they probably represent in part. The other 
 animal matters existing in the bile appear to be ill-defined, 
 and to resemble in some degree the ill-defined principles 
 found in the blood. The saline matters in the bile contain 
 relatively a larger proportion of soda than those of the blood ; 
 which soda seems to exist in union, partly with the biliary 
 principles, and partly with various acids supposed to be formed 
 from them. The biliary principles, if we except cholesterine 
 in certain forms of disease, do not crystallise, but exist in the 
 bile as first secreted, in imperfectly organised forms. 
 
 207. The urine in health contains no albuminous matters ; 
 but it contains two principles, urea and lithic acid, in both of 
 which azote is found in large proportion. The urea we sup- 
 pose to be derived from, or to represent the gelatinous, the 
 lithic acid the albuminous forms of the albuminous principle. 
 There is no oleaginous principle in the urine ; but the colour- 
 ing matter of the urine (mediately, perhaps, through the colour- 
 ing principle of the bile) seems to be partly related to the 
 oleaginous principles of the blood on the one hand, and to its 
 colouring matter on the other : neither, if we except the 
 lactic acid, does any form of the saccharine principle exist in 
 healthy urine. The saline matters of the urine differ remark- 
 ably from those of the blood and bile. The sulphur and phos- 
 
URINE. 
 
 ciii 
 
 phorus which existed in the albuminous principles of the blood 
 are converted in the urine into sulphuric and phosphoric acids. 
 So also, the calcium and magnesium found in the same princi- 
 ples, exist in the urine, as lime and magnesia. The urine 
 also contains ammonia, (derived from the decomposition of 
 urea,) which is entirely wanting in the blood. Hence the 
 number of oxidised and acidified principles found in the 
 urine, as compared with those found in the blood, is re- 
 markable, and places the functions of the kidneys in a very 
 striking point of view ; as will be shown in the following gene- 
 ral inferences from the preceding summary observations. 
 
 208. First. The liver is the organ by which the blood is 
 depurated of the unassimilated and superfluous oleaginous 
 matters ; as well as of those portions of the blood deprived of 
 its azote and vitality during the primary assimilating pro- 
 cesses. 
 
 209. Secondly. The kidneys are the organs by which the 
 blood is depurated of the unassimilated, superfluous, and effete 
 albuminous principles, as well as the mineral matters inci- 
 dental to these principles, or which are otherwise derived. 
 
 210. Thirdly. The neutral and alkalescent characters of 
 the bile, and the oxygenated and acidulous characters of the 
 urine, show that the general character of the actions going on in 
 the liver and the kidneys are directly opposed to each other — 
 in short, that the general action of the liver is of a negative, 
 the general action of the kidneys of a positive character ; and 
 that one of these two important organs thus antagonistically 
 related to each other, cannot be deranged without deranging 
 the other."^ 
 
 211. Fourthly. The liver and the kidneys (as well as certain 
 minor glandular apparatus) either in virtue of the polar arrange- 
 ments above mentioned, or of some other (vital) property, must, 
 
 * This deduction may be stated still more generally thus : — the liver 
 may be considered as the principal focus or pole of all the negative, the 
 kidneys as the principal focus or pole of all the positive, actions going on 
 throughout the organic system. 
 
civ 
 
 INTRODUCTION. 
 
 in a state of health, possess the function of selecting from the blood 
 those peculiar principles adapted for their respective opera- 
 tions ; and of producing such farther changes in them as the 
 animal economy may require. The changes produced by the 
 liver on the principles to be eliminated by that gland, are in 
 some degree of an organising kind ; that is, the principles se- 
 parated retain some of their vitality for ulterior purposes ; while 
 the changes produced by the kidneys on the principles designed 
 to be removed from the system by these glands, are, in a state of 
 health, without exception, of a disorganising kind — that is, 
 everything passed from the kidneys is denuded of its vitality, 
 which is carefully retained as it were in the system. The liver, 
 therefore, may be said to possess an organising, the kidneys a 
 disorganising function. This deduction is illustrated by what 
 takes place in diseases of the liver and kidneys. Thus, 
 when the liver is diseased, its selecting and organising func- 
 tions are impaired or lost ; and instead of selecting, and 
 further changing into bile those principles, which the welfare 
 of the economy requires should be removed from the blood and 
 employed elsewhere, such principles are retained in the sys- 
 tem ; or if they do pass through the liver and are separated by 
 that organ, they are imperfectly adapted for their ulterior func- 
 tions ; and thus in both ways great derangements of the health 
 are the consequence. Again, when the kidneys are diseased, 
 their selecting and disorganising functions are impaired or 
 lost; and the deleterious principles in the blood, (e. g. the urea,) 
 are no longer selected in preference for separation from that 
 fluid ; while the superfluous or effete albuminous principles, 
 which in the healthy kidney would have been selected and 
 converted into the lithate of ammonia, either remain in the 
 blood, or pass through the kidneys unchanged. 
 
 212. These inferences, duly understood and applied, will ex- 
 plain a great many of the phenomena of animal bodies, both in 
 health and disease ; as we shall have occasion to show in the 
 following pages; where many of them will be strikingly illus- 
 trated. 
 
URINARY CALCULI. 
 
 CV 
 
 Of Urinary Calculi. 
 
 213. It remains, in the last place, to describe briefly the 
 different forms assumed by urinary concretions. 
 
 214. From various causes to be elsewhere considered, the 
 principles described in the preceding section, as existing in 
 the urine, in health and in disease, concrete together into solid 
 masses, and form what are denominated urinary calculi. Uri- 
 nary calculi vary much in their appearances and chemical 
 composition ; but the more important varieties may be com- 
 prised under the following species : 
 
 a. The Uthic acid calculus. 
 
 h. The lithate of ammonia calculus. 
 
 c. The oxalate of lime calculus. 
 
 d. The cystic oxide calculus. 
 
 e. The hone earth, or phosphate of lime calculus. 
 
 f. The triple phosphate of magnesia and ammonia calculus. 
 
 g. The fusible calculus ; or the calculus composed of a mixture 
 of the phosphate of lime and of the triple phosphate of magnesia 
 and ammonia. 
 
 h. The alternating calculus {comprising numerous varieties.) 
 
 i. The mixed calculus. 
 
 h. The carbonate of lime calculus. 
 I. The xanthic oxide calculus, 
 m. The fibrinous calculus, 
 n. The prostatal calculus. 
 
 215. a. Thelithic acid calculus is generally of a brownish-red 
 or fawn colour ; but occasionally approaches the colour of ma- 
 tt. Chemical properties. — Before the blow-pipe, the lithic acid calculus 
 
 blackens, emits a smoke having a peculiar odour, and is gradually con- 
 sumed, leavhig a minute quantity of white ashes, which are usually alka- 
 
cvi 
 
 INTRODUCTION. 
 
 hogany. Its surface is commonly smooth ; but sometimes finely 
 tuberculated ; and on being divided, it is usually found to con- 
 sist of concentric laminae. Its fracture generally exhibits an 
 imperfectly crystallised texture ; and in this case it is nearly 
 pure ; at other times, the fracture is earthy or amorphous, 
 when it usually contains a mixture of other ingredients. The 
 lithic acid is the most common species of calculus, and occurs 
 of all sizes, from a grain or two to five or six ounces, or more. 
 Its shape also is very various ; but in general it is more or less 
 ovoid. 
 
 216. h. The lithate of ammonia calculus is generally of a clay 
 colour. Its surface is sometimes smooth, sometimes slightly 
 tuberculated. It is composed of concentric layers, and its 
 fracture is very fine earthy, resembling that of compact lime- 
 stone. This form of calculus seems to be principally confined 
 to children under puberty, and hence is generally of small size 
 and rather rare.* It often contains a mixture of other mat- 
 ters in various proportions, and particularly of the oxalate and 
 lithate of lime, and small quantities of the phosphates. 
 
 217. c. The oxalate of lime or mulberry calculus, is generally 
 of a deep-brown colour, sometimes approaching to very dark 
 olive-green or black. Its surface is very rough and tubercu- 
 
 line. Lithic acid is completely soluble in a solution of caustic potash^ 
 from which it may be precipitated again by any acid^ in the form of a 
 white granular powder. Lastly^ if to a small particle a drop of nitric 
 acid be added, and heat applied, the lithic acid is dissolved ; and if the 
 solution be evaporated to dryness, the residue assumes a beautiful pink 
 or carmine colour. 
 
 b. Chemical characters. — The lithate of ammonia in many of its pro- 
 perties resembles the lithic acid calculus. Before the blow-pipe, how- 
 ever, it frequently decrepitates, particularly when mixed with other 
 matters. It is much more soluble in water than the lithic acid calculus, 
 and always yields a strong smell of ammonia when heated with caustic 
 potash. The lithate of ammonia is also readily soluble in the alkaline 
 subcarbonates. 
 
 * Med. Chirurg. Trans, vol. x. page 389. 
 
 c. Chemical characters. — Before the blow-pipe, this species of calculus 
 expands into a kind of white efflorescence, which when moistened and 
 brought into contact with turmeric paper, stains it red. This white 
 
URINARY CALCULI. 
 
 cvii 
 
 lated, (hence the epithet mulberry.) It is usually hard, and, 
 when divided, exhibits a more or less perfectly laminated tex- 
 ture. This species of calculus seldom surpasses the middle 
 size, and is rather common. There is a variety of it remark- 
 ably smooth and pale-coloured, and usually containing a mix- 
 ture of the lithate of ammonia. Such calculi are always of small 
 size ; and, from their colour and general appearance, have been 
 termed the hempseed calculus. There is also another variety, 
 consisting of the oxalate of lime nearly pure, and in a crystal- 
 lised form. This variety, which is not common, is very 
 rough ; and usually presents numerous sharp angular facets. 
 Its colour varies, but is occasionally quite white. 
 
 218. d. Tlie cystic oxide calculus is of a yellowish white colour, 
 and its surface, which is commonly smooth, exhibits a kind of 
 crystallised appearance. When broken, it is found not to con- 
 sist of distinct laminae, but appears as one mass confusedly 
 crystallised throughout its substance. The fracture exhibits a 
 peculiar glistening lustre like that of a body having a high re- 
 fractive density ; and when in small fragments, it is semi-trans- 
 parent. This calculus is small; or seldom surpasses the medium 
 size ; and is very rare. 
 
 219. e. The bone earth or phosphate of lime calculus is gene- 
 rallyof a pale-brown colour, and its surface is frequently smooth 
 like porcelain, so as to appear highly polished. When sawn 
 through, it is found very regularly laminated, and the laminae 
 easily separate from each other. These laminae are often 
 
 alkaline substance is the caustic lime of the calculus^ deprived of its oxalic 
 acid. The oxalate of lime may be also distinguished from the phosphates^, 
 by being nearly insoluble in acetic acid^ even when newly precipitated. 
 
 d. Chemical characters. — This calculus yields a very peculiar and cha- 
 racteristic odour when exposed to the flame of a blow-pipe. It is also 
 very readily soluble both in acids and alkalies. 
 
 e. Chemical properties. — This species of calculus differs in its properties 
 according to the proportions of its constituent principles. In general^ it 
 fuses with difficulty, or is quite infusible, before the ordinary blow-pipe. 
 It is readily dissolved by muriatic acid, and reprecipitated from its state 
 of solution by pure ammonia, without decomposition, most usually in the 
 feirm of a white uncrystallised powder. 
 
cviii 
 
 INTRODUCTION. 
 
 striated in a direction perpendicular to the surface ; as from an 
 assemblage of fibres. This species of calculus has not hitherto 
 been observed of large size, and is not common. It seems 
 also to be more usually formed in cysts or cavities, than of 
 urinary origin. 
 
 220. f. The triple phosphate of magnesia aud ammonia calculus 
 is always nearly white ; its surface is commonly uneven, and 
 covered with minute shining crystals. Its texture is not lami-' 
 nated ; and it is easily broken and reduced to powder. In 
 some rare instances, however, it is hard and compact ; and 
 when broken, exhibits a crystallised texture, and is more or 
 less transparent and laminated. Calculi composed entirely 
 of the triple phosphate of magnesia and ammonia, are unusual ; 
 but specimens in which this salt constitutes the predominant 
 ingredient are very common. 
 
 221. g. The calculus composed of a mixture of the phosphate of 
 lime, and the triple phosphate of magnesia and ammonia, or the 
 fusible calculus, is commonly whiter and more friable than any 
 other species ; and sometimes leaves a white dust on the fin- 
 gers, like a mass of chalk. This species is usually not lami- 
 nated. Occasionally, however, the mass of the calculus readily 
 separates into thin laminse, the interstices of which are often 
 studded with sparkling crystals of the triple phosphate. The 
 variety of this species which is not laminated often acquires a 
 very large size, and assumes the form of a friable white mass, 
 
 /. Chemical properties. — Before the heat of the blow-pipe this calculus 
 gives off the odour of ammonia, and at length melts with difficulty. It 
 also gives off ammonia when treated with caustic potash. It is much 
 more soluble than the preceding species in dilute acids, from which 
 it is again readily precipitated by ammonia in its original crystallised 
 form. 
 
 g. Chemical properties. — This species of calculus readily melts before the 
 blow-pipe, and hence the e\>\i\\et— fusible calculus. It also dissolves 
 readily in acids, and particularly in dilute muriatic acid ; and if to the 
 solution (not too acid) the oxalate of ammonia be added, the lime is pre- 
 cipitated alone ; and the magnesia may be afterAvards separated by the 
 addition of pure ammonia. This calculus almost always contains, besides 
 the mixed phosphates, a little carbonate of lime and animal matter. 
 
URINARY CALCULI. 
 
 cix 
 
 evidently moulded to the contracted cavity of the bladder, or 
 other part in which it has been formed. This species of cal- 
 culus occurs very frequently. 
 
 222. h. The alternating calculus, as the name imports, may 
 consist of different layers of any of the preceding species. Hence 
 its general appearance, texture, &;c., will depend entirely or 
 its composition ; and may be very various. Most commonly 
 the alternating calculus consists of a nucleus of lithic acid, 
 lithate of ammonia, or oxalate of lime ; (or a mixture of all 
 three of these substances, as well as of the lithate of lime, and 
 other matters,) and an external crust of the fusible calculus. 
 In some instances, the alternating calculus may consist of three 
 or more laminae of these and other substances — the mixed 
 phosphates still continuing to constitute the external crust. 
 This species of calculus often attains a large size, and is very 
 common. 
 
 223. i. Mixed calculi are generally of small size, and are 
 most frequently found in early life ; hence they constitute the 
 
 h. Chemical characters. — The chemical characters of the alternating- 
 calculus of course vary with the composition; and as the different 
 substances must be some of the simple substances before described, the 
 nature of the different laminae can be readily ascertained from what has 
 been already stated. 
 
 «. Chemical properties. — The characters of mixed calculi of course are 
 of an ambiguous nature, and will vary with their composition. The fol- 
 lowing brief summary will enable us to detect the composition of the 
 most frequent varieties. 
 
 Mixtures of the lithate of ammonia, oxalate of lime, and the phosphates, 
 may be thus detected and separated. Boil the powdered calculi in dis- 
 tilled water. This takes up the lithate of ammonia, and leaves the oxalate 
 of lime and phosphates. The residuum may be then treated by acetic 
 acid, which takes up the phosphates, and leaves the oxalate of lime- If 
 to the solution in acetic acid the oxalate of ammonia be added, the lime 
 (of the phosphate) will be precipitated in the form of the oxalate of lime ; 
 and finally by the addition of ammonia to the solution thus freed of its 
 lime, the triple phosphate of magnesia and ammonia may be obtained. 
 
 Mixtures of the lithate and oxalate of lime may be thus detected and 
 separated. Boil the mixture in dilute muriatic acid, which decomposes 
 the lithate of lime, dissolves the lime and oxalate of lime, and leaves the 
 lithic acid. Add ammonia to the solution, which precipitates the oxalate 
 
cx 
 
 INTRODUCTION. 
 
 nuclei of other calculi. The mixture may consist, as just stated, 
 of the lithic acid, the lithates of ammonia and of lime, oxa- 
 late of lime, and sometimes the mixed phosphates. Their sen- 
 sible properties of course will vary with their composition ; but 
 usually mixed calculi assume more or less of the characters of 
 the predominant ingredient, which, generally speaking, may be 
 considered as either the lithate of ammonia, or the oxalate of 
 lime. In one sense of the term, all calculi may be said to be 
 mixed; but calculi of considerable magnitude, and consisting 
 of a mixture of pure ingredients in large proportions, as of 
 pure lithic acid, with the phosphates, &;c., are very unusual, or 
 rather do not exist ; at least I have seen no such calculi. 
 
 224. k. Carbonate of lime calculus. — I have seen some small 
 calculi composed almost entirely of this salt. They were per- 
 fectly white, and very friable. Mr. Smith has described others 
 which closely resembled in appearance the mulberry calculus.* 
 This species of calculus is very uncommon ; though, as we have 
 stated, the carbonate of lime is frequently found in small pro- 
 portions in phosphatic calculi. 
 
 225. I. The xanthic oxide calculus has been already de- 
 scribed.f I have never seen any other specimen than that 
 noticed by Dr. Marcet; though, as formerly stated, this 
 principle has been recognised in mixture with lithic acid in 
 some instances. 
 
 226. m. The fibrinous calculus, first described by Dr. Marcet, 
 has all the properties of the fibrin of the blood, of which it 
 undoubtedly consists.^ Such concretions, of which I have seen 
 
 of lime; while the remaining lime maybe finally precipitated by the 
 addition of the oxalate of ammonia. By varying these and similar pro- 
 cesses according to circumstances, other combinations still more compli- 
 cated may be detected and separated. 
 
 k. Chemical characters. — The carbonate of lime may be readily detected 
 by its etFervescing with muriatic (and other) acids ; while the lime, after 
 the acid is nearly neutralised with ammonia, may be precipitated by the 
 oxalate of ammonia. 
 
 * Med. Chirurg. Trans, vol. ix. p. 14. 
 
 t See page xci. 
 
 X See an Essay on the Chemical History and Medical Treatment of 
 Calculous Disorders, by Alex. Marcet, M.D. 
 
URINARY CALCULI. 
 
 cxi 
 
 several instances, are usually of an amber colour and waxy con- 
 sistence, and have more or less of a fibrous texture ; in short, their 
 properties differ so much from any substance of urinary origin, 
 that their nature, when they occur, can hardly be mistaken. 
 
 227. There is another species of calculus, which, though not 
 of urinary origin, is very liable to be mistaken for such, from 
 the situation in which it is found, viz. 
 
 228. n. The prostatal calculus. — Of this species of calculus 
 there seem to be two varieties. The first variety is usually 
 found in the natural cavities of the gland, before it becomes 
 much disorganised. This variety is of small size, more 
 or less rounded in shape, and of a yellowish-brown colour. 
 The second variety seems to be generally formed in an enlarged 
 cavity or abscess of the prostate gland ; where it is some- 
 times met with in great numbers. This variety is usually of 
 much larger size than the other, and sometimes has a highly 
 polished porcelainous appearance. The composition of both, 
 however, is nearly the same — that is, they consist chiefly of the 
 phosphate of lime, a little carbonate of lime, and animal 
 matter. In different instances, the relative proportions of the 
 phosphoric acid to the lime and the carbonate of lime, seem to 
 vary considerably. Prostatal calculi, however, can seldom be 
 mistaken for calculi of urinary origin ; the phosphate of lime 
 being, as we have said, very rarely if ever deposited alone 
 from the urine, so as to form urinary calculi. 
 
 For tables illustrating the relative frequency of the diffe- 
 rent species of calculi in different countries, and to one 
 another, the reader is referred to the appendix. 
 
DESCRIPTION OF THE PLATES. 
 
 i 
 
H.Adlara, so. 
 
PLATE I. 
 
 Fig. 1 . — Represents the ordinary appearance of lithic acid 
 crystals under the microscope. The crystals are rhomboidal 
 prisms ; thin, transparent, and of a yellow colour. 
 
 Fig. 2. — Rhomboidal prisms of lithic acid, thicker than those 
 depicted in the preceding figure ; and, in some instances, ap- 
 proaching to the cubic form. The cubic is much more rare 
 than the rhomboidal variety of crystal. 
 
 Fig. 3. — The usual appearance presented by the lithate of 
 ammonia ; namely, that of an amorphous powder, the particles 
 of which are either collected together into little masses, or scat- 
 tered over the field of the microscope. 
 
 Fig. 4. — Are other forms assumed by the lithate of ammo- 
 nia ; namely, dark-coloured globules dispersed through the 
 amorphous powder, around a great number of which there are 
 disposed minute radiating crystals, in the form of a star, of the 
 superlithate of ammonia. 
 
 Fig. 5. — Represents the appearance under the microscope, 
 of the oxalate of lime formed by the precipitation of the lime 
 in the urine, by the addition of oxalic acid. 
 
 Fig. 6. — Represents a flat octohaedron ; the form, stated by 
 WoUaston and others, to be that most frequently assumed 
 by crystallised oxalate of lime. According to the recent 
 observations of Mr. Brooke, however, some natural crystals of 
 the oxalate of lime, containing one proportion of water, pre- 
 sented the form of an oblique rhombic prism. Whether the 
 salts thus appearing in two different forms are the same in com- 
 position ; or whether the octoheedral form has been erroneously 
 assumed, is not ascertained. See Lond. and Edin. Philos. 
 Mag. vol. xvi. p. 449, (1840.) 
 
PLATE II. 
 
 Fig. 7. — Crystals of cystic oxide, obtained from its solution 
 in ammonia, by evaporation. They appear as transparent hexa- 
 haedral prisms, more or less regular, and of various sizes. The 
 crystals of this substance are often so thin as to assume the 
 form of hexahsedral plates. 
 
 Fig. 8. — Crystals of the neutral triple phosphate of magnesia 
 and ammonia, such as they are either spontaneously deposited 
 from neutral or alkalescent urine ; or by precipitation from 
 that secretion on the addition of ammonia. These crystals are 
 white and transparent, and their form is either derived or 
 modified from a right rectangular prism. 
 
 Fig. 9. — Different forms assumed by the bibasic triple phos- 
 phate of magnesia and ammonia, sometimes deposited by 
 putrid urine ; or when ammonia has been added in excess 
 to that fluid. 
 
 Fig. 10. — Crystals of urea, obtained from a solution of that 
 substance in alcohol. 
 
 Fig. 1 1 . — Scales and crystals of the nitrate of urea, formed 
 when nitric acid is added to concentrated urine. 
 
H. 'Vcilaa-d , sc. 
 
TlcuCe/3. 
 
 GLOBuiES or moojj. 
 
 o ^ 
 
 o 
 
 Q ^ 
 
 o 
 
 .0 o o 
 
 O e> ^ 
 o o 
 o 
 
 Fig. 13. 
 
 o 
 
 o ^ 
 
 Or- o 
 
 ° o 
 
 o o • o ^ 
 
 O D Q 
 
 GlOBtlTXS or TTJS &• OT MILK, 
 
 <5n 
 
 0 O 
 
 o 
 
 Fig. 13. 
 
 o ^ 
 
 Q 
 
 OqoO 
 
 0 0 O 
 
 0 O 
 
 00« 
 
 Oo 
 
 OO ° Q o o o 
 
 O O 
 
 Q o 
 
 O O 
 
 o o ° ° o 
 
 EPITHEIIUM & MXTCUS. 
 
 Ii.A<nard, sc. 
 
PLATE III. 
 
 Fig. 12. — Globules of blood, as they usually appear when 
 examined between two glasses in a microscope : namely, as 
 flattened disks of a deep yellow colour, with an opake point in 
 their centre. The red particles of human blood have been 
 found to vary, in different instances and by different observers, 
 from the sono to the ssW of an inch. Sir E. Home and Mr. Bauer 
 estimated their size to be larger ; or at 1,1^ of an inch. 
 
 Fig. 13. — Blood globules collected from the urine inhsema- 
 turia. The globules towards the bottom appear slashed and 
 otherwise altered, from remaining for some time in the urine ; 
 though they retain their yellow colour. 
 
 Fig. 14. — Globules of pus exhibiting a granulated surface, 
 and slashed appearance round the circumference. They are 
 nearly colourless, and frequently adhere to each other. The 
 globules of pus are not flattened like those of the blood, but 
 are perfectly spherical. Their size is said to vary a little from 
 a mean of iks of an inch. 
 
 Fig. 15. — Globules of cow's milk, such as they appear under 
 the microscope, either naturally, or immediately after they have 
 been mixed with the urine. Some are larger than others, and 
 surrounded by a well-defined edge ; others are smaller, and 
 of a paler colour. Milk globules are from J to |- less then the 
 globules of the blood. 
 
 Fig. 16. — Lamellated scales of epithelium, and globules of 
 the mucus of the urinary passages. Some of the mucous glo- 
 bules appear to be attached to the scales of epithelium. 
 
 Fig. 17. — Globules of mucus entangled in a lamina of co- 
 agulated albumen. 
 
 The objects in these plates (with one exception) are taken 
 from the plates of M. Bayer's Traite des Maladies des Beins, 
 tom. i. 
 
PLATE IV. 
 
 URINARY CALCULI. 
 
 Lithic acid series. 
 
 Fig. 1. — Is an exterior view of the common lithic acid cal- 
 culus. From a specimen in the Museum of the Royal College 
 of Surgeons. 
 
 Fig. 2. — Represents a fragment of a well-defined crystallised 
 lithic acid calculus. In this variety (abstracting the colouring, 
 matters) the lithic acid is remarkably pure. It is not a very 
 common variety, but when it does occur, sometimes ac- 
 quires a very considerable magnitude ; as was the case with 
 the specimen of which this was a portion. 
 
 Fig. 3. — Is a section of the common compact lithic acid cal- 
 culus. The centre of this calculus, though not crystallised, 
 approaches Fig. 2 in colour and purity ; while its exterior 
 laminse are much less pure, and of a paler colour ; and contain, 
 mixed with the lithic acid, more or less of the lithate of ammo- 
 nia and the phosphates. From a specimen in the Royal Col- 
 lege of Surgeons. 
 
 Fig. 4. — Represents the common lithate of ammonia calculus. 
 From a specimen in the Royal College of Surgeons, stated to 
 have been taken from a girl seven years of age. 
 
 Fig. 6. — Is a portion of a section of a calculus consisting 
 internally of the lithate of ammonia, and externally of the 
 triple phosphate of magnesia and ammonia nearly pure. This 
 calculus was the second taken from a young gentleman about 
 thirteen years of age. 
 
 Fig. 6. — Is the entire section of a calculus containing, like 
 the last, a lithate of ammonia nucleus, but surrounded by the 
 mixed phosphates, or fusible deposite. It was taken, after 
 death, from the bladder of a boy six years old, who had died 
 from the irritation produced by it. 
 
 Thus the changes which the lithic acid species of calculus 
 usually undergoes in its progress towards the phosphates, 
 are — crystallised and nearly pure lithic acid ; compact and deep- 
 coloured lithic acid; lithate of ammonia ; the triple phosphate of 
 magnesia and ammonia; and the mixed phosphates. See Tables 
 in the Appendix. 
 
ricoto4 
 
Flat&S. 
 
PLATE V. 
 
 URINARY CALCULI. 
 
 Oxalate of lime series. 
 
 Fig. 7. — Is an exterior view of an oxalate of lime or mulberry 
 calculus. From a specimen in the Eoyal College of Surgeons. 
 
 Fig. 7^. — Is a specimen of the white crystallised variety of 
 the oxalate of lime calculus noticed at page cvii. of the Intro- 
 duction. 
 
 Fig. 8. — Represents an internal view of the oxalate of lime 
 calculus. 
 
 Fig. 9. — Represents the section of a calculus showing the 
 alternation of the lithic acid and mulberry deposites. In the 
 centre is a nucleus consisting principally of the lithic acid. 
 Externally to this is the mulberry deposite ; and to this again 
 succeeds the lithic acid, which constitutes the whole external 
 crust. From a specimen taken from the kidney after death, 
 and for which the author is indebted to Dr. Elliotson. 
 
 Fig. 10. — Is from a specimen in the Royal College of Surgeons. 
 In the centre is the lithic acid ; then follows the oxalate of 
 lime ; while exterior to the whole, are the mixed phosphates. 
 
 Fig. 1 1 . — Is an external view of a calculus composed of the 
 mixed phosphates, or the fusible calculus. From a specimen 
 in the Royal College of Surgeons. 
 
 From this series we see that the lithic acid and the mulberry 
 deposites alternate with each other. The phosphates here, 
 however, as in the lithic acid species, are almost always ex- 
 ternal. 
 
 See Tables in the Appendix. 
 
PLATE VI. 
 
 URINARY CALCULI. 
 
 Cystic oxide and phosphate of lime or prostatal calculi. 
 
 Fig. 12. — Is an external view of the cystic oxide calculus. 
 From Dr. Marcet's work on Calculous Disorders. 
 
 Fig. 13. — Is a section of another specimen of this rare species 
 of deposite, in the author's possession ; and for which he was 
 indebted to the late Dr. Henry of Manchester. 
 
 The author has seen no specimen of this species of calculus 
 surrounded by the phosphates ; though an instance of such an 
 occurrence has been noticed by Dr. Wollaston, its discoverer. 
 
 Fig. 14. — Are specimens of the small rough variety of pros- 
 tatal concretion, which usually occurs in that gland before any 
 extensive disorganisation has taken place. 
 
 Figs. 15, 16, and 17, represent specimens of the porcelainous 
 variety of concretion occurring in abeesses of the prostate. 
 Fig. 15 is an external view. Fig. 16 represents a section, 
 and showing the radiating striee peculiar to the phosphate of 
 lime concretion. Fig. 17 is an irregular fragment, somewhat 
 resembling a piece of bone or shell. These specimens were 
 removed from the prostate by Sir B. Brodie. 
 
CYSTIC OXIDE &• PROSTATAL CONCRETIONS. 
 
m 
 
DISEASES 
 
 OF 
 
 ASSIMILATION AND OF SECRETION. 
 
 Pathology, or the doctrine of Disease in general, is naturally 
 comprised under three great heads or divisions, viz. — Func- 
 tional diseases, or those derangements, arising from abnormal 
 action of one or more organs of which animal bodies consist : 
 Organic diseases, or those diseases arising from actual lesions of 
 one or more of the organs themselves : and Mechanical diseases, 
 or those diseases arising from mechanical causes ; such as from 
 the imperviousness or destruction of organs by disease; or from 
 the presence of foreign bodies, as for instance, of calculi, &;c., in 
 the kidney or bladder. As, however, we rarely find diseases 
 exclusively belonging to either of these three great divisions ; 
 and as the two last divisions, in particular, are almost always 
 associated in those diseases of assimilation and of secretion which 
 form the chief objects of this volume ; we shall consider the 
 subject under two general heads only, viz. 
 
 Functional diseases ; or those diseases arising from the deranged 
 operations and less obvious lesions of the assimilating and 
 secreting organs; and 
 
 Mechanical diseases ; or those diseases arising from obvious 
 lesion-s of organs ; and from the presence of foreign bodies, as 
 of calculi in the bladder, &;c. 
 
 These two great classes of diseases will constitute the sub- 
 jects of the two Books, or Parts, into which our Treatise is 
 divided. 
 
BOOK I. 
 
 OF FUNCTIONAL DISEASES, 
 
 COMPREHENDING THE DESCRIPTION AND TREATMENT OF DISEASES 
 ARISING FROM THE DERANGED OPERATIONS AND LESS OBVI- 
 OUS LESIONS OF THE ASSIMILATING AND SECRETING ORGANS. 
 
 We have attempted to show in the Introduction, that the proxi- 
 mate alimentary principles by which the existence of animals 
 is maintained, though much modified by the assimilating pro- 
 cesses, are essentially the same as those principles of which 
 animal bodies consist. We shall now attempt to show, that the 
 processes by which alimentary matters are assimilated in animal 
 bodies are constantly liable to be deranged, both in degree and in 
 kind; — that such derangements of the assimilating processes 
 are manifested by corresponding derangements in the various 
 products secreted from animal bodies by the organs designed 
 for such purposes, and particularly by the kidneys and liver ; 
 and lastly ; — that the relations existing between the deranged 
 products of secretion and the proximate principles by which 
 animals are maintained, and of which their bodies consist, 
 enable us, in many instances, to acquire a more correct know- 
 ledge of the organ deranged, as well as of the nature of its 
 derangements , than can be obtained by any other means. 
 
DIVISION OF THE SUBJECT. 
 
 3 
 
 We divided the proximate alimentary and staminal princi- 
 ples of animals into four great classes, viz. the Aqueous, the 
 Saccharine, the Albuminous, and the Oleaginous classes ; and 
 in conformity with this arrangement, we shall consider the 
 Pathology of the assimilating processes under four similar 
 heads. The first Book or Part of our Treatise, therefore, 
 will comprise the following subjects. 
 
 Chap. I. General observations on the Pathology of Aque- 
 ous assimilation and secretion. 
 Of an Excess and Deficiency of urine. 
 Chap. II. General observations on the Pathology of Sac- 
 charine assimilation and secretion. 
 Section a. Of Saccharine urine. Diabetes. 
 
 h. Of Oxalic acid ; Oxalate of Lime, 
 c. Of Lactic acid. 
 Chap. III. General observations on the Pathology of Albu- 
 minous assimilation and secretion. 
 Section a. Of an Excess and Deficiency of Urea. 
 h. Of Albuminous urine. 
 
 c. Of Lithic acid. 
 
 d. Of Cystic oxide. 
 
 Chap. IV. General observations on the Pathology of Olea- 
 ginous assimilation and secretion. 
 Section a. Of an Excess and Deficiency of fat. 
 
 h. Of Cholesterine and its deposits, &;c. 
 The important class of diseases, arising from the Mineral - 
 matters incidental to the proximate animal principles, will be 
 separately considered under the head of 
 
 Chap. V. General observations on the Pathology of the 
 Incidental Mineral matters entering into the 
 composition of organised bodies. 
 
 Since, from the principles of the above arrangement of our 
 subjects, the abnormal condition of the secreted products is 
 supposed to constitute the prominent feature of the derange- 
 
4 
 
 DIVISION OF THE SUBJECT. 
 
 ment, or, in other words, the Disease ; in speaking of the indi- 
 vidual derangements or diseases, we shall first describe the 
 abnormal state of the secretion constituting the Disease ; and 
 afterwards point out the general constitutional symptoms or 
 derangements by which the abnormal state of the secretion is 
 usually accompanied. These points being considered, the 
 Diagnosis, Prognosis, and Treatment of the peculiar derange- 
 ment, will follow in the usual manner. 
 
CHAPTER I. 
 
 GENERAL OBSERVATIONS ON THE PATHOLOGY OF AQUEOUS 
 ASSIMILATION AND SECRETION. 
 
 It has been stated that Water enters into the composition 
 of organised beings more largely than any other principle ; 
 and that, like the other materials of which organised beings 
 consist, the water present is in a constant state of change. 
 Of those portions of water which are incessantly escaping 
 by the skin, by the lungs, and by the other outlets of animal 
 bodies, it scarcely falls within our design to inquire. Our 
 attention in the present chapter will be chiefly directed to 
 that portion of water more immediately concerned in the 
 processes of assimilation ; and which subsequently passes off 
 through the kidneys in the form of Urine. 
 
 In the consideration of the Pathology of Aqueous secretion 
 from the kidneys, the first points to be attended to are, the 
 normal quantity of urine voided by a person in health in a given 
 time ; and the average specific gravity of such normal quan- 
 tity. We have stated that both these data are subject to 
 great diversities from climate, and from a variety of other 
 causes ; so that it is impossible to name any one quantity or 
 weight that shall be universally applicable. In this country, 
 we have supposed the average quantity and specific gravity of 
 the urine voided in twenty-four hours by a person in health, 
 and who does not drink more than the simple wants of nature 
 require, to vary from thirty ounces of specific gravity 1-025 
 
6 
 
 PATHOLOGY OF AQUEOUS 
 
 in the summer, to forty ounces of specific gravity 1*015 in 
 the winter; and these averages are probably near enough 
 the truth for all practical purposes. 
 
 The secretion from the kidneys has been long divided by 
 physiologists into the urina potus, the urine voided after 
 drinking, (and moderate eating) ; and the urina sanguinis, the 
 urine liberated from the blood after the primary processes 
 of assimilation have been completed. Instead of the old and 
 limited term urina potus, we shall adopt the more comprehen- 
 sive term uiine of assimilation. To the other term, urina 
 sanguinis, there is no objection. 
 
 The urine of assimilation, in the sense to which we have re- 
 stricted the term, may be considered under two points of view ; 
 the urine consisting of water containing matters, alimentary or 
 medicinal, naturally soluble in that fluid ; and the urine con- 
 sisting of water containing matters, alimentary or medicinal, 
 not soluble in that fluid till they have been modified by the 
 organs of assimilation. 
 
 Fluids taken into an empty stomach usually soon find their 
 way to the kidneys. If, therefore, for any purpose, we wish to 
 produce a large flow of urine, we ought to administer fluids 
 when the digestive processes are quiescent ; as, by giving them 
 at such times, we are not only more likely to effect our pur- 
 pose, but avoid the risk of deranging the assimilating processes. 
 The same remark applies to the employment of mineral waters, 
 especially mineral waters of low powers, and requiring to be 
 taken in large quantities. The urine passed under such cir- 
 cumstances may be truly denominated the urina potus ; 
 and if pure water has been taken, like the Malvern water, 
 for instance, the urine differs from healthy urine, only in 
 being more dilute. Hence, in a given portion of such urine, 
 all the usual ingredients of the secretion will be found to 
 exist in the same relative proportions as in healthy urine, but 
 in much less absolute quantity. Mineral waters containing 
 alkaline and saline matters in solution, often permeate .the 
 system even more rapidly than pure water ; and, in such in- 
 
ASSIMILATION AND SECRETION. 
 
 7 
 
 stances, the mineral impregnations are found in the urine in 
 large quantities. It is on this principle that mineral waters 
 containing the alkaline carbonates are recommended, with the 
 view of disintegrating or dissolving urinary calculi in the 
 kidney and bladder ; as we shall have occasion to notice here- 
 after. The same remarks, with regard to the time of adminis- 
 tration, are applicable to those mineral waters which are 
 strongly impregnated with neutral saline matters, and which 
 chiefly exert their effects on the bowels as purgatives. Such 
 waters should be taken at periods when they are least likely 
 to interfere with the assimilating processes ; otherwise they 
 often do more harm than good. With respect to the duration 
 of a course of mineral waters, this will depend on the nature 
 of their impregnation, and on the constitution of the patient. 
 Generally speaking, the weaker alkaline and saline waters 
 can be longest persisted in with impunity. The use of the 
 stronger saline, and particularly of the chalybeate waters, re- 
 quires to be carefully watched in all instances ; as, when con- 
 tinued beyond a certain point, such waters are capable of 
 acting injuriously on the system. 
 
 In the cases above mentioned, the quantity of urine generally 
 exceeds the average standard, on account of the large quantity 
 of fluid taken. In the opposite state of things, when little 
 or no fluid is taken ; or when the skin, from the heat of the 
 atmosphere, severe exercise, or from other causes, has been 
 unusually active; the quantity of urine voided is not only 
 below the average standard, but the qualities of the secretion 
 are altered : — that is to say, the urine is darker-coloured 
 and of higher specific gravity than natural ; in short, is in that 
 state of concentration which healthy urine would assume, if 
 deprived of a certain portion of its water. This condition of the 
 system is accompanied by the sensation of thirst : the signal, 
 in a healthy individual, that fluid is wanted for the purposes 
 of the economy. If this signal be obeyed, and fluids be taken 
 in moderate quantity, all the symptoms cease, and the urine 
 
8 
 
 PATHOLOGY OF AQUEOtJS 
 
 resumes its normal and healthy condition, both in quantity 
 and quality. 
 
 The preceding remarks are chiefly applicable to water con- 
 sidered as the medium or vehicle in which organic operations 
 are carried on ; in other words, as a mere fluid taken into the 
 stomach, which, after passing through the system unchanged, 
 is finally elicited by the kidneys in the form of the urina 
 potus. We have now to make a few observations on that 
 portion of water which is more or less associated with alimen- 
 tary matters, during the processes of assimilation ; and which 
 is afterwards separated from the system, in the form of the urine 
 of assimilation,^ 
 
 To follow water, as elsewhere observed, through all the 
 combinations into which it enters in organised beings, would 
 be impracticable, even if our knowledge permitted ; as the 
 detail would include almost every organic operation. A few 
 of the leading facts connected with the appropriation and 
 separation of water during the assimilating processes, we have 
 attempted to point out in the Introduction. We have also 
 hinted at certain phenomena in which the elements of water 
 appear to perform important offices. For what has been said 
 on these subjects, however, we refer the reader to the Introduc- 
 tion. At present our attention will be principally confined to 
 the injudicious employment of fluids during the digestive 
 processes ; and to some of the leading derangements of the 
 urine arising from such injudicious employment of fluids ; as 
 well as from imperfect assimilation in general. 
 
 The appropriation of water during the processes of as- 
 similation, like the processes of assimilation themselves, is 
 a vital act ; that is to say, the appropriation of water either 
 depends on the influence and operation of the organs of 
 
 * There is reason to believe that the decomposition of water either 
 takes place when in a state of combination with other principles, or 
 during the act of its separation or combination with such principles ; and 
 that water, as water, is rarely decomposed by the animal economy. 
 
ASSIMILATION AND SECRETION. 
 
 9 
 
 assimilation immediately exerted ; or on the influence of some 
 (generally fluid) principle secreted by these organs, and acting 
 as the medium by which the vital act of appropriation is ac- 
 complished. Moreover, the processes by which water is appro- 
 priated, like all other vital processes, take place slowly, 
 and never per saltum. As instances of such deliberate change, 
 we may mention that the alimentary matters, during their re- 
 duction into chyle, are gradually and slowly combined with 
 water; and that, on the other hand, the chyle, during its 
 conversion into blood, is gradually raised or separated from its 
 associated water. The due performance, therefore, of these 
 and other functions in which water plays a conspicuous part, 
 must depend on a regulated supply ; and the presence of either 
 too much or too little water will necessarily render assimila- 
 tion difficult, and more or less incomplete. 
 
 In the healthy condition of the stomach and of the system 
 in general, when a natural thirst indicates the want of drinks ; 
 fluids taken into the stomach, even during the digestive pro- 
 cesses, interfere with these processes much less than might be 
 expected ; for, by a beautiful provision, the superfluous portion 
 of the fluids is removed from the stomach almost as fast as it is 
 introduced. The fluids thus removed, however, are liable to be 
 occasionally charged with unassimilated crudities, which, in 
 subsequently passing through the kidneys, produce more or 
 less derangement of these organs. On the other hand, when 
 fluids are taken into the dyspeptic stomach during the diges- 
 tive processes, they are apt to be retained ; and after giving 
 occasion to flatulent distension, and to many other annoying 
 symptoms, they are either tardily taken into the system, and 
 thrown on the kidneys loaded to excess with unassimilated 
 matters ; or they sometimes escape by the bowels ; or are 
 ejected by vomiting. Hence, as a general rule, the impro- 
 priety of drinking too much during a meal. 
 
 The symptoms produced by a deficiency of fluid in the sto- 
 mach, during the assimilating processes, are less understood 
 than those produced by an excess ; for, as already noticed, when 
 
10 PATHOLOGY OF AQUEOUS ASSIMILATION AND SECRETION. 
 
 fluids are really required by the system, the signal of thirst 
 becomes so urgent as not only to arrest our attention, but to 
 oblige us to resort to the use of fluids, if within our reach. 
 When, under these circumstances, fluids cannot be obtained, no 
 substitute will supply their place; and the assimilating pro- 
 cesses, in common with all other vital operations, must soon 
 entirely cease. 
 
 The effects of fluids on the assimilating processes are con- 
 siderably modified by their qualities, as well as by their quan- 
 tity. Thus, individuals, who have been accustomed to fermented 
 liquors, seem almost to require the stimulus of such fluids to 
 enable them to digest their food. The condition of the stomach, 
 however, to which the stimulus of fermented liquors or of 
 pungent condiments is necessary, may in all instances be 
 considered as unnatural. 
 
 The urine of assimilation, or that voided under the circum- 
 stances we have been considering, is exceedingly variable in its 
 properties : generally it is more or less dark-coloured, above 
 the average specific gravity, and becomes turbid on cooling, 
 from a deposition of lithic acid ; or from a mixture of lithic 
 acid with various other matters, some of which have been 
 taken into the stomach as food, and have passed through the 
 system unchanged. These depositions are occasionally seen in 
 the urine of healthy individuals; but they occur most fre- 
 quently in the urine of dyspeptics; particularly in a cold and 
 chilly state of the atmosphere, and when the skin is inactive 
 from want of exercise, or from other causes. Under these 
 circumstances, we can often distinctly detect, by the smell 
 of the urine, the nature of the preceding meal ; more especially 
 if matters containing a volatile, empyreumatic oil, or possessing 
 other strong sensible qualities, have been taken. 
 
 The urina sanguinis is the urine voided at a considerable 
 interval after food has been taken, and after the assimilating 
 processes of the stomach and other organs have been completed, 
 and the chyle has entered the blood. The urina sanguinis, in 
 fact, constitutes the standard urine ; and is that which has been 
 
EXCESS AND DEFICIENCY OF URINE. 
 
 11 
 
 I SO described in the Introduction. We need not, therefore, re- 
 j peat the description here ; but shall merely observe, that from 
 1 the urina sanguinis we more particularly learn the condition of 
 the kidneys and system in general ; while from the urine of 
 assimilation we learn more especially in what respect the 
 digestive processes are deranged. Hence, when it is intended 
 to make a formal examination of the urine, two specimens are 
 required ; viz. the urine voided after a principal meal, as after 
 dinner ; and the urine voided in the morning before breakfast ; 
 from which two extremes we may generally obtain all the 
 information that the urine is calculated to furnish. 
 
 Of an Excess and Deficiency of Urine, considered with reference 
 
 to Disease, 
 
 An increased flow of urine is usually termed Diuresis. Diu- 
 resis may be temporary, and merely dependent on the large 
 quantity of fluids taken ; or it may be associated with disease, 
 in which case Diuresis partakes of the permanent character 
 of the disease itself. When Diuresis is connected with disease, 
 it may be regarded as a symptom only ; and as a large flow of 
 urine accompanies many and very different diseases, Diuresis 
 most naturally falls to be considered along with the diseases 
 with which it happens to be associated. 
 
 Nearly the same remarks apply to a Deficiency of urine, 
 which may be the temporary result of abstinence from fluids, 
 unusual cutaneous activity, &c. ; or a Deficiency of urine may 
 be permanently associated with certain constitutional and 
 local affections, of which it may be regarded as a symptom. We 
 shall have occasion hereafter to notice some of the diseases, of 
 which Deficiency of urine is a symptom. 
 
 Lastly, it may be observed, that the conditions of the system 
 and principles of practice, usually indicated by an increased 
 and diminished flow of urine, are as opposite in their character 
 
12 
 
 EXCESS AND DEFICIENCY OF URINE. 
 
 as the symptoms themselves. Thus, an increased flow of urine, 
 or Diuresis, very constantly accompanies those diseases con- 
 nected with a peculiar state of nervous irritability, as hysteria ; 
 certain passions of the mind ; &;c. On the contrary, a dimi- 
 nished flow of urine usually accompanies active inflammation, 
 or an inflammatory state of the system in general. An in- 
 creased and diminished flow of urine, therefore, are symptoms 
 of primary importance in a great many diseases ; and, if rightly 
 understood, seldom fail to indicate the principles on which the 
 disease may be advantageously treated. 
 
13 
 
 CHAPTER II. 
 
 GENERAL OBSERVATIONS ON THE PATHOLOGY OF SACCHARINE 
 ASSIMILATION AND SECRETION. 
 
 Since the last edition of this work was published in the year 
 1825, the class of diseases connected with the imperfect 
 and mal-assimilation of the Saccharine principle has occupied 
 much of my attention ; and soon after the period mentioned, 
 my observations and researches gradually led me to form 
 peculiar views on the subject, of which an outline was given in 
 the Gulston Lectures, delivered before the College of Phy- 
 sicians.^' Subsequently to the publication of this sketch, I 
 have had abundant opportunities of verifying and extending 
 my views ; and though still far from perfect, they furnish an 
 outline, which, I trust, future observations will complete. 
 
 Before proceeding, we may remind the reader of the follow- 
 ing points already illustrated in the Introduction : First, That 
 Saccharine aliments cannot in their natural state form con- 
 stituent principles of living animal bodies, but must previously 
 undergo certain changes of a more radical character than either 
 of the other primary alimentary principles. Secondly, That 
 the function by which saccharine aliments are converted into 
 the staminal principles of living animal bodies, is not only a 
 distinct function of a most important kind ; but probably among 
 the earliest that exist, and the last that become extinct in 
 animals. Thirdly, That this function, like all the other assi- 
 milating functions, is of a twofold character ; that is to say, 
 * See Medical Gazette;, vol. viii. 1831. 
 
14 PATHOLOGY OF SACCHARINE 
 
 is partly perfornied by the primary organs of assimilation, the 
 stomach, &:c. ; by which the Saccharine principle is converted 
 into the albuminous and oleaginous matters of the blood ; and 
 partly by the secondary assimilating processes, by which the 
 blood is further converted into the several living tissues of 
 which animal bodies consist. Fourthly, That a most impor- 
 tant class of tissues thus developed from the albuminous prin- 
 ciples of the blood by the secondary assimilating processes, are 
 those tissues essentially composed of the gelatinous principle ; 
 which gelatinous principle may be considered as the repre- 
 sentative of the original Saccharine aliments. These points 
 being borne in mind, will afford a clue to the points to be 
 now briefly considered and illustrated, viz. 
 
 1. That both the primary and secondary assimilating pro- 
 cesses are liable to be deranged, not only in degree, but in kind ; 
 and that the derangement of one of the classes of assimilating 
 processes necessarily more or less involves the other. 2. That 
 one of the derangements of the primary assimilating processes 
 consists in the want of power to assimilate certain forms of the 
 Saccharine principle, (e. g. sugar ;) while another derangement 
 of the same processes consists in the imperfect or mal-assimila- 
 tion of the Saccharine principle, by which various unnatural 
 bodies, e. g. oxalic acid, lactic acid, &;c. are produced instead 
 of albuminous matters. 3. That the derangements of the 
 secondary assimilating processes resulting from, or connected 
 with, the derangements of the primary assimilating processes 
 above mentioned, consist in the imperfect development of the 
 living animal tissues, and particularly of the gelatinous tissues ; 
 and that, during the further changes which such imperfectly 
 developed tissues undergo, various unnatural and poisonous 
 matters are generated, the nature of the greater part of which 
 is unknown to us ; though among them there appear to be 
 occasionally included matters similar to, or identical with, those 
 matters, developed during the primary assimilating derange- 
 ments, viz. oxalic acid, lactic acid, &;c. 4. And lastly, That 
 the causes producing derangements, both of the primary and 
 
ASSIMILATION AND SECRETION. 
 
 15 
 
 secondary assimilating functions, are partly innate, and consist 
 in a peculiar predisposition to such derangements ; and partly 
 exciting, and consist in exposure to accidental circumstances 
 to which all individuals are subject ; such as depressing passions 
 of the mind ; a residence in certain unhealthy localities ; long- 
 continued errors in diet, &;c. 
 
 1. That the assimilating functions are liable to be deranged 
 from a variety of causes, both in degree and in kind, no one will 
 hesitate to admit. Moreover, there is little difficulty in con- 
 ceiving, when, from derangement of the primary assimilating 
 organs, unnatural matters are generated and carried into the 
 mass of blood ; that such unnatural matters, unfitted as they 
 must be for future assimilation, will more or less embarrass the 
 secondary assimilating functions. Further, we can easily con- 
 ceive, that from long-continued exposure to such embarrass- 
 ments, the secondary assimilating functions themselves, even 
 though they were originally perfect, will finally become de- 
 ranged, and thus aggravate the mischief. Independently of 
 such induced derangements, however, the secondary assimilat- 
 ing functions are seldom perfectly performed, when the pri- 
 mary assimilating functions are deranged ; for the same causes 
 which originally produce a derangement of the primary assimi- 
 lating functions, too often predispose the secondary assimilating 
 functions to derangement. 
 
 2. The blood of a perfectly healthy individual contains no 
 appreciable quantity of sugar ; though that article, in moderate 
 quantity, may have formed a portion of his food. It follows 
 therefore, that the Saccharine principle is convertible, by the 
 operation of the primary assimilating functions alone, into the 
 constituent principles of the blood. Now, from the relative 
 composition of the Saccharine principle, and of the constituent 
 principles of the blood, it follows, as we have stated, that the 
 assimilation of the Saccharine principle must constitute a 
 distinct function ; and, as so large a proportion of the food of 
 all animals consists of modifications of the Saccharine principle, 
 this function must be of the most important kind. But if the 
 
16 
 
 PATHOLOGY OF SACCHARINE 
 
 existence of such a function be admitted, it follows that, like 
 any other function, the assimilation of the Saccharine principle 
 may become deranged or suspended ; that is to say, the pri- 
 mary assimilating organs may become unable to assimilate the 
 Saccharine principle. I need not say that this point is now 
 no longer a matter of uncertainty, as in the disease to be pre- 
 sently considered, namely Diabetes, sugar has been repeatedly 
 ascertained to exist in the sanguiferous system; a fact une- 
 quivocally demonstrating that the assimilating organs had failed 
 to convert the Saccharine aliment into the constituent principles 
 of the blood. As a further illustration of this point we may 
 state, that the first step of the assimilation of alimentary mat- 
 ters is accomplished by the reducing function of the stomach. 
 Now the reduction of all the forms of the Saccharine principle 
 appears to be accompanied by the development of a low sugar ; 
 which low sugar, in the healthy condition of the stomach, is 
 speedily converted into albuminous and oleaginous matters. 
 Hence, as the existence of sugar in the stomach is only mo- 
 mentary, or, as it were, a point in transitu, its presence in 
 the healthy organ is with difficulty detected. In Diabetes, 
 however, the reducing function of the stomach is for the most 
 part morbidly active, while the converting function is more or 
 less suspended or paralysed. In the diabetic stomach, there- 
 fore, sugar is found in large quantity, particularly when vege- 
 table aliments have been taken ; and from the stomach, the 
 sugar readily passes into the sanguiferous system, as just stated. 
 The first step in the derangements, therefore, producing the 
 disease called Diabetes, does not consist, as some have sup- 
 posed, in the development of sugar in the stomach, which is a na- 
 tural process ; but in the greater or less destruction of the convert- 
 ing, and consequently of the still more important organizing 
 functions of the assimilating organs, 
 
 * In confirmation of this point, it is necessary only to refer to the 
 valuable paper published by Mr. M'Gregor of Glasgow, in the Medical 
 Gazette for May 1837. The point in question, however, had been dis- 
 tinctly determined before the publication of Mr. M'Gregor's paper ; as 
 well as repeatedly since that period. 
 
ASSIMILATION AND SECRETION. 
 
 17 
 
 In the diseases above mentioned, the function by which the 
 saccharine principle is converted into the constituents of chyle, 
 is suspended or destroyed. In other diseases, however, this 
 important function is not destroyed, but erroneously exerted ; 
 and the consequence is, that many principles, some of them of 
 a poisonous character, as, for instance, the oxalic acid, are de- 
 veloped from the saccharine principle during the assimilating 
 processes. That oxalic acid must be occasionally developed in 
 the system is evident from the fact, that this acid is found in 
 the urine when it has not been taken into the stomach. Now, 
 when we consider that oxalic acid, taken into the stomach, 
 passes through the kidneys unchanged ; ^ and that those who 
 take sugar in excess are often liable to oxalate of lime concre- 
 tions ; there can be little doubt that the oxalic acid found in 
 the urine is occasionally developed in the primary assimilating 
 organs, and most probably in the stomach itself. 
 
 3. In the healthy state of the system, sugar never appears 
 to be developed during the secondary assimilating processes. 
 There is reason, however, to believe, that in the advanced 
 stages of Diabetes, sugar is not only developed during the 
 conversion of the albuminous principles of the blood into the 
 gelatinous tissues ; but also during the secondary assimilation 
 of the gelatinous, and even perhaps of the albuminous and 
 oleaginous tissues. Moreover, we cannot doubt that the con- 
 verting function of the secondary assimilating processes, like 
 the converting function of the primary assimilating processes 
 above mentioned, is liable to be erroneously exerted ; and that 
 various unnatural products are, in consequence, developed in 
 the system. For obvious reasons, however, we know less of 
 the unnatural products resulting from the derangements of 
 
 * Majendie and others have shown, that where large quantities of the 
 Rumex, Oxalis acetocella, &c., have been employed as food, the oxalic 
 acid passes through the kidneys, and frequently gives occasion to the mul- 
 berry calculus. — Recherches physiologiques et medicales sur les causes, 
 &c. de la Gravelle, pp. 39, 126. This point will be further illustrated 
 when we come to speak of oxalic acid diseases. 
 
 c 
 
18 
 
 PATHOLOGY OF SACCHARINE 
 
 the secondary, than of tlie primary processes of assimilation ; 
 though it is probable, from the following facts, that the oxalic 
 and lactic acids are occasionally included among the unnatural 
 matters resulting from derangements of the secondary, as well 
 as of the primary assimilating functions. 
 
 It will be shown hereafter, that the oxalic acid in small 
 quantity occasionally passes through the system, without pro- 
 ducing any remarkable external symptoms of its presence ; it 
 will be also shown, that in many other instances the presence 
 of oxalic acid in the system is accompanied by certain cutaneous 
 and other diseases more immediately connected with the gela- 
 tinous tissues. Now, although we cannot prove that the 
 oxalic acid in the latter case is the result of the same derange- 
 ments of the secondary assimilating processes which give imme- 
 diate occasion to the cutaneous affection; yet when, in addition 
 to the preceding facts, we further take into account the relation 
 of the gelatinous to the saccharine principle ; no supposition 
 appears more probable, than that one of the derangements 
 of the secondary assimilation of the gelatinous principle may 
 consist in the development of oxalic acid. But if this reason- 
 ing be deemed inconclusive with respect to the development of 
 the oxalic acid during* certain derangements of the secondary 
 assimilating processes ; its validity, perhaps, will scarcely be 
 questioned with respect to the development of the lactic acid 
 during certain other derangements of the secondary assi- 
 milating processes ; for on what other supposition can we ex- 
 plain the presence of those enormous quantities of lactic acid 
 which occasionally exist in the system during rheumatic and 
 hectic fever ? Will any one contend that all this lactic acid is, 
 in such instances, developed in the stomach ? 
 
 The constitutional symptoms connected with the develop- 
 ment of sugar, and of the oxalic and lactic acids, will be con- 
 sidered in future sections of this chapter ; and we proceed to 
 notice briefly a point to which we have before alluded, viz. that 
 besides the oxalic and lactic acids, other unnatural principles 
 (of an acid and poisonous character ?) appear to be occasionally 
 
ASSIMILATION AND SECRETION. 
 
 19 
 
 developed from the saccharine principle, during derangements 
 both of the primary and secondary assimilating functions. The 
 exact nature of most of these unnatural principles is at present 
 little known ; but there cannot be a doubt, that many local 
 affections, originating in the gelatinous tissues from mal-assi- 
 milation, are accompanied by the development of such unna- 
 tural principles. So also, in those malignant fevers of tropical 
 climates, (and even perhaps of our own climate,) which more 
 especially arise from miasmata and contagion, there appear to 
 be many unknown but pernicious principles developed from 
 the saccharine radical. Thus I have been informed that the 
 fluid thrown off from the stomach in yellow fever, and deno- 
 minated the Mack vomit, is often powerfully acid. The nature 
 of this acid has not been satisfactorily ascertained ; but it pro- 
 bably is the lactic acid ; or it may be an acid of a much more 
 injurious character. I have had no opportunity of verifying 
 these remarks ; and notice the subject chiefly for the sake of 
 exciting the attention of others ; iind more especially the at- 
 tention of practitioners in hot climates, where all such unna- 
 tural matters appear to be developed in the most decided 
 forms.* 
 
 These observations are sufficient to illustrate the phenomena 
 connected with the mal-assimilation of the saccharine radical ; 
 and it only remains to observe, that organic diseases iji general, 
 but particularly those of a deep-seated and malignant charac- 
 ter, appear to be more frequently connected with derangement 
 of the gelatinous, (z. e. of the saccharine,) than of either the 
 albuminous or oleaginous radicals. We cannot explain this 
 circumstance ; but perhaps it may be referred no less to the 
 peculiar vital character of the gelatinous tissues, than to their 
 fundamental importance ; that is to say, the peculiar vital cha- 
 
 * See London Med. and Phys. Journal, vol.lix. p. 100. Also the Boston 
 Med. and Surg. Journal, vol. i. p. 134. The paper alluded to is by Mr. 
 Lyons, who shows the remarkably acid condition of the black vomit 
 in tropical fevers. Mr. L. supposes the acid to be the muriatic acid, and 
 it may be so in part ; but most probably the greater portion of the acid is 
 the lactic acid. 
 
 ♦ c2 
 
20 
 
 PATHOLOGY OF SACCHARINE 
 
 racter of the gelatinous tissues, is of that low kind, which 
 renders them liable to be easily influenced by external causes ; 
 while, at the same time, their fundamental importance is such, 
 that to derange or subvert these tissues is, in fact, to derange 
 or subvert the very groundwork of organised beings, 
 
 4. In further illustration of the preceding views, we shall 
 make a few observations on the causes, internal and external, 
 producing mal-assimilation of the saccharine principle in ge-- 
 neral. 
 
 The internal causes predisposing to the mal-assimilation of 
 the saccharine principle, like the causes predisposing to all 
 other diseases, are most generally innate or inherited ; and 
 those who are born with such predisposition, are liable to get 
 attacks from slight exciting causes, such as would not in the 
 least degree affect a perfectly sound habit. In some instances, 
 a predisposition to particular diseases is acquired by having 
 had attacks of such diseases before. But all circumstances 
 seriously affecting the general health, and depressing the vital 
 powers, are apt to predispose to the mal-assimilation, both 
 primary and secondary, of the saccharine, as well as of the 
 other proximate principles of which organised beings consist. 
 
 Among the external exciting causes of saccharine derange- 
 ments, one of the most simple and frequent is exposure to cold ; 
 or exposure to the combined influence of cold, and of moisture. 
 Thus, in many instances, I have been distinctly able to trace 
 diabetes to exposure to cold ; or sometimes to rheumatic at- 
 tacks brought on by exposure to cold and moisture. In such 
 instances, predisposition to the disease most likely existed in 
 a marked degree ; for of the thousands constantly exposed to 
 cold and moisture, comparatively very few get diabetes. Ano- 
 ther, and perhaps the most fertile exciting cause of mal- 
 assimilation in general, and particularly of saccharine mal- 
 assimilation, is malaria, I do not mean to assert that diabetes is 
 a malarious disease, though I have seen many cases of diabetes 
 from malarious districts. On the contrary, in such instances, I 
 suppose the predisposition existed ; and that the malaria, like the 
 
ASSIMILATION AND SECRETION. 
 
 21 
 
 cold and moisture, or perhaps in conjunction with cold and 
 moisture, was only incidentally the exciting cause. But al- 
 though diabetes can be hardly pronounced a malarious disease, 
 a very large proportion of the diseases arising from the mal- 
 assimilation of the saccharine principle may be justly so pro- 
 nounced. Indeed, I have no hesitation in expressing my be- 
 lief that almost every form of disease connected with the 
 development by the secondary assimilating processes, of oxalic 
 acid and the other indefinable (acid?) principles, down to lactic 
 acid ; are more frequently excited by malarious influence, than 
 by any other external cause. My attention was forcibly di- 
 rected, many years ago, to this fact, by seeing, in quick suc- 
 cession, several well-marked cases of oxalic acid disease from a 
 district notoriously malarious. Having been thus accidentally 
 led to observe the circumstance, a number of corroborative in- 
 stances soon occurred to me ; when, shortly after I had begun 
 to consider the point as established, the Asiatic cholera made 
 its appearance in this country. The effects produced by this 
 remarkable disease on the animal economy ; and the temporary 
 revolution in particular, which it occasioned in urinary diseases, 
 may not be uninteresting to the reader. 
 
 Every one is acquainted with the familiar fact, that the 
 most frequent and striking morbid appearances presented by 
 the urine from slight causes, (such as a cold, indigestion, &c.,) 
 are the common lateritious sediments. Now, the first circum- 
 stance that attracted my notice after the prevalence of the 
 Asiatic cholera, was the disappearance of these sediments from 
 the urine. The absence of these sediments was at first consi- 
 dered to be accidental ; but when, day after day, the same oc- 
 currence took place, I was induced to inquire attentively into 
 the circumstance, with the view, if possible, of ascertaining the 
 reason. On closer inspection, it was found that the urine of 
 every individual examined, whether in apparent health or 
 otherwise, not only presented the same absence of sediment ; 
 but also assumed that peculiar appearance, which I had been 
 accustomed to consider as characteristic of the presence of 
 
22 
 
 PATHOLOGY OF SACCHARINE 
 
 oxalic acid. As I had always previously found the oxalic acid 
 diathesis of unusual occurrence in London, I was much struck 
 with the phenomenon; and on reflection it occurred to me, 
 that it might be referable to the same unknown cause which 
 was then producing cholera. I was led to this notion from the 
 analogous effects above mentioned produced in the urine by 
 malaria ; and also by another curious fact, noticed below,^ which 
 likewise took place about the time the Asiatic cholera first made its 
 appearance, viz. a positive increase in the weight of atmospheric 
 air, similar to what might be supposed to be produced by the 
 diffusion of a heavy gaseous principle through the lower regions 
 of the atmosphere. My conclusion therefore was, that the 
 cause of the phenomenon in question, as well as of the cho- 
 lera, was a poisonous body analogous to malaria, whose high 
 specific gravity and feeble diffusive powers kept it near the 
 earth's surface, along which it insensibly crept, particularly in 
 
 • For some years before the Asiatic cholera appeared in this country, 
 I had been occupied with investigations regarding the atmosphere; and for 
 more than six weeks previously to the actual breaking out of this disease, 
 had almost every day been endeavouring to determine, with the utmost 
 possible accuracy, the weight of a given quantity of air, under precisely 
 the same circumstances of temperature and of pressure. On a particular 
 day, the 9th of February, 1832, the positive weight of the air suddenly 
 appeared to rise above the usual standard. As the rise, at the time, was 
 supposed to be the result of some accidental error, or of some derange- 
 ment in the apparatus employed, in order to discover its cause, the suc- 
 ceeding observations were made with the most rigid scrutiny. But no error 
 or derangement whatever could be detected. On the days immediately 
 following, the weight of the air still continued above the standard, though 
 not quite so high as on the 9th of February, when the change was first 
 noticed. The air retained its augmented weight during the whole time 
 the experiments were carried on, namely, about six weeks longer. The 
 increase of the weight of the air was small, but still decided and real. The 
 method of conducting the experiments was such as not to allow of an 
 error, at least to an amount so great as the additional weight, without 
 the cause of the error having become apparent- About the 9th of Fe- 
 bruary, the wind in London, which had previously been west, veered 
 round to the east, and remained pretty steadily in that quarter till the end 
 of the month. Now, precisely on the change of the wind the first cases 
 of epidemic cholera w^ere reported in London, and from that time the dis- 
 ease continued to spread. — See my Bridge water Treatise, page 351. 
 
ASSIMILATION AND SECRETION. 
 
 23 
 
 low and damp situations. Whether this conclusion was legi- 
 timate or not, others must decide. I do not think the point 
 worth contesting: but shall briefly mention the following 
 additional facts, connected with the subject. 
 
 During the prevalence of the above condition of the urine, I 
 likewise noticed, in almost every individual, an unusually acid 
 state of the saliva, and of the cutaneous exhalations ; such as I 
 . had never, indeed, before noticed, except in the last stages of 
 chronic diseases ; or in malarious affections. Besides these 
 circumstances, I also saw, about the time the cholera pre- 
 vailed, and a little afterwards, more cases of oxalate of lime 
 renal calculi, and of formidable haemorrhage from the kidneys, 
 &c., than I had ever previously seen during the whole of the 
 long period that urinary diseases had occupied my attention. 
 As the cholera disappeared, the above state of things gradually 
 subsided ; but I have sometimes imagined that the urine has 
 never completely recovered its former condition. Indeed, 
 during the last winter and spring, lithic acid deposites were 
 comparatively rare in London ; and the urine assumed much 
 the same appearance as during the prevalence of cholera, 
 though in a less marked degree.^' 
 
 Among the remote causes of saccharine derangements more 
 especially operating from within, may be mentioned the diet of 
 I individuals or of districts. That a free consumption of sugar 
 
 will in many persons (probably in certain seasons and in cer- 
 tain malarious districts more than in others) produce a tendency 
 to saccharine diseases, I have not the least doubt ; as I have re- 
 peatedly seen the oxalic acid diathesis kept in check, and 
 indeed entirely removed, by simple abstinence from sugar. 
 The same remark is applicable to certain articles used as food, 
 and containing the oxalic acid already formed; such as the 
 sorrel and rhubarb tribes of plants. Thus in certain districts 
 of Prance, where sorrel is much used, oxalate of lime calculi 
 
 * The winter and spring of 1837 and 1838 are here alluded to. Had 
 the condition of the urine at this time any connexion with the peculiar 
 fever then so prevalent ? 
 
24 
 
 PATHOLOGY OF SACCHARINE 
 
 are said to be very frequent."^ In this country, the only article 
 in common use that I am acquainted with, containing the 
 oxalic acid in large quantities, is rhubarb ; the stalks of which, 
 from their agreeable acidity, are much employed during the 
 spring months. I have seen repeated attacks of oxalate of lime 
 nephritic calculus follow the free employment of this article ; 
 and some of them so unequivocally traceable to its use, that no 
 doubt regarding the subject has been left on my mind. Hence 
 I have been long accustomed to prohibit this article to dys- 
 peptic individuals ; and though a strong stomach may assimilate 
 oxalic acid and many other matters equally poisonous, it would 
 be well, perhaps, if in all instances this organ were spared 
 such a trial of its strength. 
 
 To the head of deficient, and particularly of unwholesome diet, 
 may be referred the occurrence of those frightful epidemics 
 usually attendant on periods of scarcity ; and on wet and un- 
 favourable harvests. In such periods, and seasons, the Sac- 
 charine principle of the grain itself is either deficient in 
 quantity, or imperfectly developed. The consequence is, 
 that like the oxalic acid above mentioned, the poison is taken 
 ready formed with the food itself, and thus direct]y exerts its 
 baneful influence on the system. The same remarks apply, 
 perhaps in a still stronger degree, to food consisting of damaged 
 and putrescent animal matters. All writers on these epidemic 
 diseases agree in representing the blood of the sufferers as 
 unusually dark-coloured ; and moreover have generally as- 
 cribed these appearances of the blood to the presence of some 
 undefined principle of a poisonous nature. If this explanation 
 be admitted, it is obvious, as we have above stated, that such 
 poisonous principle can be only derived from the imperfect 
 condition or mal-assimilation of the alimentary matters ; and 
 particularly of the Saccharine principle. 
 
 There is an article much used in various ways, though 
 not as an aliment, the deleterious effects of which on the assi- 
 milating organs, &;c., require to be briefly noticed, viz. Tobacco. 
 * See note, page 17. 
 
ASSIMILATION AND SECRETION. 25 
 
 Although confessedly one of the most virulent poisons in 
 nature ; yet such is the fascinating influence of this noxious 
 weed, that mankind resort to it in every mode they can devise, 
 to ensure its stupifying and pernicious agency. Tobacco 
 disorders the assimilating functions in general, but particu- 
 larly, as T believe, the assimilation of the Saccharine principle. 
 I have never, indeed, been able to trace the development of 
 oxalic acid to the use of tobacco ; but that some analogous and 
 equally poisonous principle (probably of an acid nature) is 
 generated in certain individuals by its abuse, is evident from 
 their cachectic looks ; and from the dark, and often greenish 
 yellow tint, of their blood. The severe and peculiar dyspeptic 
 symptoms sometimes produced by inveterate snuff-takingare well 
 known ; and I have more than once seen such cases terminate 
 fatally with malignant disease of the stomach and liver. Great 
 smokers also, especially those who employ short pipes and cigars, 
 are said to be liable to cancerous affections of the lips.* But 
 it happens with tobacco, as with deleterious articles of diet ; 
 the strong and healthy suffer comparatively little, while the 
 weak and predisposed to disease fall victims to its poisonous 
 operation. Surely, if the dictates of reason were allowed to 
 prevail, an article so injurious to the health, and so offensive 
 in all its forms and modes of employment, would speedily be 
 banished from common use. 
 
 These observations might be much extended, did the practi- 
 cal nature of our treatise admit. What has been given, is 
 intended merely as a sketch or outline to draw the attention of 
 observers to the subject; and which they must fiil up and 
 complete. We pass on now to the consideration of some of 
 the more remarkable diseases connected with the Saccharine 
 principle. 
 
 * This has been referred to the continued action of the heat of the pipe 
 or cigar upon the lips ; but there is reason to believe that this cause alone 
 is not sufficient to explain the circumstance ailuded to in the text. 
 
26 PATHOLOGY OF SACCHARINE ASSIMIJiATION AInD SECRETION. 
 
 Section a. Of Diabetes. 
 
 The term Diabetes, implying simply an increased flow of 
 urine, is applicable to any disease in which that symptom is 
 present in a remarkable degree. This general use of the term, 
 however, has caused a great deal of confusion ; as a variety of 
 diseases, differing altogether in their nature except in the acci- 
 dental circumstance of being accompanied by diuresis, or a 
 large flow of urine, have in consequence been confounded one 
 with another. To prevent this confusion in future, I would 
 recommend that the term be restricted to those afiections in 
 which the urine is saccharine. Hence I define Diabetes to be 
 a disease in which a saccharine state of the urine is the charac- 
 teristic symptom. 
 
 Diabetic urine is almost always transparent, and of a pale 
 straw or greenish colour. Its smell is commonly faint and pecu- 
 liar ; somewhat resembling sweet hay or milk ; and its taste 
 is usually saccharine in a greater or less degree. The specific 
 gravity of diabetic urine has been stated to vary from 1020 to 
 1050 ; but I have once or twice seen the specific gravity of 
 saccharine urine as low as 1015 ; and many times as high as 
 1055, or even higher. The quantity of urea is sometimes much 
 diminished ; though I have never met with a specimen in 
 which this principle was entirely absent ; and, in some in- 
 stances, urea is said to exist in diabetic urine in greater pro- 
 portion than natural. Lithic acid also is usually found in sac- 
 charine urine in greater or less quantity; and in favourable 
 cases of the disease, the quantity of this acid is often very con- 
 siderable. The usual saline matters existing in the urine 
 are met with in diabetic urine in nearly the same relative pro- 
 portions as in health ; but the absolute quantity of saline 
 matters, viewed in relation to the quantity of urine passed, is 
 
DIABETES. 
 
 27 
 
 much diminished. Sometimes diabetic urine contains a little 
 blood and not unfrequently albuminous matter, analogous 
 to that of chyle. I have seen it also contain a white milky- 
 like fluid, precisely similar to chyle, which slowly subsided 
 to the bottom of the vessel. In this case the vinous fermen- 
 tative process was induced very rapidly in the urine ; the chy- 
 lous matter apparently acting like yeast. 
 
 TABLE. 
 
 Specific gravity com- 
 pared with 1000 parts 
 of water at 60°. 
 
 Quantity of solid ex- 
 tract in a wine pint. 
 
 Quantity of solid ex- 
 tract in a wine pint, in 
 
 
 qrains. 
 
 
 dr. 
 
 
 
 1020 
 
 382-4 
 
 0 
 
 6 
 
 1 
 
 2 
 
 1021 
 
 401-6 
 
 0 
 
 6 
 
 2 
 
 1 
 
 1022 
 
 420-8 
 
 0 
 
 7 
 
 0 
 
 0 
 
 1023 
 
 440-0 
 
 0 
 
 7 
 
 1 
 
 0 
 
 1024. 
 
 459-2 
 
 0 
 
 7 
 
 1 
 
 19 
 
 1025 
 
 478-4 
 
 0 
 
 7 
 
 2 
 
 18 
 
 1026 
 
 497-6 
 
 1 
 
 0 
 
 0 
 
 17 
 
 1027 
 
 516-8 
 
 1 
 
 0 
 
 1 
 
 16 
 
 1028 
 
 536-0 
 
 1 
 
 0 
 
 2 
 
 16 
 
 1029 
 
 555-2 
 
 1 
 
 1 
 
 0 
 
 15 
 
 1030 
 
 574-4 
 
 1 
 
 1 
 
 1 
 
 14 
 
 1031 
 
 59^6 
 
 I 
 
 1 
 
 2 
 
 13 
 
 1032 
 
 612-8 
 
 1 
 
 2 
 
 0 
 
 12 
 
 1033 
 
 632-0 
 
 
 2 
 
 1 
 
 12 
 
 1034 
 
 651-2 
 
 I 
 
 2 
 
 2 
 
 11 
 
 1035 
 
 670-4 
 
 1 
 
 3 
 
 0 
 
 10 
 
 1036 
 
 689-6 
 
 1 
 
 3 
 
 1 
 
 9 
 
 1037 
 
 T08-8 
 
 1 
 
 3 
 
 2 
 
 8 
 
 1038 
 
 728-0 
 
 1 
 
 4 
 
 0 
 
 8 
 
 1039 
 
 747-2 
 
 1 
 
 4 
 
 1 
 
 7 
 
 1040 
 
 766-4 
 
 1 
 
 4 
 
 2 
 
 6 
 
 1041 
 
 785-6 
 
 1 
 
 5 
 
 0 
 
 5 
 
 1042 
 
 804-8 
 
 1 
 
 5 
 
 1 
 
 4 
 
 1043 
 
 824-0 
 
 1 
 
 5 
 
 2 
 
 3 
 
 1044 
 
 843-2 
 
 1 
 
 6 
 
 0 
 
 3 
 
 1045 
 
 862-4 
 
 
 6 
 
 1 
 
 2 
 
 1046 
 
 881-6 
 
 1 
 
 6 
 
 2 
 
 1 
 
 1047 
 
 900-8 
 
 1 
 
 7 
 
 0 
 
 0 
 
 1048 
 
 920-0 
 
 1 
 
 7 
 
 1 
 
 0 
 
 1049 
 
 939-2 
 
 1 
 
 7 
 
 1 
 
 19 
 
 1050 
 
 958-4 
 
 1 
 
 7 
 
 2 
 
 18 
 
 * Watt on Diabetes, pp. 47, 74 
 
28 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 The preceding table, constructed by Dr. Henry, shows the 
 quantity of solid extract in sixteen ounces of urine of different 
 specific gravities, from 1020 to 1050. In the experiments which 
 furnished the data of this table, the urine was evaporated by a 
 steam heat till it ceased to lose weight ; and till it left an 
 extract which became solid on cooling. =^ 
 
 This table enables us to ascertain with considerable precision 
 the quantity of solid matter voided by a diabetic patient in a 
 given time. Thus, suppose ten pints (old wine measure) are 
 passed in twenty-four hours, of the average specific gravity of 
 1-040 ; it appears from the table that this quantity will contain 
 lOx Ipz- 4 dr. 2scr. 6grs. = 15 oz. 7 dr. 2scr. ; or upwards of a 
 pound and a quarter of solid extract. 
 
 A saccharine condition of the urine, as before observed, is the 
 characteristic symptom of Diabetes ; but another most striking 
 and almost constant symptom present is diuresis. Diuresis 
 exists in every possible degree ; and sometimes the quantity of 
 urine voided is enormous. Thus cases are on record in which 
 thirty pints and upwards have been discharged in twenty-four 
 hours, for weeks and even for months together. In such in- 
 stances, the quantity of urine voided has been said to be more 
 than double the whole ingesta — a circumstance which physio- 
 logists have puzzled themselves a good deal to explain. I be- 
 lieve, however, that in the best authenticated cases, this enor- 
 mous difference between the quantity of fluid taken, and of 
 urine passed, has not been observed, f 
 
 The other symptoms, and general history of Diabetes may 
 be thus stated. The commencement of diabetic attacks can 
 seldom be accurately determined ; but by inquiring minutely as 
 to the period when the urine was last observed to be turbid, I have 
 several times traced attacks very nearly to their origin. In 
 
 * Annals of Philosophy, (Old SerieSj) vol. i. p. 27. 
 
 t Watt on Diabetes, p. 158. Mr. McGregor, in the paper before 
 alluded to, has shown that the weight of the egesta occasionally surpasses 
 that of the ingesta ; and refers the difference, as others have done, to ab- 
 sorption of fluid by the lungs. 
 
DIABETES. 
 
 29 
 
 such instances, patients have usually stated, that at some former 
 period, the continued turbidity of the urine was such as to at- 
 tract their observation ; and on being questioned as to the sup- 
 posed cause of such turbidity, some have ascribed it to exposure 
 to cold ; others to an attack of gout or rheumatism ; others to 
 disordered health from mental anxiety ; &;c. In most instances, 
 the cessation of this turbidity was not accurately noticed ; in a 
 few, the termination was observed to take place rather abrupt- 
 ly ; and the urine, on becoming clear, was likewise observed to 
 become increased in quantity. Now it is probable that at the 
 time the urine became clear, its saccharine condition com- 
 menced, or at least became confirmed ; though, in general, 
 the increased flow of urine was not so great, as to attract the 
 patient's attention for several weeks ; sometimes for several 
 months, after this period. At the commencement, and during 
 this early stage of diabetes, the following are among the most 
 usual and prominent attendant symptoms. 
 
 In proportion as the urine becomes clear and copious, the 
 mouth becomes clammy ; the tongue loaded with a white frothy 
 mucus; and the thirst increases. The appetite, nevertheless, 
 remains unimpaired ; indeed, in general is better than ordi- 
 nary ; yet the patient, to his surprise, daily loses flesh and 
 strength; and finds himself less and less adequate to his 
 former exertions, both bodily and mental. At this time also he 
 usually complains of chilliness, accompanied by dull pain and 
 sense of fatigue in the back and loins, and in the lower extre- 
 mities. The skin likewise becomes dry and harsh ; and the 
 bowels more or less constipated. Such are the symptoms, 
 with modifications, which usually present themselves in the 
 earlier stages of diabetes ; and if the disease be now recognised 
 and properly treated, its progress may in many instances be 
 arrested ; or the disease, for the present, may perhaps be re- 
 moved altogether. But if, as is unfortunately often the case, 
 the patient neglects to apply for medical advice at this early 
 period of the affection ; or if the nature of the disease be over- 
 looked, and it be treated as a common affection of the general 
 
30 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 health, with blue pill, &:c. ; all the symptoms soon rapidly in- 
 crease, and the affection assumes the form of confirmed Dia- 
 betes. 
 
 In the second or confirmed stage of Diabetes, the quantity 
 of urine is increased far above the natural standard ; and the 
 thirst, and all the accompanying symptoms, increase in pro- 
 portion. The mouth is constantly dry and parched ; the 
 edges, and finally the whole tongue, become preternaturally 
 clean and red ; the gums are often spongy, bleed readily, and 
 by contracting from the teeth, leave them liable to become 
 loose. There is a frequent uneasiness and heat in the region 
 of the stomach; accompanied by a sensation of sinking and 
 faintness, and a consequent incessant craving after food and 
 drink, which are taken in inordinate quantities. Still the 
 thirst is not allayed ; nor the hunger satiated ; nor the flesh nor 
 strength increased ; on the contrary, the emaciation and debi- 
 lity progress rapidly ; the quantity of urine, particularly in cold 
 and damp weather, becomes greater than ever ; and the per- 
 son and breath of the patient often exhale a sweetish hay-like 
 odour. Accompanying these bodily symptoms there is great 
 depression of spirits and despondency ; the once vigorous mind 
 becomes feeble, oblivious, and vacillating— the once amiable 
 temper, fretful, suspicious, and intolerant. The pulse, which 
 had hitherto been but slightly affected, is now usually quicker 
 than in health, and indicates debility. As the disease proceeds, 
 disorganisation of some important organ, particularly of the 
 lungs, commences or becomes active. In addition to the 
 other symptoms, there are now flying pains about the chest ; the 
 breath becomes short ; and there is more or less of cough and 
 expectoration. This constitutes the last, and usually the brief- 
 est stage of the disease. The emaciation and debility now 
 rapidly approach the maximum ; the tongue and fauces assume 
 a dark-red colour, and often become aphthous ; the urine gene- 
 rally diminishes in quantity, and loses much of its saccharine 
 property ; the feet and legs become oedematous ; and, finally, 
 after almost a total suppression of the renal secretion, ^he pa- 
 tient becomes comatose, in which state he expires. 
 
DIABETES. 
 
 31 
 
 Such is the history of Diabetes in its simplest form. We 
 shall briefly illustrate some of the more prominent symp- 
 toms, with the view of pointing out their modifications and 
 complications. 
 
 The thirst is an invariable symptom ; I have never seen it 
 entirely absent ; but some suffer much more from thirst than 
 others, even in the same stage of the disease. Thirst increases 
 by indulgence in the use of fluids ; and those who drink most, 
 invariably suffer most from this distressing symptom. The 
 appetite is often capricious and deficient in the early stages of 
 Diabetes ; and in a few instances is not inordinate at any 
 period. 
 
 A dr2/ state of the skin is one of the next most constant 
 symptoms present in Diabetes. I have, however, seen many 
 cases of confirmed Diabetes in which this symptom was want- 
 ing ; and in which perspiration, and even profuse sweating, was 
 induced by slight exercise. The same may be remarked of 
 constipation of the bowels ; which is by no means invariably 
 present in Diabetes. Even the chilliness so frequently com- 
 plained of in Diabetes is not constantly present ; and I have 
 seen one or two cases in which the patient was almost insen- 
 sible to the effects of cold, however intense. 
 
 The red state of tongue, and the sense of heat in the stomach, 
 which usually accompany this symptom, frequently extend to 
 the urinary organs ; where it appears in the form of inflam- 
 matory redness at the external orifice of the urethra ; and 
 sometimes in the form of phymosis. These symptoms are 
 occasionally among the first that have been noticed in diabetic 
 individuals ; while in other individuals they never appear at 
 all.* 
 
 Emaciation and debility are almost invariable symptoms ; 
 yet Diabetes is not a disease peculiar to spare and feeble 
 habits : for I have repeatedly met with it in individuals from 
 
 * This inflammatory irritation about the orifice of the urethra 
 is often a source of great annoyance and suffering to females labouring 
 under Diabetes. 
 
32 PATHOLOGY OF SACCHARINE ASSIMILATJON AND SECRETION*. 
 
 whose appearance alone it never should have been suspected ; 
 and in two instances I have seen Diabetes occur in unusually 
 fat and powerful individuals. In the first of these instances, 
 the patient was a middle-aged gentleman who had spent many 
 years of his life in India, from whence he had returned, I be- 
 lieve, on account of bad health. About the period of his re- 
 turn he informed me that he weighed twenty-seven stone, or 
 nearly three hundred weight and a half! When he consulted 
 me a few months afterwards, he weighed twenty-three stone. At 
 this time he laboured under well-marked symptoms of Diabetes ; 
 the urine was large in quantity, and very saccharine ; the 
 thirst was most urgent ; there was troublesome phymosis, &;c. 
 He was put on the plan to be presently detailed, and in a few 
 weeks went on the Continent. Shortly afterwards, at Aix-la- 
 Chapelle, where he had used the baths, he was seized with a 
 violent nephritic attack,, with bloody urine, &;c., apparently 
 caused by renal calculus ; but none was observed. Nearly two 
 years elapsed before I again saw^ him, when he informed me 
 that he had rigidly adhered to my advice, and was quite well. 
 His weight was now about twenty-one and a half stone. The 
 specific gravity of his urine was under 1030 ; it was free from 
 sugar ; abounded in the common lithate of ammonia sediments ; 
 and was natural in quantity. The thirst, phymosis, kc, had 
 also left him. He was able to take a great deal of exercise, 
 and shortly afterwards returned to India ; since which time 
 I have not heard of him. The second instance was that 
 of an athletic gentleman about sixty, weighing upwards of 
 seventeen stone. When I first saw him, three years ago, the 
 urine was much above the healthy standard, and very sac- 
 charine. He suffered also from constant thirst, &;c. Under 
 the plan prescribed, the urine soon became much diminished 
 in quantity, and the thirst less urgent ; and he now feels little 
 inconvenience from either. He has also gained considerably 
 in weight ; though the urine still contains sugar. About two 
 years ago, also, a third instance of Diabetes occurred to me, 
 in an athletic and corpulent man, whom I have not since 
 
DIABETES. 
 
 33 
 
 seen. I learn, however, from his friends, that he goes on with- 
 out suffering much inconvenience ; but whether the urine still 
 remains saccharine, I have had no opportunity of ascertaining. 
 
 Dehility is always present in Diabetes, particularly in the 
 last stages of the disease ; when both emaciation and debility 
 often become extreme. These, however, as well as many 
 others of the distressing symptoms of Diabetes, are obviously 
 referable to the enormous drainage from the system, rather 
 than to the mere saccharine condition of the urine. " The 
 loss of so much matter from the system," as Dr. Elliotson 
 justly remarks, " sufficiently explains the hunger ; the feeling 
 of emptiness and sinking in the stomach; the emaciation; 
 debility ; anaphrodisia ; coldness of the legs ; pains both of 
 them and of the loins ; the depression of spirits, &;c., without 
 attributing the disease to the stomach or kidneys exclusively. 
 The excessive escape of fluid, or, when this does not take 
 place, the feverishness, equally explains the thirst and dryness 
 of the skin."^ That this is a just explanation is proved by the 
 fact, that under a proper regimen, &c., most of these symptoms 
 disappear along with the increased flow of urine. To mention an 
 extreme instance, I may state, that I knew a gentleman who 
 long laboured under confirmed Diabetes, and who recovered 
 so far as to marry and to have two children ; though the 
 saccharine condition of the urine never left him. Indeed a 
 saccharine condition of the urine exists in dyspeptic and gouty 
 individuals much oftener than is supposed; and hundreds 
 pass many years of their lives, with this symptom more or less 
 constantly present, who are quite unaware of it, till the quan- 
 tity of urine becomes increased. 
 
 With respect to the terminations of Diabetes ; phthisis, as 
 already stated, is the most frequent. Besides phthisis, however, 
 I have seen Diabetes prove fatal by disease of the liver and 
 jaundice ; by apoplexy ; by a peculiar affection of the stomach, 
 
 * Numerous cases illustrative of the efficacy of hydrocyanic or prus- 
 sic acid in affections of the stomach, &c., p. 90. 
 
34 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 brought on by improper food, or by over-distension; by 
 acute gastritis induced by taking cold fluids when heated ; 
 by inflammatory fever excited by exposure to cold, and rapidly 
 assuming the typhoid character ; &;c. Occasionally Diabetes is 
 said to terminate in incurable dropsy, and in various other 
 afiections. In short, a great many circumstances which would 
 not afiect a sound constitution, often prove fatal in this disease. 
 Hence a diabetic individual may be considered as existing on 
 the brink of a precipice ; and the general prognosis must be 
 always unfavourable. 
 
 Causes, — It is a remarkable fact, that Diabetes seems to be 
 peculiar to mankind. Horses and other animals are indeed 
 subject to diseases accompanied by a large flow of urine ; but I 
 am assured that in such cases the urine is never saccharine ; 
 nor am I aware that sugar has been found in the urine of any 
 inferior animal. If such an immunity from Diabetes really 
 exists among the inferior animals, its cause is very obscure. 
 Can the exemjDtion be referred to the absence of that fertile 
 cause of bodily disorder in human beings, the influence of 
 mind ? 
 
 A predisposition to Diabetes is, I believe, much more fre- 
 quently inherited than acquired ; I have seen repeated instances 
 of such an inherited, and family tendency ; and the circum- 
 stance has been noticed by others, so that I do not think it 
 necessary to enter into details on this point. Other causes 
 predisposing to this affection may be classed under the heads 
 of temperament, sex, and age. Thus I have seen more cases 
 of Diabetes in individuals of the sanguine temperament with 
 light or reddish hair, than in any other. The disease, how- 
 ever, occurs in all temperaments ; and perhaps next in fre- 
 quency to the sanguine, in the melancholic temperament. In 
 strumous individuals, with dark hair and eyes, fair skin, &;c.. 
 Diabetes often assumes its most unmanageable and fatal form. 
 Diabetes is less frequent in w^omen than in men ; and rarely 
 occurs in infancy or in old age. There is, however, a modi- 
 
DIABETES. 
 
 35 
 
 fication of Diabetes occasionally occurring in very young chil- 
 dren, to which the attention of the profession was first dis- 
 tinctly drawn by Dr. Venables ; and of which we shall presently 
 speak.* 
 
 A predisposition to Diabetes may, however, be acquired as 
 well as inherited ; and that perhaps by a variety of causes. To 
 some of these causes we have before alluded ; and it is only 
 necessary to mention here, that a predisposition to this affec- 
 tion seems to be occasionally acquired by a residence in a cold 
 and damp situation, or in a malarious district, particularly if 
 at the same time conjoined with a poor and unwholesome diet, 
 or the too free use of sugar, &c. ; also by venereal excesses ; 
 by the abuse of mercury ; and, in short, by any cause having 
 a tendency to sap the foundations of organic life ; and more 
 especially of the processes of assimilation. 
 
 The exciting causes of Diabetes have not been so clearly 
 ascertained as could be desired ; but it is probable that when a 
 strong predisposition to the disease exists, a variety of slight 
 circumstances will bring on the affection. The most frequent 
 exciting causes that have fallen under my own notice, have 
 been exposure to cold ; attacks of rheumatism and of gout ; the 
 drinking of cold fluids while heated ; mental anxiety or dis- 
 tress arising from a variety of causes, such as a sudden reverse 
 of fortune ; &;c. Other causes assigned by authors have been 
 the too free use of diuretic and diluent fluids, as cider. Also 
 concussions or injuries of the back, from hard riding ; or from 
 falls, strains, &;c. Another class of causes, or rather of concur- 
 rent diseases, are various affections of the cutaneous and cellular 
 tissues. I have seen several instances referable to this class ; 
 and were I permitted to draw a general inference from my 
 experience, I should say, that Diabetes w.&\]idX\j follows cutaneous 
 affections ; and accompanies (perhaps precedes) the affections 
 of the cellular tissue. Thus I have several times heard patients 
 observe, that they were formerly subject to eruptions in various 
 
 * See a Practical Treatise on Diabetes, &c., by R. Venables, M.B., &c. 
 
 D 2 
 
36 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 parts of the body, but that such eruptions disappeared after 
 the diabetic complaint became established ; nor do I remember 
 more than one instance, in which Diabetes actually accom- 
 panied a severe cutaneous affection. On the contrary. Dia- 
 betes very frequently (as far as my personal experience goes, 
 always) accompanies carbuncles, and malignant boils or ab- 
 scesses allied to carbuncles. This is a fact mentioned by several 
 of the older writers ; and is of great importance to surgeons, 
 who usually have the management of these affections. Some 
 years ago, an interesting case of this kind occurred to me. 
 The patient was a middle-aged man, who told me that for a long 
 period he had been subject, at intervals of a year or two, to 
 boils, one of which, generally on the back or neck, assumed the 
 form of carbuncle ; and that, during such attacks, he always 
 passed a large quantity of saccharine urine. When I saw him, 
 he was recovering from one of these carbuncular suppurations; 
 and the urine was copious and very saccharine. I lost sight 
 of him soon afterwards, and am therefore unable to state 
 whether the urine, in the interval of the attacks, recovered its 
 healthy character. He repeatedly assured me, however, that 
 its quantity, after a certain time, always became quite natural. 
 
 The proximate cause of Diabetes has much puzzled physi- 
 ologists ; and a great deal has been said and written on the 
 subject, which it would be useless to repeat here. If the 
 principles advanced in the introduction to this volume be well 
 founded, the proximate cause of Diabetes may be at least as 
 intelligibly explained, as the proximate cause of any other 
 disease. According to these principles, the proximate cause of 
 Diabetes lies partly in the assimilating organs, and partly in 
 the kidneys ; and may be thus stated. f 
 
 * See Cheselden s Anatomy, p. 139. Fifth Edition. 
 
 t To prevent the necessity for reference, the principles alluded to, as far 
 as they are involved in the present question, may be thus briefly re-stated. 
 1st, That the assimilation of the Saccharine principle isa distinct function ; 
 2nd, That the cellular tissue represents the Saccharine aliment ; 3rd, That 
 a secondary assimilating process, analogous to that in the digestive or- 
 gans, is constantly going on in all parts of the body ; and lastly. That 
 
DIABETES. 37 
 
 When crystallised sugar is taken into the stomach by a 
 diabetic individual, it is reduced to a low state, remains more 
 or less unassimilated, and passes through the system to the 
 kidneys, by which organs (being already crystallisable) it is 
 separated unchanged. 
 
 When organised saccharine principles, as farinaceous matters, 
 &c., are taken into the diabetic stomach, they are in the first 
 place reduced to the form of low sugar; part of which low 
 sugar is assimilated as in the healthy stomach ; while another 
 part is modified or remains unassimilated. The portion that is 
 assimilated is applied to the purposes of the economy ; the 
 portions modified and unassimilated pass together through the 
 system to the kidneys, by which glands, the portion modified 
 is disorganised, and finally appears in the urine as crystallisable 
 sugar, along with the portion originally remaining unassimi- 
 lated in the stomach. The same remarks are applicable to gela- 
 tinous, and in extreme cases, perhaps, to albuminous and ole- 
 aginous aliments. The secondary assimilating processes in dia- 
 betic individuals participate in the derangements of the primary 
 processes just detailed ; — that is to say, the gelatinous tissues 
 are either reduced to sugar, and thus not assimilated at all ; or 
 they are imperfectly assimilated ; or they are mal-assimilated ; 
 in all which conditions, the saccharine principle derived from 
 the gelatinous and other tissues, may be supposed to pass 
 through the system to the kidneys ; by which organs, like 
 similar matters brought from the stomach, the various modifi- 
 cations of the saccharine principle are further disorganised, and 
 converted into crystallisable sugar.^ 
 
 Such are the modes in which the phenomena of Diabetes 
 
 an important function of the kidneys is of a disorganising character ; 
 that, is, consists in the reduction of organised into crystallisable com- 
 pounds. 
 
 * These views seem to be almost demonstrated by the important ob- 
 servations of Mr. M'Gregor, before alluded to. Mr. M'Gregor found that 
 sugar is not only developed from vegetable and animal matters in the 
 stomach ; but that it exists in the blood, saliva, Ike, and even in the alvine 
 evacuations of a diabetic patient. 
 
38 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 appear explicable on our principles. I shall not trouble the 
 reader with corroborative details ; but shall mention one cir- 
 cumstance only illustrative of the subject, on account of its 
 practical importance. When, in diabetic individuals, the dis- 
 organising function of the kidneys is suspended ; or when 
 these glands are partially diseased, the urine, besides albuminous 
 matters and more or less of crystallisable sugar, often contains 
 the saccharine principle in imperfectly developed forms. Hence 
 such urine, almost without perceptibly becoming vinous, passes 
 at once into the lactic or acetous fermentation ; and acquires, 
 from the quantity of lactic and acetic acids developed, the 
 strong acid smell of sour milk.* 
 
 The Diagnosis, for the most part, is sufficiently easy in Dia- 
 betes. When the urine of an individual is constantly/ of a pale 
 colour, transparent, and of a specific gravity of 1030 or up- 
 wards, the presence of Diabetes may be suspected, even though 
 the quantity of the secretion may not exceed the standard of 
 health. If the properties of the urine above mentioned be oc- 
 casional only. Diabetes may or may not be present ; and in 
 this and in other doubtful cases, recourse must be had to the 
 means pointed out in the introduction, for determining the 
 presence or absence of sugar in the urine. 
 
 The general Prognosis in Diabetes must, as already stated, 
 be considered as unfavourable. 
 
 Among the favourable symptoms in this affection may be 
 enumerated, a moderate flow of urine of a specific gravity not 
 higher than 1035 ; the appearance in the urine of lithic acid 
 either in its amorphous or crystallised form ; the recent ap- 
 pearance of the disease, and absence of thirst ; the retention or 
 gain of flesh and strength ; and more than all, immunity from 
 organic disease, more especially from organic disease of the 
 lungs. On the contrary, when the flow of urine is permanently 
 excessive, and of high specific gravity ; or when this secretion 
 
 * This phenomenon is often exhibited by the chylous urine, to be 
 hereafter mentioned; a disease in which the disorganising function of the 
 kidneys is either destroyed, or suspended. 
 
DIABETES. 
 
 39 
 
 is pale coloured, opalescent, and serous ; when the thirst, 
 emaciation, and debility are extreme ; or when organic disease, 
 particularly of the lungs, is present, the chance of recovery is 
 much diminished. But when, as is too frequently the case, 
 several, or all of these unfavourable symptoms co-exist ; the 
 chance of recovery is not only diminished, but absolutely hope- 
 less. 
 
 The post mortem appearances throw little satisfactory light 
 on the nature of Diabetes. As may be inferred from what has 
 been stated ; in different instances, different organs have been 
 found affected ; while in other instances, scarcely a trace of 
 disease has been discovered in any organ. Thus, besides the 
 lungs, which are the organs most generally affected, I have 
 seen, in different individuals, the liver, the mesenteric glands, 
 the prostate gland and bladder, and one or both kidneys, in 
 a state of organic disease ; while, in other individuals, each and 
 all of these organs have been observed to be apparently sound. 
 Such diversity in the organs affected, and particularly the oc- 
 casional absence of all organic disease, seem to render it pro- 
 bable, that the presence of sugar in the system neither neces- 
 sarily depends on, nor produces visible organic lesion of any 
 particular organ ; but that organic diseases, when they do 
 exist, are merely concurrent affections. This inference is still 
 further corroborated by the fact, that sugar is constantly pass- 
 ing through the sanguiferous system in Diabetes, without pro- 
 ducing any very striking disturbance, much less organic disease. 
 This remarkable peculiarity of the saccharine principle proba- 
 bly arises no less from its mild and innoxious character, than 
 from its great solubility in water. Did sugar possess active 
 properties ; or were it as insoluble as the albuminous princi- 
 ple ; there can be little doubt that the constitutional disturb- 
 ance produced by it would be much greater ; and that morbid 
 deposites and organic diseases would be a frequent consequence 
 of its presence in the blood. 
 
 The most constant diseased appearances I have noticed 
 after death in diabetic individuals have been rather of a die- 
 
40 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 mico-mecbanical nature, than strictly organic. These diseased 
 appearances may be comprised under the following three 
 heads : First, an enlarged, flaccid, and occasionally a congested 
 state of the kidneys ; a section of which organs, when first re- 
 moved from the recently dead body, has usually assumed, on 
 exposure to the air, a peculiar deep orange-red tint, diflicult to 
 be described ; Secondly, a gorged condition of the veins termi- 
 nating in the portal system, particularly of the veins of the 
 mesentery ; and an unusually dark-coloured and fluid condi- 
 tion of the venous blood throughout the assimilating organs ; 
 Thirdly, but not so constantly, a vascular state of the mucous 
 membrane of the stomach, and upper portion of the alimentary 
 canal. 
 
 Treatment. — The treatment of Diabetes proposed by authors 
 has been as various as their opinions respecting its nature ; 
 and perhaps there is no disease in which so much mischief has 
 been done on false principles, and by random experiment, as 
 in this. The facts and observations I have to oSer on the 
 subject, are founded on the opinion abeady advanced, viz. 
 that Diabetes is nothinoj more nor less than a form of dvs- 
 pepsia ; that this dyspepsia principally consists in a difficulty 
 of assimilating the saccharine alimentary principle ; and that, 
 like all other forms of dyspepsia, whether it be an inherited 
 or an induced afiection, Diabetes is liable to be much modified 
 and aggravated by concomitant circumstances. 
 
 In a practical point of view, Diabetes ought always to 
 be considered in a twofold light ; as a simple saccharine 
 condition of the urine, without any increase in its quantity ; 
 and as complicated, with a preternatural flow of that secretion. 
 Want of attention to this simple distinction has caused great 
 confusion in the history of the disease ; and substances in con- 
 sequence have been extolled as remedies, which have acted 
 simply by diminishing the flow of urine and its consequences, 
 without altering in the least degree its saccharine condition. 
 Whether there be any remedy that exerts a specific action in 
 improving the qualities of the urine, is exceedingly doubtful ; 
 
DIABETES. 
 
 41 
 
 certainly, at least, there is none at present known. If, there- 
 fore, the qualities of the urine be improved at all, they must, I 
 think, be improved through the medium of those remedies that 
 have a tendency to diminish the quantity of the urine, and 
 to restore the general health. At any rate, these are necessary 
 as preliminary steps ; for it seems to be quite absurd to look 
 for any improvement in the quality of this secretion, while its 
 quantity remains unnatural. 
 
 The first and chief point to be attended to in the treatment 
 of Diabetes is diet ; under which head are included both solid 
 and liquid aliments. 
 
 For some years past, a diet exclusively animal has been 
 much insisted on in this disease ; and, from the principles we 
 have attempted to establish, it will be readily understood that 
 an animal diet ought to form an essential principle in the 
 treatment. I do not, however, approve of a diet exclusively 
 animal ; but consider a certain proportion of farinaceous 
 matters proper. The recommendation of this admixture of 
 farinaceous matters is founded upon a fact already alluded to, 
 and apparently well established, viz. that the assimilation of 
 the saccharine principle is one of the last functions that be- 
 comes extinct in animals. The proportions of these two forms 
 of aliment must be varied according to the circumstances of the 
 patient ; and particularly according to the degree in which he 
 is able to assimilate albuminous, in preference to farinaceous 
 matters ; a point not difficult to be determined by a little 
 attention. Of farinaceous matters, the high or strong, as the 
 farina of wheat in the shape of bread, &;c., seem to be most 
 easily assimilated. The low kinds of farinaceous matters, as 
 arrow root, potatoes, &;c., (with the exception perhaps of rice^) 
 seem to be reduced to a species of sugar, more difficult of assi- 
 milation than the sugar from wheat flour, &:c., and in general, 
 therefore, should be avoided. Every variety of the saccharine 
 principle in its crystallisable form, is absolutely inadmissible as 
 an article of food in Diabetes. This rule excludes therefore, 
 at once, all fruits, whether subacid or sweet ; as well as every 
 
42 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 compound, natural or artificial, into which sugar enters. The 
 practical importance of this rule is so great, that I am doubt- 
 ful, if it be neglected, whether good can be obtained from any 
 plan of treatment. Even its occasional infringement cannot 
 be indulged with impunity. Thus I have known the use of 
 a few saccharine pears undo, in a few hours, all that I had 
 been labouring for months to accomplish; and the disease, 
 with all its horrors, has been re-established in an aggravated 
 form. In the use of all prohibited articles. Dr. Johnson's 
 saying with respect to himself, viz. that he found it easier 
 to abstain than to be abstemious, should be constantly kept in 
 view. In general, therefore, in diabetic cases, it will be found 
 much better to prohibit altogether the use of doubtful articles, 
 than to allow a little of them to be taken : for the latitude which 
 inclination gives to the term little, and the want of stoicism to 
 resist, are certain to lead to abuse and all its consequences. 
 
 A point to be attended to, of fully as much importance as 
 the qualities of diet, is its quantity. The constant craving for 
 food which is generally present in this disease, is liable to in- 
 duce the patient to take by far too much at one time ; the con- 
 sequences of which are not only unfavourable to his recovery, 
 but sometimes dangerous, and even fatal. Indeed, I believe 
 the greater number of cases of sudden death in Diabetes (which 
 is by no means an uncommon termination of it) have been 
 distinctly referable to errors either in the quality or quantity 
 of the food, or to both ; that is to say, the patient has been 
 usually cut off after a hearty meal, as it is vulgarly termed. As 
 a general rule with respect to diet, it may be said that a quan- 
 tity, greater or less according to circumstances, but always 
 strictly regulated, should be taken at periods of four, five, or 
 six hours; and that at the time of taking solid food, and for an 
 hour or two afterwards, all fluids should be abstained from as 
 much as possible. Were I to particularise the species of food, 
 I should say, generally, that mutton or beef, plainly cooked, 
 and particularly mutton-chops or beef-steaks, rarely done, 
 should be taken twice in the twenty-four hours ; and that the 
 
DIABETES. 
 
 43 
 
 other meals should consist of any simple article that can be 
 prepared from farinaceous matters with milk, eggs, &c., only.* 
 The recommendation of this solid plan of diet is chiefly founded 
 on the well-known fact, that the reducing or dissolving func- 
 tion of the stomach is unimpaired or morbidly active in Dia- 
 betes. When the reducing function is impaired, as happens in 
 a few instances, a system of diet less solid, and consisting of 
 animal matters reduced to the pulpy state by stewing after the 
 French fashion, will be more appropriate. 
 
 Many of the remarks above applied to the use of solid 
 matters apply equally to the use of fluids ; that is to say, the 
 quantity and quality of the fluids taken in Diabetes must be 
 carefully attended to ; otherwise benefit can scarcely be ex- 
 pected from any plan of treatment. So urgent is the thirst, 
 and so great is the mental imbecility and want of stoicism for 
 the most part in diabetic individuals, that they will often drink 
 by stealth, when they cannot for shame, or want of opportu- 
 nity, do it openly. The management of drinks, therefore, in 
 the treatment of this disease, often becomes a point of con- 
 siderable difficulty ; and, as a certain indulgence must be 
 allowed, it becomes necessary to consider those drinks of which 
 the least quantity is likely to be taken by the patient; and from 
 which, at the same time, least harm may be probably expected. 
 
 The Bristol Hotwell, and other waters containing carbonate 
 of lime in solution, have been long celebrated in diabetic affec- 
 tions ; and, as Dr. Marsh observes, they appear to quench the 
 thirst in those affections better than most other mere diluents.f 
 
 * It is worth observing, that oleaginous matters often agree so remark- 
 ably well in Diabetes, that some have gone so far as to propose them 
 as remedies. When freely taken, they usually cause a flow of saliva, and 
 thus diminish the urgent thirst. When they agree, also, they give a sen- 
 sation of satisfaction and support to the stomach, which other alimentary 
 substances do not. Perhaps butter is the most agreeable form in which they 
 can be taken, and this, under proper circumstances, may be taken freely. 
 When oleaginous matters disagree, as is sometimes the case, they should 
 be carefully shunned. 
 
 t Dublin Hospital Reports, vol. iii. p. 430. 
 
44 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 Allied to these are waters artificially impregnated with lime or 
 magnesia ; as lime-water, which, either alone, or with milk, 
 has been a favourite remedy in Diabetes with some writers ; the 
 same may be said of water containing magnesia held in solu- 
 tion by carbonic acid, kc. Waters containing fixed alkalis, 
 and their salts, are generally too diuretic in their efiects to be 
 recommended in this affection ; yet when saturated with carbonic 
 acid gas, and held in the mouth for a few seconds without 
 swallowing them, they often remove or mitigate thirst better 
 than most other fluids. All the stronger saline waters, from 
 theii- diuretic properties, should be carefully avoided. As a 
 simple diluent, I am disposed to think very highly of distilled 
 water. The use of water, however, in all its forms, should be 
 sparingly allowed, as it is exceedingly liable to be abused ; and 
 various animal decoctions, milk, kc, should be taken instead. 
 'SYhen the patient has been in the habit of taking fermented 
 liquors, I have been accustomed for some years past to recom- 
 mend sound porter in preference to wine or spirits. ^ The 
 quantity/ must be determined by the circumstances of the pa- 
 tient ; but the minimum quantity should be rarely surpassed. 
 With very few exceptions, I have seen more relief from thirst, 
 and more support given by porter in diabetic cases, than by 
 any other means whatever. As general rules, also connected 
 
 * The marked differences often produced by porter and common ales in 
 Diabetes and dyspepsia in general, 1 have been accustomed to refer to 
 the different states in which the saccharine principle exists in the malt 
 of which they are prepared. In the manufacture of malt designed for 
 making ales and other pale-coloured liquors, the heat employed is barely 
 sufficient for the purpose of exsiccation. On the contrary, the heat em- 
 ployed in the manufacture of malt designed for making porter^ is so great, 
 as to modify, if not to decompose, a large portion of the saccharine prin- 
 ciple, and thus to render it more easy of assimilation, ^yhethe^ this ex- 
 planation be admitted or not, the fact is undoubted, that many dyspeptic 
 individuals can assimilate porter, who, from the symptoms they produce, 
 cannot assimilate the sweeter ales. Some of the finer kmds of Burton ale, 
 however, are unobjectionable ; particularly those prepared for the Indian 
 market, which are not only carefully fermented, so as to be quite dri/, 
 or free from saccharine matter ; but they also contain double the usual 
 proportion of hops. 
 
DIABETES. 
 
 45 
 
 with the subject of fluids, it may be observed; first, that as 
 the sudden abstraction of fluids in diabetic cases is sometimes 
 followed by unpleasant consequences, the quantity should be 
 gradually diminished ; secondly, that in order to induce the 
 patient, whose craving is generally after cold drinks, to take 
 as little as possible, all fluids should be recommended in a 
 tepid state ; and lastly, that fluids should be taken at those 
 periods in preference to others, when the stomach is not loaded 
 with solid food. 
 
 The system of diet and regimen generally applicable in Dia- 
 betes has been laid down in the first place, because it contri- 
 butes more directly, perhaps, than any other means we possess, 
 towards the attainment of the two great desiderata in the 
 treatment of the disease, viz. the diminution of the quantity, 
 and the improvement of the quality, of the urine. The adap- 
 tation of this system of diet and regimen to particular cases 
 and complications, may be inferred from what follows respect- 
 ing the medical treatment of the aflection. 
 
 We have already stated, that no specific remedy is known 
 for the essential symptom of diabetes ; in other words, we can no 
 more directly restore the paralysed function of the assimilating 
 organs, than we can directly restore the paralysed function of 
 an arm or of a leg. The medical treatment of Diabetes, therefore, 
 must be conducted on general principles ; and consequently 
 must not only vary according to the degree and complication 
 of the affection ; but according to the general state of health 
 and the peculiar constitution of the patient. 
 
 In cases of recent occurrence, and of an acute character, 
 there cannot be a doubt about the propriety and even necessity 
 of general blood-letting ; which may be repeated as often as the 
 circumstances of the case may seem to require. In very pro- 
 tracted cases, however, occurring in old subjects ; and indeed, 
 wherever the debility is excessive, this remedy can be seldom 
 required : though even in such cases it has been shown that 
 blood-letting can be borne much better than could be expected. 
 In most cases, also, frequent local bleedings from the epigastric 
 
46 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 region have been found beneficial ; particularly when an ex- 
 traordinary sense of fulness, heat, or tenderness, has been 
 experienced about the region of the stomach. 
 
 Another powerful class of remedies is purgatives ; from the 
 active use of which, some have stated that much benefit may 
 be derived. Purgatives certainly diminish the quantity of 
 urine, for the obvious reason, that they divert the fluids of the 
 body into other channels ; but I have seen no permanent be- 
 nefit from their employment with this intention. The occa- 
 sional use of active purgatives may be proper, and even 
 necessary ; but as a general rule, according to my expe- 
 rience, purgatives are most beneficial when their use is limited 
 to the regulation of the bowels. Of the remedies belonging 
 to the purgative class, castor (or olive) oil, upon the whole, is 
 perhaps the best adapted for general use. When oil is objected 
 to, rhubarb may be substituted. If more active purgatives be 
 required, care should be taken to select those which are least 
 likely to act as diuretics as well as purgatives. Hence, with 
 the exception, perhaps, of the phosphate of soda, the whole class 
 of saline purgatives may be generally considered as excluded 
 in Diabetes.^ 
 
 Another important class of remedies in Diabetes, are those 
 which determine the fluids of the body to the surface. The dry 
 and unperspirable state of the skin in this disease naturally 
 suggested the use of diaphoretics, as they are termed, at an 
 early period ; and when such remedies can be brought to 
 
 * The action of diuretics is at all times uncertain and capricious, even 
 in Diabetes. Thus I have know^n a patient labouring under this disease 
 in its worst form, drink largely of the Leamington vraters, without in- 
 creasing the quantity of his urine ; and even with some apparent improve- 
 ment of his health. The effects could not in this case be referred to the 
 purgative effects of the waters, for his bov/els were only moderately ex- 
 cited. Similar remarks might be made with respect to other remedies 
 which no one would think of recommending in this disease. On the con- 
 trary, so capricious is the action of the kidneys, that a remedy — for in- 
 stance, opium — which rarely fails to diminish the quantity of urine, will 
 occasionally act as a powerful diuretic. 
 
DIABETES. 
 
 47 
 
 act favourably, they no doubt contribute much to the com- 
 fort of the patient, by removing one of the most distressing of 
 the morbid train of symptoms. Among the most efficient reme- 
 dies of this class may be mentioned the use of warm cloth- 
 ing, and particularly of flannel next the skin ; frictions over 
 the whole body with the flesh-brush ; the use of the warm 
 or vapour bath, &c. In conjunction with these, Dover's pow- 
 der, antimonials, sulphur, camphor, &c., may be given inter- 
 nally in various doses and combinations, according to the cir- 
 cumstances of the case ; or according as the stomach of the 
 patient will tolerate them. 
 
 Other important classes of remedies, sometimes of the greatest 
 utility in the treatment of Diabetes when judiciously applied, 
 are sedatives, astringents, and tonics. Of sedatives, opium 
 claims the first place ; and in acute cases, after the more 
 urgent symptoms have been subdued by bleeding or purga- 
 tives, and in almost all chronic cases, opium, either alone or in 
 the form of Dover's powder, is one of the most useful remedies 
 we possess. Generally speaking, the form of Dover's powder 
 constitutes the preferable mode of giving opium ; on account of 
 its determining the fluids to the skin, at the same time that it 
 allays morbid irritation. In a few instances, however, crude 
 opium, and even some of the salts of morphia, will be found to 
 interfere less with the functions of the stomach, than Dover's 
 powder ; and consequently to be better adapted to such in- 
 stances. While I thus willingly admit that opium is one of 
 the best remedies we possess for many of the symptoms of Dia- 
 betes, I cannot help observing, at the same time, that those 
 who have announced it as a cure for the disease, have much 
 overstated its powers. I have seen opium freely given for a 
 great length of time, with the effect certainly of reducing the 
 quantity of urine almost to the healthy standard, and of remov- 
 ing many of the more distressing symptoms ; but never with 
 the effect, even approximately, of removing the saccharine con- 
 dition of the urine ; nor do I believe opium possesses any such 
 power. Moreover, there is this bad effect apt to be produced 
 
48 PATHOLOGY OF ?ACCHARI>'E AS5IMIL A.TIO>' AND -SECRETION. 
 
 by such prolonged use of larofe closes of opium, that the patient 
 becomes an opium-eater, and cannot exist without it. Indeed, 
 when the opium is withdrawn, particularly if suddenly with- 
 drawn, all the s^Tuptoms of the disease usually return: sometimes 
 with increased violence. J!*edatiTes are often advantageously 
 combined with astringents and tonics in the chronic forms of 
 Diabetes. Thus, opium may be associated with tannin, or with 
 its modifications, catechu and kino ; also with the mineral 
 acids, and particularly with the sulphuric acid, either alone, or in 
 combination with quinine, iron, zinc, copper, or alumine. I 
 have occasionally had recoiu'se to all these combinations ; but in 
 general have preferred the supersulphate of quinine or of iron ; 
 and at the same time made it the rule to do with as little opium 
 as possible. The blue phosphate, and the carbonate of iron, 
 are also excellent remedies. Of the phosphate of iron in par- 
 ticular I am disposed to think very favourably ; but I have 
 been disappointed with the use of phosphoric acid : which has 
 not in my hands produced the good effects some have ascril^ed 
 to it ; even when very fi-eely and perseveringly administered. 
 
 Besides these, a variety of other remedies, not referable to 
 either of the preceding classes, have been employed in Dia- 
 betes. Indeed, it has been too much the fashion, as already 
 stated, to try at random new remedies, particularly if potent; the 
 novelty and the potency of a remedy, without reference to its 
 properties, being deemed sufficient to authorise a trial of it in 
 this disease. To enumerate all the remedies that have been 
 emploved on these, or other grounds, would be quite out of the 
 question. Among the most recent and active may be men- 
 tioned creosote, hydrocyanic acid, colchicum, strychnine, the 
 hvch'iodate of potash, dec. All these, and various others, have 
 been recommended, either publicly or privately, as remedies 
 for Diabetes : and on the faith of such recommendation I have 
 myself tried a few of them ; but I cannot say with any extraor- 
 dinary success. Like many other remedies, some of them, as, 
 for instance, creosote, have sensibly diminished the quantity of 
 urine, and its immediate consequences ; but here their good 
 
DIABETES. 
 
 49 
 
 effects have ceased ; and, as already stated, neither these nor 
 any other remedies that have been yet proposed, exert, to my 
 knowledge, any direct effects in improving the saccharine qua- 
 lity of this secretion. 
 
 When Diabetes, as is frequently the case, is complicated 
 with other diseases, the nature of these complications must be 
 taken into account, and the treatment adjusted accordingly. 
 The complications usually existing in the early stages of the 
 affection are by far the most important ; for when the accom- 
 panying disease is recognised, there is often a possibility of 
 averting, by its means, the diabetic affection itself ; whereas 
 a single false step at this early period may determine 
 the fate of the patient, by developing the saccharine disease in 
 its confirmed state. The most usual complications of Diabetes 
 in its latter stages are, as we have stated, affections of the 
 lungs, or some other equally formidable organic lesion. Even 
 when such affections are present, and when, in consequence, 
 the chance of giving permanent relief is greatly diminished, or 
 altogether absent, it is still possible to do a great deal of mis- 
 chief by injudicious treatment ; and thus to hasten the fatal ter- 
 mination of the disease. 
 
 A frequent complication in the earlier stages of Diabetes is 
 hepatic disorder, or disease. The consideration of such a com- 
 bination of diseases naturally introduces the subject of mercury ; 
 on the free and too often indiscriminate use of which important 
 remedy, in diseases of the assimilating organs, I shall make 
 a few remarks. 
 
 The extraordinary and immediate benefit often afforded by 
 mercury in common affections of the assimilating organs, is 
 one of the great sources of its abuse. Medical men know 
 they can produce, by its means, a certain off-hand effect ; and 
 to save themselves trouble, and at the same time to gain the 
 doubtful reputation of being decisive and quick in their prac- 
 tice^ they resort to mercury without due regard to its remote 
 consequences. Twenty or thirty years ago, this abuse of mer- 
 cury w as carried to a much greater extent than it is at present. 
 
 E 
 
50 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 A calomel pill at night, and a black dose in the morning, were 
 the panacea for all diseases in all kinds of constitutions — from 
 the congested liver of the overgorged alderman, to the torpid 
 liver of the weak and indolent female. Although the 
 miserable consequences of this indiscriminate use of mercury 
 were often too apparent to escape notice ; yet such was its con- 
 venience, and such the force of habit, that the practice long 
 maintained its ground. IN ay, even yet, the abuse of mercury 
 is not so entirely obsolete as to cease to be an object for ani- 
 madversion. 
 
 The effects of mercury on different constitutions, and in 
 different states of the same constitution, are remarkably various. 
 Some individuals, both in a state of health and of disease, 
 are almost insensible to the action of mercury ; while other 
 individuals, under all circumstances, are affected by the mi- 
 nutest doses. As a general rule, I believe it is admitted, that 
 a state of health is more susceptible of the influence of mercury 
 than a state of disease ; particularly of inflammatory disease. 
 Hence many individuals who would be instantly salivated by a 
 few grains of calomel when in health, will be often found to 
 bear almost any quantity of that drug when labouring under 
 an acute inflammatory attack. These peculiar and important 
 properties of mercury point at once to the following maxims 
 regarding its use : 
 
 First, Mercury ought in no instance to be administered for 
 those slight deviations from health which can be readily re- 
 moved by safer expedients. 
 
 Secondly, Mercury ought to be cautiously administered to . 
 strangers ; and to those on whose constitution its effects have 
 not yet been ascertained. 
 
 The practical value of these maxims may be thus illustrated : 
 
 First, one of the supposed effects of mercury is its stimula- 
 ting operation on the liver ; and admitting this common opi- 
 nion of its action to be well founded, let us briefly inquire into 
 the consequences of perpetually subjecting the liver and the 
 other assimilating organs to the stimulus of mercury. 
 
DIABETES. 
 
 51 
 
 The stimulating effects of mercury may be analogically 
 illustrated by the stimulating effects of dram-drinking. As 
 the stomach accustomed to ardent spirits will scarcely tolerate 
 any weaker beverage ; so the liver, accustomed to the stimulus 
 of mercury, will hardly respond to any other influence. Those, 
 therefore, who in early life have on all trivial occasions resorted 
 to the powerful stimulus of mercury, like early dram-drinkers, 
 are usually obliged to persist in the baneful habit. The truth 
 of this analogy will be scarcely questioned : for the most super- 
 ficial observer must have noticed, that patients who habitually 
 take calomel are more than ordinarily subject to periodical 
 congestions, or hiliary attacks as they are termed ; and that 
 such biliary attacks will rarely yield to any other remedy than 
 calomel. Nor is the insensibility to gentler expedients, thus 
 too often produced in the soundest constitutions by the use of 
 mercury, its only fault ; the habitual use of this remedy is 
 capable of exerting positive mischief on the assimilating func- 
 tions and on the kidneys of some individuals ; as will be shown 
 in subsequent parts of this volume. Moreover, those who 
 are under the influence of mercury in a degree far short of 
 salivation, are notoriously liable to take cold, rheumatism, &:c., 
 from slight exposure ; and various formidable and fatal diseases, 
 as phthisis, &c., can be often distinctly traced to such exposure 
 under the influence of mercury. 
 
 Many, I have no doubt, whose views have been limited to 
 the immediate operation of mercury, will be disposed to think, 
 that what is here said of its ulterior effects, is exaggerated. If, 
 however, they will take the pains to investigate the history 
 of mercurialised patients ; and particularly the condition of 
 their assimilating organs and kidneys ; they will soon find 
 ample proof of the truth of what has been stated : at least I 
 can truly say, that a large proportion of the most inveterate 
 dyspeptic and urinary diseases which I have seen, have been 
 distinctly referable to the abuse of mercury. I am prepared 
 for the objection, that many individuals begin the use of mer- 
 cury early, and continue it with the same evident advantage 
 
 E 2 
 
 UBRARY 
 
52 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 to extreme old age ; and I meet this objection by the state- 
 ment, that many individuals begin the free use of wine and of 
 spirits at an early age, and continue to use them to extreme 
 old age ; but no one, forgetting the millions that have in the 
 mean time fallen victims to the abuse of fermented liquors, 
 will contend that such ought to become the rule ; and the same 
 remark is strictly applicable to the abuse of mercury. 
 
 In these observations on the subject of mercury, I must beg 
 not to be misunderstood. When a real disease exists, for 
 the cure of which mercury is appropriate ; and when the con- 
 stitution of the patient, or the nature of the concomitant 
 disease, does not forbid its use, no one has a higher opinion 
 of the good effects of this active remedy than myself, or em- 
 ploys it more freely. My object is to impress on the reader 
 the important fact, that when it has no real disease to combat, 
 mercury is liable to give occasion to a disease ; and consequently 
 to warn him against the indiscriminate use of this active re- 
 medy on trivial occasions, and in all diseases and constitu- 
 tions. 
 
 The second maxim above mentioned, regarding the employ- 
 ment of mercury, is in fact included in the first ; and has been 
 separately spoken of solely on account of its importance. In a 
 large proportion of chronic affections of the assimilating organs, 
 inquiry should be made, before administering mercury, whether 
 the patient has been accustomed to the remedy, and what are 
 its effects on the system. If the patient has been accustomed 
 to mercury, recourse in general must be had to it again for 
 accomplishing the simplest purposes. If, on the contrary, he 
 be a stranger to the stimulus, it will be often found that he 
 will recover just as well without. When mercury may be 
 deemed necessary for patients labouring under chronic dis- 
 eases, and who have not taken the remedy before, it will be 
 prudent to begin with small doses, and to carefully watch the 
 effects. Indeed in all instances it should be borne in mind, 
 that in chronic disease more especially, the good effects of 
 mercury are not in proportion to the largeness of the dose, but 
 
DIABETES, 
 
 53 
 
 rather to the length of time during which the salutary powers 
 of the remedy can be made to bear on the system. 
 
 The preceding remarks on the use of mercury in chronic 
 affections of the assimilating organs, are more especially ajjpli- 
 cable in cold and variable climates like our own ; and in those 
 derangements in which the assimilation of the Saccharine prin- 
 ciple is particularly involved. They have been introduced 
 here, therefore, once for all, as an appropriate introduction to 
 the employment of mercury in Diabetes, the point we have in 
 the next place to consider. 
 
 The effects of mercury in Diabetes have been variously repre- 
 sented; and indeed they are so different in different instances, 
 that mercury has even been proposed as a remedy in this 
 affection. Sometimes, however largely given or applied, this 
 drug neither produces salivation, nor increases the quantity of 
 the urine ; but even under these circumstances, which are rare, 
 and the most favourable that can occur, I am compelled to state 
 that I have never seen mercury do good in diabetic disease ; 
 but, on the contrary, almost invariably do mischief. This mis- 
 chief has been displayed in various ways connected with the 
 urinary secretion ; that is to say, the specific gravity of the 
 urine has been increased ; or the secretion has become serous, 
 or otherwise deteriorated. Moreover, when the effects of the 
 mercury have ceased, the patient has usually become worse 
 than before ; and the disease, after assuming its most un- 
 favourable form, has rapidly advanced to its fatal termination. 
 In other instances, in which the diabetic affection has been 
 partially subdued by appropriate treatment, I have seen a few 
 grains of blue pill inadvertently given, in the short space of a 
 day or two, double and even triple the quantity of urine ; and 
 thus the benefit, to obtain which perhaps months had been 
 required, has been lost as it were in a moment, and the patient 
 has been reduced to a worse state than he was in at first. 
 
 If the opinions deduced from the observations stated be ad- 
 mitted to be well founded, perhaps the use of mercury in Dia- 
 betes may be limited to the following three cases, or compli- 
 
54 PATHOLOGY OF SACCHARIDE ASSIMILATION AND SECRETION. 
 
 cations, First, General inflammatory or phlogistic fever ; Se- 
 condly, Acute or clironic inflammation of the liver; and thii'dly, 
 The temporary congestion apt to occur in those individuals, 
 who have been long accustomed to the stimulus of mercury. 
 On each of these points we shall make a few remarks. 
 
 First, according to my obsei'vations, acute phlogistic fever 
 and inflammation are of rare occurrence in diabetic individuals. 
 Something of the kind, indeed, occasionally arises in plethoric 
 individuals, in the earlier stages of the affection, from exposure 
 to cold ; but the acute stage, though perhaps at the outset 
 strongly marked, is usually of short duration, and rapidly 
 passes into the adynamic form, with a disposition in the inflamed 
 parts to become gangrenous. The acute stage of such attacks 
 therefore is so transient, that it usually disappears before 
 medical advice can be obtained ; otherwise, if promptly met 
 at the very beginning by free abstraction of blood, and the judi- 
 cious application of calomel and opium, there is a chance that 
 the progress of such attacks may be arrested. But if the 
 peculiar adynamic state become once established, I fear nothing 
 can be done ; at least, no mode of treatment I have hitherto 
 seen tried has succeeded ; and the patient, in every instance, 
 has died in a few days with symptoms more or less resembling 
 those of typhus fever. 
 
 Secondly, aftections of the liver, as we have already stated, 
 are not unfrec^uent complications in Diabetes. I have never, 
 indeed, seen acute hepatitis, in the sense I understand the term, 
 in a diabetic patient ; but I have seen chronic inflammation 
 with congestive enlargement and jaundice, and too frecjuently 
 organic disease of the liver, accompany this disease : and it is 
 in the management of such cases that mercury in Diabetes is 
 most liable to be abused. In the treatment of complications 
 of this nature, the rule to be attended to, is to do everything 
 in the first place that can be done by the aid of other ex- 
 pedients ; so as to leave that only to be done by mercury, 
 which mercury alone will accomplish. General and local 
 activity, therefore, should be reduced as speedily and eftectually 
 
DIABETES. 
 
 55 
 
 as possible, by tbe abstraction of blood, by blistering, and by 
 other well-known expedients ; and when these means have 
 effected all they are capable of doing, the aid of mercury 
 may be resorted to. The peculiar circumstances of the case must, 
 in some degree, determine the mode of employing this active 
 remedy ; but in general as little as possible should be given 
 internally, and the form of inunction, plasters, &:c., should be 
 preferred. When given internally, mercury should, for the 
 most part, be conjoined with opium ; and of the different pre- 
 parations of the drug, perhaps calomel so associated constitutes, 
 on the whole, the least objectionable mode of administration. 
 Under this plan of treatment I have known several cases in 
 which the hepatic affection has been apparently subdued, with 
 a temporary aggravation only of the diabetic symptoms ; and 
 the patient has lived for many years afterwards, without any 
 return of the affection. On the other hand, I have seen the 
 diabetic symptoms neglected, nay, even laughed at, by the 
 medical attendant, and mercury rudely administered in the 
 ordinary modes ; with some apparent relief certainly of the 
 hepatic symptoms in a few instances, but always with the ulti- 
 mate aggravation of the Diabetes, which has speedily proved 
 fatal. When hepatic disorder is accompanied by organic dis- 
 ease of the liver, the use of mercury requires caution in every 
 case ; but particularly when Diabetes is likewise present. In 
 such unfortunate complications, mercury, without a chance of 
 doing good, can be only expected to accelerate the fatal event. 
 
 Thirdly, the occasional use of alterative doses of mercury, 
 either combined with sedatives or with mild purgatives, or with 
 both, according to circumstances, is beneficial in some consti- 
 tutions ; and particularly in those who have always from early 
 life been previously accustomed to the stimulus of mercury. 
 With respect to the dose, as well as the frequency and mode of 
 exhibiting the remedy in such cases ; these will depend on 
 the circumstances and constitution of the patient, and must be 
 left to the judgment of the practitioner. 
 
 Such is an outline of the general plan of treatment recom- 
 
56 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 mended in Diabetes. To lay down a specific plan that shall 
 be adopted in all cases is impossible ; for the disease varies so 
 much according to the constitution of the patient, and other 
 circumstances, that no one remedy, or set of remedies, will in 
 all cases be appropriate. The expedients stated, therefore, 
 must be so applied and associated as to meet most effectually 
 the circumstances of the case ; and when so applied, they 
 will probably accomplish all that can be reasonably hoped for 
 in this disease. Under such a plan of treatment, I have now 
 seen a few cases in which the saccharine quality of the urine 
 has, for the time, entirely disappeared ; and a very great num- 
 ber of cases, in which the symptoms have been so far subdued 
 as to give little trouble to the patient. Indeed I have seen no 
 case of a favourable nature which has not been more or less 
 benefited ; provided the patient has steadily adhered to the 
 plan of regimen, &:c., prescribed for him, and considered him- 
 self, what every diabetic individual ought, through life, to 
 consider himself, an invalid ; that is to say, as a person whose 
 ordinary state of health is such as to require in all respects more 
 than usual care and attention. 
 
 I shall close these remarks with a short account of Diabetic 
 Diuresis as it occurs in very young children. 
 
 In young children, as in adults, diuresis is a symptom of 
 very different forms of disease ; in all these diseases the urine, 
 as well as being excessive in quantity, is more or less un- 
 natural. Thus in infantile diuresis the urine almost always 
 contains albuminous matters. In other instances an excess of 
 urea, or of the phosphates, is present ; while in a few cases 
 saccharine matters, more or less perfectly developed, exist either 
 alone, or in conjunction with the above or other unnatural 
 ingredients. Those forms of diuresis in which urea, albumi- 
 nous matters, and the phosphates exist in unnatural propor- 
 tions, will be considered when we speak of those diseases. It 
 
DIABETES. 
 
 67 
 
 remains to make a very few remarks here on diuresis as asso- 
 ciated with saccharine matter in the urine. 
 
 The saccharine diuresis of young children usually com- 
 mences soon after the period of weaning. From having been 
 up to that time healthy, the child begins to get dull and 
 inactive, and to daily lose flesh. The skin also becomes harsh 
 and dry, and feels hotter than natural. As the disease pro- 
 ceeds, the bowels become irregular, and the motions assume 
 an unnatural, often greenish appearance ; the abdomen also 
 usually becomes prominent, so as to lead to the suspicion of 
 mesenteric disease. The pulse is quick, and denotes great irri- 
 tability. In connexion with these symptoms, the quantity of 
 urine begins to gradually increase, at first so slowly as to 
 escape notice ; but at length the quantity becomes so great, 
 and the accompanying thirst so urgent, that these circum- 
 stances can no longer be overlooked. The urine is sometimes 
 quite limpid ; at other times of a pale straw or greenish colour ; 
 sometimes opalescent or milky. The specific gravity fluctuates 
 considerably even in the same individual ; and though it often 
 falls within the diabetic range, the specific gravity seldom 
 reaches the high point of the diabetic urine of adults. From 
 the almost invariable presence of albuminous matter more or 
 less perfectly developed, and which acts as a ferment, the 
 diabetic urine of children is apt to undergo rapid changes 
 from saccharine or acetous fermentation, or from both ; and 
 soon begins to emit an odour somewhat resembling sour milk. 
 
 This disease occurs most frequently in the children of pro- 
 fligate, dyspeptic, and gouty individuals, more especially in 
 large towns ; while the immediate exciting causes in such pre- 
 disposed individuals are commonly want of air and proper 
 nourishment ; or injudicious management. The disease is of a 
 formidable nature, and generally proves fatal ; particularly if 
 its nature be overlooked at the outset ; and it be in conse- 
 quence improperly treated. The treatment consists, in the first 
 place, in removal to a purer air, or to the sea ; and in the em- 
 ployment of a regulated and nutritious diet, consisting, as far 
 
58 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 as the tender age of the little patient will admit, of animal 
 matters ; at least, sugar and all sweet articles should be avoided. 
 The state of the bowels should be attended to ; and while calomel 
 purges should be most carefully shunned, some gentle altera- 
 tive, as the hydrarg. cum creta, combined with rhubarb and 
 magnesia ; or the carbonate of soda, calumba, &c. may be often 
 given with advantage. The warm sea bath, with friction upon 
 the skin, &c., will be also useful. The quantity of fluid taken 
 should be strictly limited ; and in addition to the other 
 means, such tonics as appear to be suited to the age and cir- 
 cumstances of the patient, may be given with advantage. Dr. 
 Venables, who first drew attention to this disease in children, 
 recommends the use of the blue phosphate of iron ; and this 
 or the carbonate of iron, combined with a little magnesia or 
 calumba, is often highly useful.^^ 
 
 * Ubi supra. 
 
OXALIC ACID. 
 
 59 
 
 Section 5. — Of the Oxalic Acid Diathesis. 
 
 In treating of this subject, I shall, in the first place, give an 
 outline of the phenomena usually presented by the urine during 
 the presence of oxalic acid in the system, as shown more par- 
 ticularly by the formation of oxalate of lime calculi ; and after- 
 wards point out such variations and modifications in the phe- 
 nomena as arise from differences in the constitution of the pa- 
 tient, or from differences in the exciting causes, &c. The Diag- 
 nosis, Prognosis, and Treatment will then be considered in the 
 usual order. 
 
 When oxalic acid is produced in the system, the urine is 
 generally transparent, and remarkably free from sediments ; of 
 a pale citron-yellow, or greenish, hue ; and of moderate specific 
 gravity ; that is to say, the specific gravity usually oscillates 
 about 1020 as a mean point, but is often less than this — a 
 circumstance chiefly referable to variations in the quantity of 
 the urine secreted ; which is frequently above the healthy 
 standard. 
 
 The properties of the urine here described, when well 
 marked, are sufficiently definite to lead those who are con- 
 versant with the phenomena presented by the urine in glass 
 vessels, to suspect the presence of the Oxalic Acid Diathesis ; 
 but they are not sufficiently definite to enable the most ex- 
 perienced eye, much less the inexperienced, to decide at once 
 upon the point. For the urine of healthy individuals may, 
 from accidental causes, such as peculiar articles of diet, (fee, 
 occasionally assume appearances so resembling those stated, 
 as not to be distinguishable from them. The judgment, there- 
 fore, must in all instances be formed from the general tenor of 
 the phenomena ; and from the concomitant symptoms to be 
 presently^ detailed ; and these taken together, for the most 
 
60 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 part, leave little doubt on the subject ; even though an oxalate 
 of lime calculus may not have been known to have passed 
 from the kidney. 
 
 The symptoms usually connected with the Oxalic Acid 
 Diathesis, belong to the irritable or nervous class, rather than 
 to the congestive or inflammatory. The stomach is apt to be 
 oppressed with flatulence, especially when empty ; and the 
 gaseous matters extricated generally contain an unusual pro- 
 portion of azote. This state of flatulence is very often con- 
 nected with irregular action of the heart, and particularly with 
 intermission of the pulse. The reducing function of the sto- 
 mach is much less active than in Diabetes ; but sometimes 
 there is great craving for food, which, as far as the stomach is 
 concerned, is apparently disposed of readily ; and without pro- 
 ducing that acidity so frequently caused by solid matters, when 
 the reducing function of the stomach is weak. I have occa- 
 sionally seen pain on pressure in the region of the stomach 
 accompanied by a sense of heat, and, in a few instances, by severe 
 gastrodynia ; but these symptoms, according to my observa- 
 tions, are not so frequent as in some other forms of dyspepsia. 
 Those who labour under this form of dyspepsia have generally 
 less desire for solid animal food than for vegetable matters ; 
 and there is not unfrequently a strong propensity for sweet 
 things, and particularly for sugar ; which is apt to be indulged 
 to great excess. In some the tongue is loaded with a white fur, 
 particularly in the morning ; in many this organ presents no re- 
 markable appearance ; and in a few it is preternaturally clean 
 and red, especially round the edges. 
 
 At a certain period after eating, greater or less according to 
 circumstances, there is commonly a sense of uneasiness arising 
 from flatulent distension of the duodenum, which by degrees is 
 propagated to the region of the coecum ; and during the time 
 this portion of the assimilating processes is going on, the 
 patient commonly feels most uncomfortable. The bowels, like 
 the secretion of the bile by which they are principally in- 
 fluenced, are capricious and irregular ; the quantity of the bile 
 
OXALIC ACID. 
 
 61 
 
 being either deficient, or in excess ; and the bowels responding 
 accordingly. The qualities also of the bile are subject to great 
 variety, being sometimes of a greenish hue ; at other times of 
 an orange red, or chocolate brown tint ; at other times almost 
 black. Under these circumstances the faeces are imperfectly 
 formed ; or are loaded with mucus ; or are preternaturally 
 acid. Moreover, there is occasionally a tendency to periodical 
 discharges of dark-coloured blood, both from the rectum and 
 bladder ; particularly in swarthy individuals. 
 
 The constitutional symptoms vary exceedingly in this Dia- 
 thesis, both in degree and in kind. In some instances they 
 are so trifling as almost to escape notice ; while in others, 
 they are exceedingly troublesome. The kind or character of 
 the symptoms is much influenced by the peculiar temperament 
 of individuals. In individuals of the sanguine temperament, 
 for instance, particularly when subject to cutaneous diseases, 
 the constitutional symptoms are usually manifested in the form 
 of extreme irritability of temper or manner ; more especially if 
 the cutaneous affection has, from any cause, been suddenly 
 repelled. In individuals of the melancholic temperament, on 
 the contrary, the constitutional symptoms usually partake of 
 the desponding and hypochondriacal character. External 
 circumstances also of various kinds have often the effect of 
 determining the symptoms into favourable or unfavourable 
 channels ; and thus of mitigating or of aggravating them, as 
 the case may be. 
 
 When the obvious presence of a small calculus in the kid- 
 ney or bladder leaves the nature of the case no longer doubt- 
 ful, and occasions for the first time the appearance of blood in 
 the urine ; the occurrence, whether accompanied by pain or not, 
 is apt to forcibly attract the patient's attention. He has now 
 a definite object to complain of, and, forgetting everything 
 else, becomes alive to every little symptom connected with the 
 urinary organs, which otherwise would scarcely have attracted 
 his notice. At length he suffers a nephritic attack ; gets rid 
 of most of his troubles with his calculus; and, after a greater 
 
62 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 or less period, recovers, perhaps for years, his former state of 
 health. 
 
 The following are some of the more remarkable varieties 
 presented by the symptoms accompanying the Oxalic Acid 
 Diathesis ; as they occur in different individuals, under differ- 
 ent circumstances and complications. 
 
 The Oxalic Acid Diathesis is sometimes associated with 
 serous urine, and with organic disease of the kidney, particu- 
 larly in young subjects ; in which case the urine is generally 
 opalescent and of a greenish tint. When a great deal 
 of saccharine matter is consumed as food, the urine is often 
 of considerable specific gravity, and contains sugar as well as 
 oxalic acid. Moreover, when sugar, and particularly oxalic 
 acid, are thus freely taken, oxalic acid may be frequently de- 
 tected in the urine ; and the sediments deposited almost always 
 contain more or less of oxalate of lime. 
 
 It has been already stated, that the peculiar symptoms at- 
 tending the oxalate of lime diathesis vary exceedingly in de- 
 gree as well as in kind. Sometimes they are so slight as to 
 pass unnoticed by the patient ; or at most are considered as 
 dyspeptic derangements of no great importance. At other 
 times, the bodily suffering is considerable ; while the mental 
 excitement verges on insanity. Flatulence and irregular action 
 of the heart perhaps constitute the most frequent symptoms 
 present ; and although these symptoms can by no means be 
 considered as characteristic of the Diathesis ; when the other 
 symptoms exist at the same time, the combination serves to 
 confirm our diagnosis. Haemorrhage from the kidneys is per- 
 haps more frequently produced by an oxalate of lime, than by 
 any other form of concretion. This may depend in part on the 
 peculiar form of the calculus; but the chief cause probably 
 lies in the nature of the Diathesis. As a point in illustration, 
 I may remind the reader of the fact before mentioned, that 
 more cases of haemorrhage from the urinary organs occurred 
 to me during the season following the prevalence of cholera 
 in this country, than I had ever before seen in the same time. 
 
OXALIC ACID. 
 
 63 
 
 This unusual tendency to haemorrliage at first misled me in my 
 prognosis ; for before this period I had almost invariably no- 
 ticed, that the appearance of blood in the urine indicated 
 either the presence of stone or of malignant disease in some 
 part of the urinary organs ; whereas, in a great many of the 
 instances alluded to, the haemorrhage ceased after a time, with- 
 out being apparently attended by either of these circumstances. 
 Within the last few years, the phenomena of haemorrhage 
 from the urinary organs have in a great degree resumed their 
 former characters. 
 
 Finally, I wish it to be particularly borne in mind, that of 
 the hundreds of individuals in whom the Oxalic Acid Diathesis 
 prevails, a few only suffer from calculus. The formation of a 
 renal calculus of oxalate of lime seems to be generally an acci- 
 dental circumstance ; and, in almost every instance, the forma- 
 tion of such concretion depends either on the presence of some 
 foreign body, or some local inflammatory action in the kidney. 
 And, provided these concurring causes are absent, in a very 
 few cases only does the mere presence, even in excess, of the 
 oxalate of lime, seem to give occasion to the formation of a 
 calculus.* 
 
 Causes, — The formation, or at least the existence of oxalic 
 acid, is not peculiar to the human subject, but occurs in some 
 rare instances in the inferior animals. Thus calculi composed 
 of this substance have been found in the dog and rat, and I 
 believe in other animals.f 
 
 A predisposition to the Oxalic Acid Diathesis, as to Diabetes, 
 appears in some cases to be inherited, but not, I think, so fre- 
 quently. In other words, perhaps, the predisposing causes 
 have less influence in the production of the Diathesis, than 
 the exciting ; though, as in Diabetes, both kinds of cause 
 usually co-operate to produce the most decided instances. 
 
 A syphilitic taint, whether remote and inherited, or acquired, 
 
 * The subject of renal calculi will be fully considered in a subsequent 
 part of this volume. 
 
 t Fourcroy and Vauquelin, Ann. de Mus. de Hist. Nat. iv. 338. 
 
\ 
 
 64 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 seems occasionally to give a predisposition to this Diathesis. 
 I have seen many individuals so circumstanced labour under 
 the worst forms of syphilitic dyspepsia, and the most inveterate 
 cutaneous disease, in connexion with the Oxalic Acid Dia- 
 thesis. Other predisposing causes, like the predisposing causes 
 of Diabetes, may be classed under the heads of temperament, 
 sex, and age. 
 
 The Oxalic Acid Diathesis occurs in all temperaments ; but 
 individuals of the sanguine temperament on the one hand, and 
 of the melancholic on the other, seem to be most liable to it. 
 In subjects of the first class, it is generally associated with 
 light or reddish hair ; a dry and irritable skin ; and with a 
 tendency to an impetiginous, or some allied cutaneous affection, 
 which is not unfrequently inherited. In subjects of the second 
 class, in whom the hair and eyes are usually dark, there is 
 commonly less tendency to cutaneous irritation and disease ; 
 but a much greater tendency to affections of the cellular and 
 parenchymatous tissues. In further illustration of this point 
 I may also observe, that the most inveterate tendencies to this 
 Diathesis which have fallen under my observation, have occurred 
 in individuals of a mixed temperament. Thus I know a gen- 
 tleman who inherits, in the highest degree, the irritable skin of 
 the sanguine temperament, with the dark and swarthy aspect 
 of the melancholic, and in whom all the symptoms of this 
 Diathesis exist in a strongly marked form.* When the Dia- 
 thesis is strongly marked, the skin in all temperaments is apt 
 to assume an unnatural appearance difficult to describe ; but 
 the colour of which may be said to vary from dull greenish 
 yellow in the sanguine, to dark olive or livid in the melan- 
 cholic temperament. Both classes of individuals also are often 
 liable to boils, which in old and enfeebled habits are apt to 
 degenerate into carbuncles. 
 
 Like Diabetes, this Diathesis, according to my observations, 
 is much more rare in women than in men : and though it oc- 
 
 * It may be worth mentioning that this gentleman's wife is as dark 
 as himself ; yet three of his children, out of six, have light red hair. 
 
OXALIC ACID. 
 
 65 
 
 casionally occurs at all intermediate periods between infancy 
 and old age ; the periods of life most subject to it seem to be 
 between two and twenty-four, and forty and sixty-five years 
 of age. 
 
 Among exciting causes of the Oxalic Acid Diathesis, one of 
 the most striking I am acquainted with, as before observed, 
 is a residence in a damp and malarious district. In such a 
 district the predisposed seldom escape, sooner or later ; and 
 even those who are not predisposed, are apt, after a time, to 
 become more or less affected ; particularly if their diet consists 
 of a large proportion of saccharine or of unwholesome farinaceous 
 matters. The Oxalic Acid Diathesis seems to differ remark- 
 ably from Diabetes, in not being liable to be excited by mere 
 exposure to cold, nor by an attack of rheumatism, or of gout. 
 I have never been able to distinctly trace an oxalate of lime 
 calculus to mere exposure to cold ; nor have I seen it follow 
 acute rheumatism. This form of concretion, however, is often 
 accompanied by chronic rheumatism ; and occasionally 
 an attack of gout. Diet, under all circumstances, but particu- 
 larly in strongly predisposed habits, has perhaps more influence 
 in exciting this Diathesis than any other cause. I have seen 
 repeated cases in which the too free use, or rather abuse, of 
 sugar has given occasion to the oxalic acid form of dyspepsia ; 
 and sooner or later, under favourable circumstances, to the 
 formation of an oxalate of lime calculus. I have also seen, 
 as before noticed, well-marked instances in which an oxalate 
 of lime nephritic attack has followed the free use of rhubarb, 
 (in the shape of tarts, (fee.,) particularly when the patient has 
 been in the habit, at the same time, of drinking hard water. 
 Other exciting causes in certain habits are the depressing 
 passions ; and more especially grief or mental anxiety. I could 
 give a long list of instances apparently referable to such causes 
 alone. The influence of certain epidemic diseases, as, for in- 
 stance, cholera, has been already noticed. With respect to dis- 
 eases of the skin and cellular tissue, as exciting or rather con- 
 comitant circumstances of the Oxalic Acid Diathesis ; nearly the 
 
66 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 same remarks are applicable, as to the occurrence of these af- 
 fections in Diabetes. There is this remarkable difference, how- 
 ever, that in diabetic affections cutaneous disease is rather 
 uncommon ; whereas these affections are of frequent occurrence 
 in the Oxalic Acid Diathesis. As an illustration of this position, 
 I may remark, that I have seen the cutaneous disease gradually 
 disappear, as the Oxalic Acid Diathesis has passed (as it some- 
 times does) into the Diabetic. 
 
 The presence of oxalic acid in the system, as far as the pri- 
 mary assimilating processes are concerned, arises from one of 
 two causes, which, for want of a better name, we term proxi- 
 mate causes ; viz. the non-assimilation of oxalic acid taken as 
 food ; and the mal-assimilation of saccharine aliments, and in 
 extreme cases, perhaps, of albuminous and oleaginous aliments. 
 The first of these causes may exist without the second, and 
 may even give occasion to the formation of a nephritic oxalate 
 of lime attack, without producing, in a marked degree at least, 
 the constitutional symptoms usually present in this Diathesis ; 
 of which I have seen instances. It is probable that the first 
 cause operates principally in those in whom the converting 
 function of the stomach \s deficient in power ; and in whom, at the 
 same time, there is a predisposition to the Oxalic Acid Diathesis; 
 for there is every reason to believe that the perfectly healthy 
 stomach can convert small quantities of the oxalic acid when 
 mixed with the articles of food. The second cause consists in 
 something more than mere weakness ; there is in this case a 
 positive derangement of the converting function of the stomach. 
 These two conditions, however, of the converting functions of 
 the stomach, may be supposed to be nearly allied, and not only 
 to occasionally co-exist, but to pass into each other. With 
 respect to the formation of oxalic acid during the secondary 
 assimilating processes, we have nothing to add to what has 
 been already stated in the general remarks prefixed to this 
 chapter. 
 
 The diagnostic phenomena of the Oxalic Acid Diathesis, 
 though well marked as a group, require consideral experience 
 
OXALIC ACID. 
 
 67 
 
 and attention to discriminate them. Moreover, from the com- 
 parative rarity of the affection in certain localities and seasons, 
 the necessary opportunities for studying the affection cannot 
 be always commanded. Of such importance, however, is the 
 knowledge of the affection in other localities and seasons, that 
 no pains should be spared to study the phenomena ; not only 
 for their own sake, but for the sake of the light they will here- 
 after throw on some of the most painful scourges of humanity. 
 
 The 'prognosis in the Oxalic Acid Diathesis is favourable or 
 unfavourable, according to the degree in which it exists ; and 
 according to a variety of other circumstances. In slighter cases 
 there is no affection more manageable, if properly treated. In 
 severe cases, particularly if complicated with organic disease, 
 there is no affection more formidable, nor more apt to take on 
 a malignant and intractable character. 
 
 Post-mortem examinations, as in Diabetes, have thrown 
 very little light on the cause or nature of the Oxalic Acid Dia- 
 thesis. In the few opportunities I have had of examining the 
 bodies of those who have died with this Diathesis, the imme- 
 diate cause of death has been either organic disease of the kid- 
 neys, (generally combined with oxalate of lime calculus,) or 
 some malignant disease of other organs. As in Diabetes, there 
 has been great tendency to acidity in the system ; and the veins 
 of the abdominal system have been unusually congested with 
 dark-coloured blood. 
 
 Treatment. — The plan of diet, &c., applicable to the Oxalic 
 Acid Diathesis, coincides nearly with that applicable to Dia- 
 betes. We refer the reader, therefore, for details to the pre- 
 ceding section, and shall content ourselves here with briefly 
 stating the leading facts ; and pointing out the most remark- 
 able differences applicable to the Oxalic Acid Diathesis. In the 
 first place, the patient should carefully abstain from all saccha- 
 rine articles of food, and particularly from sugar ; and his diet 
 should principally consist of animal, and of the stronger farina- 
 ceous matters. As, however, the reducing function of the sto- 
 mach is often considerably impaired in this Diathesis, solid and 
 
 F 2 
 
68 PATHOLOGY OP SACCHARINE ASSIMILATION AND SECRETION. 
 
 indigestible matters should be sparingly taken, or shunned alto- 
 gether. Hence the French cookery, by which animal and other 
 matters are reduced to a semifluid or pultaceous mass, often 
 agrees better than the crude and solid chops or steaks of this 
 country. There are many exceptions, however, to this observa- 
 tion ; and if the reducing function be not very much impaired, 
 it is proper in all instances to take a certain portion of food of 
 an easily reducible character ; the best method of restoring the 
 reducing, as well as all other weakened functions, being to 
 moderately exercise them. When the stomach, as is often the 
 case, cannot reduce oleaginous aliments, butter should be 
 avoided ; otherwise there is no objection to its use. As drinks, 
 fermented liquors should in general be abstained from as much 
 as possible ; in this respect, however, everything will depend 
 on the previous habits of the patient. Sometimes a little 
 good porter agrees well, and may be taken. When porter is 
 deemed objectionable, weak brandy and water is preferable to 
 most wines ; particularly those wines containing unfermented 
 sugar. Sound and dry sherry, or even hock and claret, occa- 
 sionally agree, and may be cautiously taken in some cases. 
 The quality of the water employed is of the utmost impor- 
 tance. Those whose assimilating organs form oxalic acid, 
 and who at the same time drink water containing lime in 
 solution, are exceedingly liable to get an oxalate of lime calcu- 
 lus. The purest water, therefore, that can be obtained, even 
 distilled water, should in all instances be preferred. 
 
 The principles to be kept in view in the medical treatment 
 of the Oxalic Acid Diathesis, like the diet, &c., are not very dis- 
 similar to those before laid down in Diabetes. In general, the 
 fixed alkalis are seldom beneficial, particularly in large doses ; 
 in which form they often do absolute mischief. The volatile 
 alkali, combined with camphor and sedatives, in cases of great 
 irritability, are sometimes useful. The mineral acids, either 
 alone or combined with tonics, as the sulphate of iron or of qui- 
 nine, are usually grateful to the stomach, and may be taken with 
 advantage ; indeed, generally speaking, I have seen more bene- 
 
OXALTC ACID. 
 
 69 
 
 fit derived from this class of remedies than from any other. The 
 effects of the mineral acids must be watched ; and when they 
 begin to produce a deposition of the lithate of ammonia or of 
 lithic acid, their use must be suspended. Indeed, in all in- 
 stances, the mineral acids require to be left off after a time ; as, 
 when too long persisted in, they not only cease to do good, but 
 in most instances do harm. In cases of this Diathesis, where 
 the patient lives at a distance in the country, I commonly re- 
 commend the use of the muriatic acid, (or nitro-muriatic acid, as 
 the case may be,) to be persisted in till the lithate of ammonia, 
 or the lithic acid, begins to appear in the urine ; or for a month ; 
 and by adopting such a course of acids three or four times in 
 the year, and by a carefully regulated diet, I have seen the 
 Diathesis gradually subdued, and at length removed altoge- 
 ther. As a means of relieving the distressing flatulence and 
 irregular action of the heart, so often present in this affection, 
 the hydrocyanic acid, either alone or conjoined with digita- 
 lis, is often useful. Nearly the same remarks apply to the 
 use of mercury in this Diathesis as in Diabetes. There can be 
 no objection to the occasional use of this remedy as an altera- 
 tive or purgative, in those individuals who have been accus- 
 tomed to the stimulus of mercury ; or in whom the hepatic 
 system is congested ; but the specific effects of this remedy are 
 very seldom beneficial in this Diathesis, and in many cases do 
 irreparable mischief. 
 
70 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 Section c. Of Lactic Acid, Sfc. 
 
 A detailed consideration of the derangements to be spoken 
 of in this section, scarcely falls within my present design. 
 My chief object in noticing them, has been to point out their 
 relation and analogy to the subjects of the volume in general, 
 and thus, so far, of completing the outline of my plan. At 
 some future time I may be induced to enter more at length 
 into the matters discussed in the present section, perhaps in a 
 separate volume. In the mean time, I am not without a hope 
 that the hints now thrown out may set other observers to work, 
 not only in this country, but in tropical climates ; where all the 
 prominent features of these derangements are usually much 
 more boldly delineated. 
 
 As Lactic Acid, and the nearly related acetic acid, are alike 
 developed from the saccharine and the albuminous, (or at least 
 from the gelatinous form of the albuminous) principles ; the 
 consideration of the phenomena attending the development of 
 these acids forms an appropriate link between the saccharine 
 and albuminous derangements. Under the same head also, for 
 the sake of convenience, we shall consider the subject of the 
 muriatic and other acid principles usually develoj)ed in con- 
 junction with the lactic acid during the assimilating processes. 
 
 The reader will bear in mind that we divide the assimilating 
 processes into primary and secondary. Now the undue deve- 
 lopment or presence of the Lactic and other acids in these two 
 divisions of the assimilating processes, gives occasion to two 
 distinct classes of diseases ; requiring a separate consideration. 
 
 Of the development or presence of the Lactic Acid, Sfc, during 
 the primary assimilating processes. — It will facilitate our inquiry 
 into this portion of our subject, if we still further subdivide it 
 into two parts, viz. the development or presence of the Lactic 
 
LACTIC ACID, &;C. 
 
 71 
 
 acid, (fee. in the stomach ; and the development or presence of 
 the Lactic acid, Sec. in the subsequent assimilating organs. We 
 shall, accordingly, make a few remarks on the leading pheno- 
 mena and diseases attending the undue development or presence 
 of the Lactic acid, &c., in these two portions of the assimilating 
 organs; and afterwards, in a general review, briefly notice the 
 principles on which their treatment requires to be conducted. 
 
 The acids found in the stomach are derived from two 
 sources — from the blood circulating in the vessels supplying the 
 stomach, or from changes occurring in the matters secreted by 
 these vessels ; and from the alimentary matters taken into that 
 organ. The Lactic and muriatic acids are principally derived 
 from the blood, and from the matters secreted or introduced 
 into the stomach ; w^hile the oxalic, butyric, acetic, carbonic, 
 and perhaps occasionally the Lactic, acids, are developed from 
 the food during its imperfect assimilation ; which imperfect assi- 
 milation is often a concomitant circumstance attending the 
 abnormal development of the Lactic and muriatic acids. 
 Hence in cases of severe dyspepsia, accompanied by great 
 acidity, the acids present have possibly in all cases a double 
 origin ; though their development from the blood, or from 
 matters derived from the blood, rather than from the food, may 
 be considered as constituting the index of the disease to be com- 
 bated. 
 
 We have stated in the Introduction, that the muriatic and 
 Lactic acids are always present in the stomach during the re- 
 ducing process, and that their presence in some peculiar form 
 of combination appears to be necessary to the accomplishment 
 of that process ; it is therefore the abnormal presence of these 
 acids in the stomach that we have now to consider ; and parti- 
 cularly the circumstances that determine the presence of the 
 one acid rather than of the other ; for, in general, it may be 
 observed, that though both acids may be in excess, one almost 
 always predominates. 
 
 The circumstances that determine the predominance of on^ 
 acid in the stomach rather than the other, cannot perhaps, in 
 
72 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 the present state of our knowledge, be followed out in all their 
 details. The following observations, however, may afford a 
 clue to the subject. The predominance of the muriatic acid 
 seems in general to denote a phlogistic or inflammatory 
 state of the system ; while the predominance of the Lactic acid 
 marks rather a state of irritation. Such is the general law, 
 and as a general law it is worth bearing in mind ; but many 
 exceptions and modifications exist; and the two classes of 
 phenomena run so imperceptibly into each other, that it is 
 impossible to draw the precise line between them. As illustra- 
 tions of the subject, I may mention that in the dyspepsia of ple- 
 thoric gouty individuals, I have generally found the predomi- 
 nating acid the muriatic acid ; so also in what are called bilious 
 attacks, and gall-stones, as they occur in the same class of in- 
 dividuals, the predominating acid is usually the muriatic. In 
 these and similar instances the stomach may be primarily in 
 fault ; but, in general, the stomach is affected by sympathy with 
 some distant part. Thus, in bilious attacks, the hepatic system 
 is supposed to be congested, so as to perform its functions im- 
 perfectly ; or, as happens in some severe cases, the fault lies 
 in one of the great nervous centres. So, in the same class of sub- 
 jects, gouty or inflammatory action of the kidney, uterus. Sec, 
 is apt to be accompanied by a predominance of the muriatic 
 acid. On the other hand, the same derangements and remote 
 sympathies, when they occur in weak and delicate, or in nervous 
 subjects, are very often attended by the presence of an excess 
 of Lactic acid in the stomach. Moreover, in all dyspeptic sub- 
 jects, hard and crude indigestible matters, when taken into the 
 stomach, irritate that organ, and cause it to throw out a large 
 quantity of the mixed acids, in which the Lactic acid almost 
 always predominates ; especially in the weak and delicate. 
 An excess of acid, and particularly of Lactic acid, in the 
 stomach, is frequently accompanied by more or less of gas- 
 trodynia ; that is to say, of rheumatic neuralgia, similar to 
 that affecting other nerves of sensation. This happens most 
 frequently in gouty and rheumatic subjects, in whom the ex- 
 
LACTIC ACID, &C. 
 
 73 
 
 citing cause of the acid development has been some foreign 
 indigestible substance. 
 
 With respect to the other acids formed in the stomach, these 
 seem also to occur most generally in dyspeptic individuals in 
 whom the muriatic and Lactic acids abound ; and in vrhom, in 
 consequence, the digestive processes are imperfectly performed. 
 These acids appear to be chiefly derived from the food, and 
 therefore are probably various in their nature. Among others, 
 the carbonic acid is frequently developed not only from the 
 food, but apparently from the stomach itself ; and, in its gaseous 
 form, occasionally proves a source of flatulent eructation. 
 Another, and by far the most troublesome, source of flatu- 
 lence, is azote. This, in nervous subjects, is occasionally de- 
 veloped from the stomach in enormous quantities in conjunc- 
 tion vrith the Lactic, and particularly w^ith the oxalic acid, as 
 formerly mentioned. At other times azote is probably derived 
 from the food ; but from v^^hatever source this gaseous princi- 
 ple be derived, it usually gives much annoyance ; for while 
 the carbonic acid gas, on account of its stimulating qualities, 
 generally escapes from the stomach, the passive character of 
 the azote, and the peculiar spasmodic constriction which 
 usually accompanies its development, cause it to be retained ; 
 and thus, by distending the stomach, to add greatly to the 
 miseries of the patient. 
 
 As we suppose the muriatic acid developed in the stomach 
 to be derived from the muriate of soda existing in the blood ; it 
 is probable that when the liver does its duty, the greater part 
 of the free muriatic acid of the chyme, when it enters the duo- 
 denum^ is neutralised by the soda of the bile. The case, however, 
 appears to be very different with the Lactic acid, particularly 
 when in great excess ; for as much of this excess of Lactic 
 acid is usually generated, of course there can be no 
 equivalent of alkali in the duodenum to neutralise it. The 
 consequence is, that the free acid is either taken up with the 
 chyle into the lacteals ; or descends into the intestines ; where, 
 in conjunction with other acids there developed or separated. 
 
74 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 it produces various secondary symptoms, which we have in the 
 next place to consider. 
 
 There is reason to believe that the perfectly natural con- 
 dition of the whole intestinal canal, with the exception, perhaps, 
 of the coecum, is either neutral, or occasionally verges towards 
 slight acidity on the one hand, and slight alkalescence on the 
 other. When therefore the contents of the stomach have con- 
 tained a quantity of acid too great to be neutralised in the duo- 
 denum, they of course enter the inferior portions of the aliment- 
 ary canal in a more or less acid state, where they produce 
 a variety of unpleasant symptoms. These symptoms are either 
 local or remote ; and moreover differ remarkably in different 
 individuals, and at different ages. In adults, while the 
 acid ingesta remain in the duodenum, great discomfort and 
 uneasiness of various kinds are experienced. Again, peculiar 
 symptoms, among which are a sense of heat and painful cholic, 
 often attend the passage of acid matters down the small intes- 
 tines ; while the lodgment of such acid matters in the coecum 
 occasionally appears to be connected with a train of symptoms 
 to be more particularly described in the next paragraph. If the 
 acid matters pass unneutralised from the coecum, they usually 
 give occasion to more or less of pain throughout the region of 
 the colon, and sometimes excite diarrhoea. In young children, 
 these and many other distressing symptoms, produced by 
 acidity in the primse vise, are still more strongly marked. 
 Thus acid matters, in passing from the duodenum through the 
 small intestines, often produce violent tormina, occasionally 
 terminating in intus-susception ; while the presence and 
 retention of acids in the coecum and colon not unfrequently 
 give occasion to convulsions. 
 
 It is proper to remark, that some of the symptoms above 
 alluded to as connected with the presence of acids in the pri- 
 mae vise, may arise from the absorption of a portion of such 
 acids into the system. Admitting this, however, to be the case, 
 and that we cannot accurately distinguish between the symp- 
 toms produced by absorption of acid matters into the system, 
 
LACTIC ACID, kc. 
 
 75 
 
 and by their contact with the irritable lining of the intestines ; 
 the general fact, that the presence of acid matters in the intes- 
 tinal canal occasions distressing symptoms of a secondary 
 character, both local and remote, in certain individuals, cannot 
 be doubted. We have no space for details ; but the following 
 instance of distressing symptoms occasionally connected with 
 morbid acidity of the contents of the coecum, may serve to 
 illustrate the point in question. 
 
 Excessive acidity of the coecum is generally accompanied by 
 a deficient secretion of bile ; and sometimes by a complete 
 temporary suppression of the bilious discharge, apparently from 
 spasmodic constriction of the common gall-duct ; or, it may be, 
 of the biliary ducts themselves. In this state of things, all 
 individuals feel more or less of uneasiness ; but the point we 
 wish to mention is, that certain individuals under these circum- 
 stances experience what is called nervous headache. This 
 species of headache is frequently accompanied by nausea ; is 
 confined to the forehead ; and when severe, produces complete 
 intolerance of light and sounds, and a state of mind bordering 
 on delirium. After a greater or less period the pain ceases ; 
 sometimes quite suddenly ; and the remarkable circumstances 
 to be mentioned are, that this sudden termination is preceded 
 by a peculiar sensation (sometimes accompanied by an audible 
 clicking noise) in the region of the gall-ducts ; that immediately 
 afterwards, a gurgling sensation is felt in the upper bowels, as if 
 a fluid was passing through them ; and that in a few seconds, 
 when this fluid, which we suppose to be bile, has reached the 
 coecum, the headache at once vanishes like a dream. One of the 
 greatest martyrs to this species of headache I have ever seen, 
 invariably experiences the train of symptoms above described ; 
 and I have witnessed it in a greater or less degree in many 
 instances ; indeed I have experienced it in my own person. 
 
 Of the development of the Lactic Acid,^c., during the Secondare/ 
 Assimilating Processes. — We have stated that the acids deve- 
 loped in the stomach and primse viae appear to be absorbed 
 into the system, and there tp contribute towards producing 
 
76 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 various secondary effects, many of which are very distressing; 
 we have also stated that these secondary effects are with dif- 
 ficulty defined or separated from the effects produced by 
 acidity in the primae vise ; and we have now to state further, 
 that these two classes of effects are with still greater difficulty 
 distinguished from the effects produced by the acids developed 
 during the secondary assimilating processes. For this reason, 
 therefore, and for the additional reason that the three classes 
 of effects often co-exist ; we shall briefly speak of the whole 
 in conjunction. 
 
 In dyspeptic individuals who pay no attention to diet, &;c., 
 and who suffer from acidity in the stomach and its conse- 
 quences, the acid and unnatural matters developed in the 
 primae vi^ appear to be absorbed into the system ; where they 
 probably tend to act as exciting causes of derangements in the 
 secondary assimilating processes. The symptoms resulting 
 from such combined derangements, like all symptoms connected 
 with derangements of the assimilating organs, have more or 
 less of a periodic character, and show themselves in occasional 
 attacks of bilious congestion, gout, lithic acid gravel, catarrhal 
 affections, ague, rheumatism, &:c., according as exposure to 
 cold, malarious influence, kc, co-operates with the original 
 predispositions, and determines their nature. 
 
 It is remarkable that those who suffer least from derange- 
 ments of the primary digestive processes, often experience the 
 greatest inconvenience from the derangements of the secondary 
 class, or from their consequences. This is perhaps referable in 
 a certain degree to the fact, that such individuals pay less atten- 
 tion to diet, than those whose condition of stomach obliges them 
 to live more cautiously. As an illustration of this point, we may 
 observe, that we frequently hear such individuals boast that 
 nothing disagrees with their stomach ; and the consequence is, 
 that they cannot be persuaded to abstain from the most im- 
 proper things, but partake of everything alike that comes in 
 their way. In the prime of life, and in sound constitutions, 
 this state of things goes on for periods varying according to 
 
LAGTIC ACID, &C. 
 
 77 
 
 circumstances, and particularly according as individuals are 
 indolent or active. In almost all instances, however, sooner 
 or later, the urine becomes loaded, the liver congested, and 
 more or less of fever and derangement of the stomach and 
 bowels, — in short, what is usually called a bilious attack, takes 
 place. For this a calomel pill and a black dose are resorted 
 to, and all being apparently righted, the individual resumes 
 his former habits, and after a time again undergoes the same 
 round of changes. To this state of things we shall have 
 occasion to recur : in the mean time we shall make a few 
 remarks on a different series of events which now and then 
 present themselves. 
 
 There are some individuals in whom, though the primary 
 assimilating processes are imperfectly performed, and though 
 they eat and drink immoderately, and of everything that comes 
 in their way, suffer comparatively little inconvenience from 
 their excesses ; nay, even seem to be all the better for them, if 
 we believe their own account of the matter. In such indivi- 
 duals the bowels are usually lax, and enormous quantities of 
 fa3ces are passed, consisting of matters taken as food, and which 
 have never been assimilated at all ; while the portion that has 
 been imperfectly assimilated and taken into the system readily 
 passes off by the kidneys, skin, &;c., without materially affect- 
 ing the constitution. Subjects of this description, for the most 
 part, are of a lax scrofulous habit, and require to be well 
 supported, in order that enough of matters may be assimilated 
 by their imperfect organs to carry on the vital processes. If 
 such individuals be well fed, they often attain old age ; but 
 they are liable to hypertrophies and morbid growths of various 
 kinds ; and generally die of dropsy connected with extensive 
 organic disease. The children of such individuals, if they have 
 any, which is frequently not the case, are usually sickly, 
 and very often die in their infancy ; and a third generation of 
 such a race, unless counteracted by favourable intermarriages, 
 rarely exists. Habits of this description are met with in 
 various grades, and states of combination ; and individuals in 
 
78 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 whom such habit is associated with gout, gravel, or, in short, 
 with any other inherited predisposition to disease, are commonly 
 remarkable sufferers. 
 
 We now revert to that state of the system above alluded 
 to, which, in healthy individuals who have lived fully and 
 indolently, usually precede what is called a hilious attack. 
 
 In those Vv^ho suffer from indigestion, whether from excess 
 or from disease, the acid and unassimilated matters appear, as 
 we have stated, to accumulate in the system, and to be thrown 
 off periodically by the bowels, or by other organs. Such attacks 
 in the strong and healthy are usually displayed in the form of 
 simple feverish excitement, with more than usual derangement 
 of the stomach and bowels, and generally sickness and diar- 
 rhoea ; but in the delicate, and in those predisposed to other 
 diseases, the weak part, wherever it may be, is usually involved 
 in the affection, and suffers in a greater or less degree. Of all 
 other parts of the system, the mucous membranes seem to be 
 most liable on such occasions to go wrong ; and of all exciting- 
 causes, cold is perhaps the most common. Thus every one 
 must have observed that when the system is so charged, 
 he is liable, on the slightest exposure, to get cold ; particularly 
 if the lungs are in the least degree predisposed. Others, as 
 above observed, in such a state of the system from a similar 
 exposure, get an attack of rheumatism ; others gout or erysi- 
 pelas ; others a nephritic attack ; according as they are 23re- 
 disposed to these different diseases ; and in all such instances 
 the affection is of a mixed nature, and cannot be advantageously 
 treated without reference to the original derangement of the 
 assimilating processes ; and sometimes, when this is removed, 
 all the other symptoms disappear."^ Nearly the same remarks 
 
 * When a cold is caught, particularly in old and dyspeptic individuals, 
 one of the first symptoms often experienced is an immense discharge of 
 glairy aqueous fluid from the salivary glands, and even from the stomach, 
 (analogous to the water-hrash,') and which is not acid. This discharge of 
 fluid is often accompanied by indigestion and flatulence, and a sort of 
 spasmodic constriction of the cardia, so that the gaseous matters are ex- 
 pelled with difficulty. The watery discharge has often a cold feel, and is 
 
LACTIC ACID, &C. 
 
 79 
 
 apply to malaria, and, indeed, to every other exciting cause of 
 disease. Thus bilious individuals are very liable, on compa- 
 ratively slight exposure to malarious influence, to get an attack 
 of acute rheumatism, or of ague. For instance, I have known 
 individuals thus predisposed, get an attack of rheumatism or 
 ague, by simply passing through a malarious district, or resid- 
 ing for a few hours only in its neighbourhood ; while, in other 
 states of the system, the same road has been frequented ; or 
 the same residence occupied for months, and even for years, 
 without any such accident. These facts are well known to 
 every one who has paid attention to the subject ; and indeed 
 are, we believe, generally admitted. They have been men- 
 tioned here from their connexion with the present subject ; 
 as well as with the view of illustrating their pathology. 
 
 The condition of the system above described preceding what 
 is called a bilious attack, being so obviously calculated to pre- 
 dispose the constitution to take on further diseased action, 
 we are neither surprised to find that, in such a state of the 
 system, the secondary assimilating processes going on in all 
 parts of the economy, become more than usually deranged 
 from slight exciting causes ; nor that those organs should 
 specifically suffer, which happen, from any particular cause, 
 
 frequently most copious in the night. The stomach also feels cold. These 
 phenomena seem to occur most frequently in gouty and rheumatic sub- 
 jects, and in some are constantly present, in a greater or less degree ; but 
 in all are increased by exposure to a damp and raw atmosphere. 
 Under these circumstances, the stomach is apt to be particularly 
 embarrassed by any indigestible and cold articles of food, which aggra- 
 vate the affection. This state of the salivary glands, &c., seems to re- 
 semble closely that state of the skin which gives occasion to what is 
 termed a cold sweat ; or that condition of the kidneys produced by ex- 
 posure to cold, which in certain habits is accompanied by diuresis, &c. 
 Such a state is always attended by a peculiar atonic condition of the nerves 
 of the parts affected ; which nervous atony paralyses or renders the organs 
 insensible, as it were, to every stimulus except that of water, which in 
 consequence passes off in excess. In aged individuals who are constantly 
 subject to this flow of watery fluid in a profuse degree, the discharge 
 seems to operate vicariously to the kidneys, and perhaps to other organs ; 
 and I have several times seen coma supervene on its sudden cessation. 
 
80 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 to be predisposed. The inferences, however, we wish to draw 
 from these obvious facts are, that the severe derangements of 
 the secondary assimilating processes going on all over the 
 system, are nearly allied to certain forms of fever ; while the 
 local and specific derangements are identical with certain spe- 
 cific inflammations. 
 
 In what fever and inflammation in general consist, we do 
 not venture to offer an opinion ; but as no one will deny that 
 certain forms of fever and inflammation are always accom- 
 panied by more or less of derangement of the assimilat- 
 ing processes, both primary and secondary ; and that such 
 forms of fever and inflammation are not only preceded by 
 long-continued derangements of the primary digestive pro- 
 cesses, but frequently have their origin in such primary de- 
 rangements ; we may perhaps be allowed to assume, without 
 opposition, that some diseases to which we apply the terms fever 
 and inflammation, are, practically speaking, at least, what we 
 have above inferred them to be, viz. only severer derangements 
 of the secondary assimilating processes, modified by the pecu- 
 liar nature of the organs or textures in which such derange- 
 ments exist — inferences that will enable us to explain the prin- 
 ciples on which derangements of the primary assimilating 
 processes predispose to the peculiar derangements of the secon- 
 dary processes now under consideration ; and which we 
 consider to be nearly connected, if not identical, with those 
 forms of fever and inflammation usually denominated inter- 
 mittent fevers, rheumatism, and neuralgia; on each of which 
 aff"ections we shall make a few remarks. 
 
 The exciting cause of the diseases just mentioned is gene- 
 rally admitted to be malaria ; and, if viewed abstractedly, 
 and with reference to their specific nature, it is probable 
 that malaria is the only exciting cause of these diseases. 
 These diseases, however, are so generally associated with 
 other diseases, arising from other exciting causes, that we 
 rarely see them in their simple condition ; moreover, diseases, 
 as hectic, &;c., simulating them in many respects, are produced 
 
LACTIC ACID, &C. 
 
 81 
 
 by other exciting causes than malaria, so that it often be- 
 comes a work of great difficulty, or even of impossibility, to 
 distinguish one disease from another ; and, consequently, to 
 refer each exactly to its true exciting cause. How malaria acts 
 in producing ague, rheumatism, and neuralgia, we do not know ; 
 but every one who has observed these diseases attentively, will 
 probably admit, that the derangements of the assimilating 
 organs constitute one of the first perceptible links in the 
 series of symptoms ; and, moreover, that these derangements 
 of the assimilating organs are usually accompanied by the pre- 
 sence of great acidity in all parts of the system. Thus, in 
 ague and rheumatism, during the sweating stages of the pa- 
 roxysms, immense quantities of acid (chiefly of lactic acid) 
 are thrown off by the skin ; and sometimes by the kidneys. In 
 these cases the saliva is commonly acid; and, in the severe 
 and malignant diseases of this type, occurring in tropical cli- 
 mates, not only the saliva, but the whole assimilating organs, 
 and even the blood itself circulating in these organs, have been 
 observed to be in an acid condition. Thus, as formerly stated, 
 the dark-coloured fluid ejected from the stomach in yellow 
 fever, and some other analogous diseases, appears to owe its 
 colour solely to the presence of blood, which has been black- 
 ened by the large quantity of (lactic ?) acid present ; and which 
 blood and acid must have been thrown off together, from the 
 unnatural fluids circulating in the vessels of the stomach itself. 
 Now, the presence of so much lactic acid cannot be ac- 
 counted for, except on the supposition that a certain portion 
 of what ought to constitute, or actually has constituted, the 
 albuminous, or, rather, gelatinous parts of the system, are 
 decomposed or destroyed ; and as gelatinous and albuminous 
 matters or textures cannot be converted into lactic acid alone ; 
 that consequently, other unnatural and probably poisonous 
 principles are developed in conjunction with the lactic acid ; 
 to which in part, as well as to the lactic acid, many of the se- 
 condary consequences of mal-assimilation are to be referred. In 
 other words, the alimentary matters, which ought to be convert- 
 
 G 
 
82 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 ed into albumen, by the primary assimilating organs ; and the 
 albuminous matters of the blood, which, in the secondary 
 assimilating processes, ought to be converted into the living 
 gelatinous and albuminous tissues, are, by the deficient or dis- 
 ordered operations of the vital processes, converted, in a greater 
 or less degree, into lactic acid, and other unnatural combina- 
 tions. 
 
 Such, then, are the conditions of the assimilating processes, 
 which we conceive to exist in the three classes of disease we are 
 now considering; the next question is, what constitutes the 
 difierence between ague, rheumatism, and neuralgia, when 
 the cause and general conditions of the system in these afiec- 
 tions are assumed to be the same ? If our assumption be 
 correct, the only answer this inquiry appears to admit of is, 
 that the circumstances constituting the varieties in question 
 are ; difierence in the degree in which the same organs are 
 affected ; or differences in the seat of disease or organs afiected ; 
 or, what is most likely, a combination of both these kinds of 
 differences. 
 
 With respect to difference in degree, we do not think that 
 this cause alone is sufficient to account for the varied charac- 
 ter of the diseases in question. It is admitted, indeed, that 
 difference in degree will, by causing the affection to be gene- 
 rally spread over the system, considerably modify the symp- 
 toms ; but unless specific organs be actually involved, there can 
 hardly be supposed to be any difference in the kind of the 
 disease. We are, therefore, driven to the conclusion, that 
 these different forms of disease arise from derangements in the 
 secondary assimilating processes proper to different tissues or 
 structures. Thus we may suppose (and the supposition seems 
 to be rendered probable by the phenomena) that, in intermit- 
 tent fevers, the primary assimilating organs, the stomach, the 
 liver, and the spleen, are principally in fault ; that the secon- 
 dary assimilating processes, by which the structure or tissue of 
 these organs is produced and maintained, are impaired ; and 
 that to the consequent imperfect development of thes^ organs 
 
LACTIC ACID, &C. 
 
 83 
 
 we may not only refer the formation of the lactic acid, and other 
 unnatural matters, generated during the digestive processes; 
 but also those organic lesions and morbid hypertrophies, which 
 are so apt to take place in the spleen, &c., during severe and 
 long-protracted fevers of this type. In rheumatism, the same 
 derangements, to a less extent, appear to exist in the primary 
 assimilating organs ; but, in this case, the secondary assimilating 
 processes, by which the gelatinous portion of the muscular 
 system and its appendages are produced and maintained, may 
 be supposed to be more especially implicated ; and the loss of 
 power, and the great degree of pain usually present in rheu- 
 matism, may be referred to the disorder of the numerous nerves 
 of motion and of sense, which, as well as the fibrinous portion 
 of the muscles, are likewise necessarily affected by the derange- 
 ments. Moreover, on these suppositions, we may explain the 
 formation of the large quantities of lactic acid usually present 
 in rheumatic affections, as well as the swelling, Sec. ; for as all 
 the organs are more or less involved, and their functions para- 
 lysed, not only imperfect assimilation takes place in the part 
 affected; but the apparatus destined to remove matters which 
 are unfitted, or no longer useful, from the scene of operation, 
 likewise cease to act; and hence such unfitted and useless mat- 
 ters accumulate, and cause swelling in the part affected. In 
 simple neuralgic affections, nearly the same explanation may 
 be given. Derangements of the primary assimilating proces- 
 ses, analogous to, or identical with, those existing in ague and 
 rheumatism, are always present in a greater or less degree in 
 these affections ; while the derangements going on in those se- 
 condary assimilating processes, by which the nervous substance 
 and its immediate appendages are produced and maintained, 
 may be supposed to be the immediate cause of the pain and other 
 distressing symptoms of the disease.* 
 
 * The reader is distinctly required to bear in mind that rheumatic 
 neuralgia only is here alluded to. Neuralgic affections, arising from me- 
 chanical or other injuries of the nerves, are referable to another class of 
 affections ; but, even in such instances, the formation and presence of 
 
 g2 
 
84 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 Such is a summary statement of the three most remarkable 
 and most common of the effects of exposure to malarious in- 
 fluence. It is not, however, to be understood that these com- 
 prise all the modifications of disease arising from this fertile 
 source. When the predisposing circumstances favour such 
 derangements, errors of the secondary assimilating processes 
 take place in other parts, as well as in the textures named. 
 For instance, derangements of the secondary assimilating pro- 
 cesses take place in the mucous membrane or its immediate ap- 
 pendages, lining the intestines, the bladder, the urethra, &:c., of 
 which I have seen instances ; and though such forms of derange- 
 ment are comparatively of rare occurrence in this country, their 
 existence is well understood in warmer climates, where exten- 
 sive malarious districts abound. I have also sometimes thought, 
 from the similarity of the effects produced by iodine in goitre, 
 and in certain rheumatic enlargements, that these different 
 affections are somehow related ; perhaps by having a common 
 origin. 
 
 Treatment, Sfc, — The same reasons which induced us to limit 
 our attention to the general history of the class of diseases now 
 under consideration, induce us to confine our observations to 
 the general principles of their treatment. 
 
 The principles of treatment to be kept in view in the present 
 class of diseases, like the principles of treatment of most other 
 diseases, are divided into the empirical and the rational. 
 Knowledge, founded on observation and experience, suggests to 
 us the application of those remedies which control the diseased 
 actions producing mal-assimilation, such as quinine and what 
 are called tonics in general; while knowledge founded on me- 
 chanical and chemical principles, suggests the employment of 
 those counter-mechanical or chemical expedients, which are 
 calculated to neutralize the effects of mal-assimilation ; and 
 thus to prevent their secondary operation on the living system. 
 These two classes of remedies are quite distinct ; and though 
 
 unnatural matters of another sort may contribute to the patient's suf- 
 ferings. 
 
LACTIC ACID, (fee. 
 
 85 
 
 they gradually run into each other, they cannot, except in a few 
 instances only, be substituted one for the other. Moreover, 
 in almost every case, the two classes of remedies are more 
 effective when separately administered, than when associated. 
 
 In the treatment of the development of acidity during the 
 primary assimilating processes, the first point to be determined, 
 as far as we are able, is the nature of the cause which appears 
 to give occasion to the symptom ; that is to say, we have to 
 inquire whether the cause lies chiefly in the stomach itself, and 
 consists in inflammatory excitement, or in mere debility of that 
 organ; or whether the cause lies in the inflammatory action or 
 other disease of some remote organ ; more especially of the 
 hepatic system, or of one of the great nervous centres. When 
 this point has been satisfactorily determined, the application of 
 the empirical part of the treatment is for the most part compa- 
 ratively easy. Thus, if the cause lies principally in the stomach 
 itself, and the symptoms denote an inflammatory tendency, the 
 due administration of local blood-letting, &:c., wdll be found 
 beneficial ; if mere irritation be indicated, sedatives, as the hy- 
 drocyanic acid, various tonics, &;c. will be found useful. If the 
 cause be chiefly remote, as in the hepatic system, the employ- 
 ment of means calculated to remove inflammatory or passive 
 congestion, as mercury and other deobstruents, will be indi- 
 cated. If the cause be organic disease ; and if such organic 
 disease lie deep in the system, as in one of the great nervous 
 centres, very little beyond palliatives can be advantageously 
 employed ; and it becomes as much our duty on the one hand 
 to avoid improper remedies, as it is on the other to mitigate, 
 as far as we are able, the severity of the prevalent symptoms. 
 Such are the points to be inquired into in the treatment of 
 these derangements — points quite distinct in their character, 
 though in practice we find that one of them seldom occurs 
 alone; but that all the three, not unfrequently, exist at the 
 same time. Complications of this kind are exceedingly for- 
 midable and difficult of management, and too often resist our 
 utmost means, however skilfully applied ; though, on the other 
 
PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 hand, sucli complications are easily aggravated by injudicious' 
 treatment. 
 
 The other great class of remedies mentioned, viz, those cal- 
 culated to prevent the secondary effects of mal-assimilation, 
 are, as we have stated, usually applied on rational principles; 
 hence, in their application, reason should be attended to, other- 
 wise they are apt to do more harm than good. The two great 
 objects to be kept in view in the administration of this class of 
 remedies, is either the mechanical object of getting rid of the 
 unnatural material whose effects we wish to obviate ; or the 
 chemical object of neutralizing the acid, and other unnatural 
 products of the primary assimilating processes. Now, as both 
 these objects have reference to certain periods, and depend upon 
 the time when the assimilating organs are called upon to per- 
 form their duty ; it is obvious, that to obtain the utmost benefit 
 of this class of remedies, their administration must in a great 
 degree be regulated by such periods.^' Thus the acid residua 
 of a meal should be neutralized when the digestive processes 
 are completed ; that is to say, from three to six hours after the 
 meal has been taken ; and for this purpose, even in the worst 
 cases, from ten to twenty or thirty grains of the carbonate of 
 potash will be quite sufficient. To the carbonate of potash, I 
 find that four or five grains of nitre may be usually added with 
 good effect; though I do not pretend to explain its modus ope- 
 randi. Those who wish to prevent the distressing secondary 
 effects of acidity in the primae vise, must steadily persist in the 
 use of this remedy daily, not for a few days or weeks, but un- 
 til the affection has been entirely subdued by other means, viz. 
 by the joint effects of appropriate diet and medicines ; for it 
 should be constantly borne in mind that alkaline remedies 
 
 * The injudicious use and abuse of alkaline remedies in acidity of the 
 stomach is often a source of great mischief. Alkalis, as stated in the 
 text^ exert no curative elFect: that is to say, they will not prevent /w^wre 
 acidity. On the contrary, when taken in large doses, and at improper 
 times, the effect of alkalis is to cause an absolute increase of acid. 
 Thus, when a large quantity of alkali is taken into an empty stomach, 
 the immediate effect is, that the stomach, in endeavourhig to resume its 
 
LACTIC ACID, &C. 
 
 87 
 
 have no effect m preventing acidity; their effects are solely con- 
 fined to neutralizing the acids already formed. 
 
 When acidity prevails in the lower portion of the intestinal 
 canal, and particularly in the coecum, the treatment must be 
 modified to meet the circumstances. The soluble antacids in 
 this case have comparatively little effect, from their being neu- 
 tralized and absorbed before they reach the seat of the affection ; 
 hence the insoluble antacids, and particularly magnesia, will 
 in general be found more useful in such cases. The shortest 
 mode, however, of getting rid of the immediate inconvenience 
 of acidity in the lower bowels, is usually to inject a pint or two 
 of warm water, (or of soap and water,) and thus of removing 
 the offending cause. By this simple remedy I have often seen 
 the severe nervous headaches, and other unpleasant symptoms 
 usually accompanying acidity in the lower bowels, immediately 
 removed. Those who suffer from such causes usually require 
 the aid of purgatives, which in general are better taken at bed- 
 time. Purgatives of a mild but effectual kind, such as the 
 
 natural condition, throws out an additional quantity of acid to neutralize 
 the redundant alkali. When alkaline remedies, therefore, are injudiciously 
 persisted in, a daily contest arises between the stomach and the doctor. 
 If the constitution be sound, the stomach, in spite of the doctor, usually 
 gains the ascendency ; but at the expense of extraordinary labour in the 
 secretion of a greater quantity of acid. If, on the contrary, the vital 
 powers of the stomach be weak, the doctor may conquer, but at the 
 risk of still further enfeebling the vital powers of that organ ; and in 
 both instances the general result will be, that the diseased functions of 
 the stomach producing acidity will be augmented rather than improved. 
 The beneficial effects of alkaline remedies, therefore, are confined, as we 
 have stated, to the neutralisation of acids already formed, and thus of 
 preventing their secondary effects on the system. The primary derange- 
 ments of the vital operations, on which the morbid formation of such acids 
 depend, must be combated by the empirical means before spoken of. 
 As mere antacids, the alkaline carbonates are in general infinitely preferable 
 to the pure alkalis. To obtain their maximum effects also, they are 
 usually much better exhibited alone. Those who combine antacids with 
 tonics generally defeat their purpose, both with respect to the antacid 
 and the tonic as, to ensure their maximum effects, the two classes of re- 
 medies require to be given at totally different times, relatively to the diges- 
 tive processes. 
 
88 PATHOLOGY OF SACCHARINE ASSIMILATION AND SECRETION. 
 
 Decoct, aloes comp. with magnesia, often suit well ; as do pills 
 taken at a late dinner, if duly adjusted to the circumstances of 
 the case. Drastic purgatives in general should be avoided; 
 for though they sometimes give immediate relief, they usually 
 leave the patient more inveterately disposed to the disease. 
 Neither this class of diseases, nor the remedies adapted to re- 
 move them, have been so carefully studied as they deserve to 
 be. We shall have occasion to revert to them hereafter. 
 
 In what is called a bilious attack, one of the indications, in 
 almost all instances, is to relieve the congested viscera by ap- 
 propriate purgatives. If the patient has not been accustomed 
 to the stimulus of mercury, this active remedy will scarcely be 
 required in the slighter instances : if he has been so accustomed, 
 nothing probably but mercury will remove the congestion, and 
 set the system free. Bilious attacks are so common among 
 the indolent and over- fed inhabitants of great towns, that every 
 body, patients as well as doctors, think they understand them, 
 and treat them accordingly. The truth is, however, that these 
 derangements are not half so well understood as they are sup- 
 posed to be ; and that there is no class of diseases, particularly 
 as they occur about the middle or stationary period of life, 
 which require greater discrimination or judgment on the part 
 of the medical practitioner; on whose mode of treatment very 
 often depends not only the future comfort, but sometimes even 
 the very existence, of the patient. 
 
 We have stated that the congested condition of the assimi- 
 lating organs now under consideration, strongly predisposes to 
 disease, in those parts of the system, which, from original or 
 accidental causes, are weaker or more obnoxious to disease than 
 the others. It becomes, therefore, the duty of the medical 
 practitioner to study the weak points of the patient's constitu- 
 tion, and to direct his remedies accordingly. Calomel pills and 
 black doses will not do for all ; and when misdirected, they too 
 often bring on irreparable mal-assimilation and its consequences. 
 As, however, the affections to which this congested state of the 
 system predisposes, and with which it is complicated, are so xiu- 
 
LACTIC ACID, kc. 
 
 89 
 
 merous, details are out of the question. Some of these compli- 
 cations have been already described ; others will be noticed in 
 subsequent parts of this volume ; while many of them fall en- 
 tirely without the range of our present design. The principal 
 object in noticing the subject in this place is to arrest attention; 
 and to show that one of the complaints of the most frequent 
 occurrence, is likewise one of the greatest interest and import- 
 ance. 
 
 We pass on to the treatment of ague, rheumatism, and 
 neuralgia — affections generally admitted to result from expo- 
 sure to malarious influence, and to which those who are already 
 predisposed by the derangements of the assimilating organs 
 above described, seem to be particularly obnoxious. The same 
 reasons which induced us to avoid detailed descriptions of these 
 diseases, now limit us to the general principles of their treat- 
 ment. 
 
 In obstinate attacks of either of the above diseases, the re- 
 medies of first application usually partake of a rational charac- 
 ter, or are such as are calculated to remove unnatural accumu- 
 lations or congestions mechanically impeding vital operations ; 
 as blood-letting, general and local, purgatives, kc. These ob- 
 jects being accomplished, we resort to our empirical remedies, 
 that is to say, to general or specific tonics, stimuli, or sedatives, 
 or to various combinations of such remedies, with the view of 
 removing, as far as we are able, the immediately urgent symp- 
 toms, and of restoring the languishing vital powers. In con- 
 junction with these remedies, the secondary effects of the 
 mal-assimilation always present in such derangements, should 
 be attended to and obviated by appropriate counter-agents. 
 Of the secondary derangements, as we have said, acidity is 
 always one ; though, as the acid developed is usually the lactic 
 or some other destructible acid; for the reasons formerly given, 
 no less than from the remote situations in which the acid is 
 developed, alkalis are not so immediately beneficial in the dis- 
 eases under consideration, as they are in those affections in 
 which their development is limited to the primae vise. 
 
90 
 
 CHAPTER III. 
 
 GENERAL OBSERVATIONS ON THE PATHOLOGY OF ALBUMINOUS 
 ASSIMILATION AND SECRETION. 
 
 Although the assimilation of albuminous principles, in some 
 form or other, is probably requisite to all the more perfect 
 animals, and cannot be long, if at all, suspended without destroy- 
 ing their existence ; yet, as far as regards the human subject, 
 the primary assimilation of animal albuminous matters may 
 certainly for a time, if not altogether, be dispensed with. 
 Whether the primary faculty of assimilating vegetable albu- 
 men or gluten, and the caseous principle of milk, can be per- 
 manently suspended, is not known ; but my belief, as just 
 stated, is, that the function of assimilating albuminous matters, 
 taken in its general sense, like the function of assimilating the 
 organized saccharine principle, is never entirely suspended ; in 
 other words, that the complete suspension of this function is 
 equivalent to the death of the organized being. 
 
 The phenomena and symptoms attending the non-assimila- 
 tion and mal-assimilation of albuminous matters, vary so re- 
 markably, that their general relationship will be better under- 
 stood after they have been described in detail. We shall pro- 
 ceed, therefore, at once, to describe the most remarkable de- 
 rangements resulting from the causes stated ; and as these 
 derangements are most prominently marked, or at least are 
 best identified, by the changes they induce in the urinary se- 
 cretion ; we shall make the changes thus induced in the urinary 
 secretion the basis of our arrangement and description. In 
 
PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 91 
 
 other words, we shall consider the urinary derangements as 
 constituting so many distinct diseases, under the following 
 heads : — 
 
 a. Derangements of the assimilating processes, accompanied 
 by excess or deficiency of urea in the urine. 
 
 h. Derangements of the assimilating processes, accompanied 
 by the presence of albuminous matters in the urine. 
 
 c. Derangements of the assimilating processes, accompanied 
 by the presence of lithic acid and its compounds in the urine ; 
 and, 
 
 d. Derangements of the assimilating processes, accompanied 
 by the presence of cystic oxide in the urine. 
 
 These four classes of derangements, therefore, will constitute 
 the subjects of the four sections into which the present chapter 
 is divided. 
 
92 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 Section a. Of an Excess and Deficiency of Urea in the Urine, 
 
 Before the first edition of this work was published in the 
 year 1821, the diseases connected with a derangement of the 
 quantity of urea in the urine were little understood, and seem 
 to have been confounded with other diseases. Since that time 
 they have attracted more attention; though even yet they have 
 not obtained that consideration among medical men which 
 their importance demands. 
 
 Of Affections connected with an Excess of Urea in the Urine 
 — The proportion of urea in healthy urine is such, that on the 
 addition of nitric acid, no crystallisation takes place till the 
 urine is concentrated by evaporation. In a variety of cases, 
 however, the quantity of this principle is so increased, that 
 crystallisation takes place on the addition of nitric acid, with- 
 out any previous concentration of the urine ; and in many 
 such cases, on analysis, we find that this excess of the urea is 
 not only absolute but relative ; that is to say, that the quantity 
 of urea in the urine is not only absolutely greater than natural, 
 but relatively far greater to the other ingredients, than it is, or 
 ought to be, in the healthy secretion. Now this absolute and 
 relative excess of urea in the urine gives occasion to two forms 
 or rather modifications of disease, which, as in diabetes, are 
 chiefly distinguished by differences in the quantity of urine 
 passed, viz. Excess of urea without diuresis, and Excess of 
 urea with diuresis. These two forms of disease, precisely as 
 in diabetes, without or with diuresis, sometimes gradually 
 pass into each other in the same individual; and in fact they 
 seem to differ from each other little more than in degree. 
 In the first form of the disease, the quantity of urine passed 
 seldom much exceeds the healthy standard, and in this case 
 the quantity of urea is both absolutely and relatively greater 
 than in health. In the second form of the disease, the quantity 
 
EXCESS OF UREA. 
 
 93 
 
 of urine is sometimes excessive; and in this instance the 
 quantity of urea, in a given specimen of urine, may be less 
 than in health; though the quantity of urea relatively to the 
 other ingredients may be greater than natural ; and the abso- 
 lute quantity of urea passed in a given time, may thus, as in 
 the other modification of the disease, exceed the natural stand- 
 ard. Before the period above mentioned, neither of these forms 
 of disease seems, as just stated, to have been distinctly recog- 
 nised ; and the second form in particular, when it attracted at- 
 tention at all, was usually confounded with diabetes. 
 
 It will be proper to notice, before we proceed, that when the 
 specific gravity of the urine is high — for example, above 
 r030 — the absolute proportion of urea, in common with the 
 other principles, is necessarily larger than natural ; and in this 
 case, spontaneous crystallisation will frequently take place in 
 such urine on the addition of nitric acid. This concentrated 
 state of the urine not unfrequently takes place in febrile and 
 other diseases, and is quite unconnected with any specific dis- 
 ease ; but depends on a diminished secretion of water only. 
 Hence, though this abundance of urea, as in all other cases, may 
 be considered as indicative of disease, yet in the present in- 
 stance it is obviously no more indicative of disease than the 
 abundance of the other principles, and consequently leads to 
 no particular plan of treatment ; which must be regulated by 
 the general nature of the affection. 
 
 In other instances, not only an absolute, but a relative excess 
 of urea is occasionally present in the urine. This happens, for 
 instance, occasionally in the urine of children, as well as of 
 adults, when the secretion abounds in the triple phosphate of 
 magnesia and ammonia. In such cases, however, more obvious 
 and urgent symptoms are commonly present, and these become 
 so prominent as to constitute the characteristic feature of the 
 derangement. Hence the symptom of an excess of urea, though 
 important, must be considered as subordinate ; and our prac- 
 tice must be regulated by the more prominent and characteris- 
 tic symptoms of the disease. 
 
94 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 In the first form of the disease now under consideration, 
 distinguished by the presence, both of an absolute and relative 
 excess of urea, the average specific gravity of the urine seems 
 to be a little above I*020; and occasionally to vary from 1'015 
 to r030, or even higher. Most generally the secretion is trans- 
 parent and pale coloured; but occasionally assumes somewhat 
 the appearance of porter more or less diluted with water; and 
 this variety in colour not unfrequently takes place in the 
 urine of the same person. When first voided, the urine reddens 
 litmus paper, and consequently has the usual acid reaction 
 of healthy urine. For the most part it is entirely free from 
 sediment, except the mucous cloud invariably present in the 
 secretion ; and the only remarkable property which it appears 
 to possess, is that of containing so much urea as to speedily 
 form a crystallized compound on the addition of nitric acid. 
 Urine containing a large proportion of urea is prone to decom- 
 position, and generally soon becomes alkaline ; especially in 
 warm weather. 
 
 Those who are subject to this form of the disease, have usu- 
 ally a frequent and urgent desire of passing water both by 
 night and day. This frequent desire of passing water, which 
 seems to be principally occasioned by an irritable sensation re- 
 ferred to the neck of the bladder, and occasionally extending 
 along the urethra, is sometimes also referable, in part, to 
 actual diuresis; that is to say, to an increased quantity of urine 
 in the bladder ; though it can be rarely ascribed to this cause 
 alone, as the quantity of urine passed at one time is often by 
 no means large. In almost every instance, however, even of 
 the form of disease now under consideration, which has fallen 
 under my notice, the quantity of urine voided in a given period, 
 as in twenty-four hours, has appeared to be somewhat above 
 the natural standard. The quantity also is particularly liable 
 to be increased by causes which would scarcely affect a person 
 in perfect health, at least in the same degree ; such as by a 
 chilly state of the atmosphere, mental emotion. Sec. 
 
 Besides the symptoms immediately referred to the urinary 
 
EXCESS OF UREA. 
 
 95 
 
 organs, there is sometimes a sense of weight or dull pain in 
 the back, accompanied by a disinclination to bodily exertion. 
 The patient also complains of more or less uneasiness in the 
 assimilating organs, though the tongue usually presents nothing 
 peculiar ; and there is no remarkable thirst ; nor craving for food ; 
 nor emaciation. Moreover, the functions of the skin appear to 
 be little deranged ; hence perspiration, from the fatigue it is apt 
 to produce, often takes place readily under exercise. In short, 
 though there is great susceptibility to derangement, as well as 
 to actual disease of the assimilating and other functions, I am 
 not aware that any one derangement of any one organ can 
 with certainty be pronounced to be characteristic of an excess 
 of urea in the urine. 
 
 In the second modification of the disease, in which the quan- 
 tity of urine passed is excessive ; besides most of the symptoms 
 above enumerated in an aggravated form, there exists, in addi- 
 tion, more or less of thirst and morbid craving after food. 
 The patient likewise complains of general coldness and great 
 bodily weakness. In some instances also there is considerable 
 emaciation; though not to the same remarkable extent as in 
 diabetes. 
 
 The causes predisposing to an excess of urea in the urine, 
 seem to be nearly allied to those predisposing to diabetes ; 
 hence the tendency to the disease, like the tendency to dia- 
 betes, is probably often inherited. With such an inherited or 
 constitutional predisposition, a variety of circumstances, having 
 no common character, except that of alike enfeebling the 
 vital powers, will, as in diabetes, give occasion to the develop- 
 ment of an excess of urea in the urine. Among such circum- 
 stances I have observed an abuse of the sexual powers in early 
 life as one of the most frequent. Next to this has been long- 
 continued and severe dyspepsia from inattention to diet ; in- 
 temperance in the use of fermented liquors ; mental anxiety ; 
 mercurial irritation, &:c. ; while in several instances I have not 
 been able to elicit from the patient any circumstance to which 
 the disease could be reasonably referred. 
 
96 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 Most of the subjects of the disease in the forms above de- 
 scribed, which I have hitherto seen, have been middle-aged 
 men, of thin and spare habit, with a sort of hollow-eyed anx- 
 iety of expression in their countenance ; unusually nervous 
 and susceptible, but by no means always hypochondriacs ; and 
 free also from gout, and, as far as 6ould be ascertained, from 
 structural disease of the urinary or any other organs. In ge- 
 neral, the subjects of the slighter form of the disease had been 
 induced to apply for medical advice, not so much from actual 
 suffering, as from the inconvenience of the disease, and the 
 dread of its ending in something worse : while those who la- 
 boured under the severer forms of this affection, imagined that 
 their disease was diabetes, and had been sometimes treated 
 accordingly by the medical men they had consulted. Perhaps 
 it may be worth while to mention that hitherto I have seen no 
 well-marked instance of the disease in a female ; Dr. Venables, 
 however, seems to have met with instances.^ 
 
 If I might venture to express an opinion founded on the 
 experience of the last twenty years, since I first recognised the 
 disease, I should say that, in its well-marked form, the present 
 affection is rare ; for where I have seen one case of an excess 
 of urea in adults, I have seen twenty cases of diabetes. There 
 is reason, however, to believe, that this unusual occurrence of 
 the disease is more apparent than real ; and that, in a great va- 
 riety of instances, patients do not apply for medical advice till 
 the complaint has merged into diabetes or some other formi- 
 dable disease; to which it often constitutes the transition-step. 
 That the disease, if permitted to proceed unchecked, or if inju- 
 diciously treated, passes into diabetes or some other formidable 
 disease, (perhaps the form of disease to be next considered,) 
 I have the strongest presumptive evidence, both from observa- 
 tion and analogy ; but I have hitherto had no positive proof 
 of such a termination ; for every instance of the affection which 
 I have yet seen in adults, has yielded more or less readily and 
 completely to the means recommended. 
 
 * See his treatise before referred to. 
 
EXCESS OF UREA. 
 
 97 
 
 With respect to the proximate cause or intimate nature of the 
 disease ; I have been long of the opinion that it depends upon 
 derangements of the secondary assimilating processes, rather 
 than of the primary; that is to say, that the chief source of the 
 urea in the system is that peculiar modification of the albumi- 
 nous principle distinguished as gelatine ; and which, as is well 
 known, is not found in the blood, nor in any previous stage of 
 the assimilating processes; but is developed only during the 
 secondary assimilating processes. To the same source we have 
 referred in part the saccharine matter in Diabetes; also the lactic 
 and other acids immediately allied in composition to the saccha- 
 rine principle ; (that is to say, composed of carbon and water ;) or 
 derived from the saccharine principle, as the oxalic acid, &c. ; all 
 which principles seem to be complementary to urea and its deri- 
 vatives; in other words, the gelatinous principle is changed into 
 urea and its derivatives on the one hand, and the saccharine 
 principle or its congenerous acids and derivatives on the other. 
 This apparent relationship between the different principles men- 
 tioned, has induced me to consider the present disease in im- 
 mediate connexion with Diabetes, and the diseases associated 
 with unusual development of the lactic acid, &:c., in the last 
 chapter ; of many of the phenomena of all which diseases it 
 offers an explanation. The same relationship will also enable 
 us to explain the fact, now I believe universally admitted by 
 physiologists ; that the greater portion of the urea found in the 
 urine is not formed in the kidneys, but elsewhere in the sys- 
 tem ; and that these organs are little more than the outlets, by 
 which, as an excreted principle, urea is removed from the eco- 
 nomy.^ 
 
 There is a modification of the second form of the affection 
 occasionally occurring in very young children, nearly allied to 
 
 * I do not believe that the kidneys are entirely passive w^ith reference 
 to this point ; and thhik it not improbable that in some instances imper- 
 fectly developed urea may be formed in the system, which, in subsequently 
 passing through the kidneys, is reduced to the crystallized form. Indeed 
 it is most likely that in the healthy condition of the system this is the 
 rule ; as it seems to be with respect to lithic acid. 
 
 H 
 
98 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 the infantile diabetic affection pointed out by Dr. Venables, 
 of which, in fact, it may be considered as a variety. The affec- 
 tion had not been entirely unnoticed by preceding writers ; 
 but, in common with infantile diseases in general, had been re- 
 ferred to, or confounded with, other diseases arising from that 
 fertile source of most infantile suffering, abdominal derange- 
 ment. Dr. V. considered the affection as a •sAariety of diabe- 
 tes, under which head we have more particularly described it ; 
 and it is probable, that like the class of diseases in adults dis- 
 tinguished by an excess of urea, it may be considered as an 
 intermediate state of disease between diabetes and the diseases 
 to be presently spoken of, in which the quantity of urea is less 
 than natural ; and in which there is a tendency to, if not actu- 
 ally existing, organic disease. 
 
 For an account of the symptoms of the present affection, 
 which, like the infantile diabetes formerly described, usually 
 makes its appearance after the child has been weaned, we refer 
 to what was then stated.^ It will be sufficient to remind the 
 reader that the urine at first is sometimes scanty and high 
 coloured ; becomes turbid immediately on cooling ; and lets fall 
 a pale, clay-coloured deposite. The quantity of the secretion, 
 however, soon rapidly increases, and the thirst being commen- 
 surate, large quantities of fluid are consequently taken ; so that 
 in twenty-four hours an infant under twelve months old, 
 will be often found to pass from two, to four or five pints of 
 urine. This urine, like that of incipient diabetes, is commonly 
 transparent, and of a pale yellow or greenish tint. Its specific 
 gravity varies from 1*010 to 1*025; and on examination it will 
 be found to contain a great excess of urea; and occasionally 
 traces of albumen and sugar. The progress of this infantile 
 affection, if mal-treated or neglected, seems, as just stated, to be 
 towards diabetes on the one hand, and a deficiency of urea, or 
 organic disease on the other ; under which heads its further 
 history is considered. 
 
 This disease occurs most frequently among the children of 
 
 * See page 56. 
 
EXCESS OF UREA. 
 
 99 
 
 the poor, who are not only badly clothed and fed, but in every 
 way neglected. It is, however, occasionally met with in the 
 children of scrofulous parents in every rank of societ}' ; particu- 
 larly when there has been great inattention to diet, and injudi- 
 cious medical treatment. 
 
 Treatment, — In the first place, with respect to diet ; in the 
 two first forms of the disease this should be light and nutri- 
 tious, but not stimulating; and in general should consist prin- 
 cipally of animal and farinaceous matters. If the patient has 
 been accustomed to the use of fermented liquors, a small quan- 
 tity of the more generous wines, or sound porter, may be 
 allowed ; but all diluent and diuretic fluids should be abstained 
 from as much as possible; and, as in Diabetes, he should avoid 
 indulging his thirst, the gratification of which will only aggra- 
 vate the disease. Moderate exercise, either on foot or horse- 
 back, will be proper ; but fatigue both bodily and mental should 
 be carefully shunned ; and, as far as it is possible, the patient 
 should endeavour to divest himself of mental anxiety of every 
 description. 
 
 From the various forms which this disease assumes in differ- 
 ent individuals, no uniform plan of medical treatment can 
 perhaps be laid down that will be found applicable in all 
 instances. The great principle to be kept in view is to do no 
 harm by rough treatment. Calomel pills, black doses, and 
 saline purgatives, are calculated to do infinite mischief, and 
 will probably render a manageable disease perfectly unman- 
 ageable. Hence, though the use of purgatives and alteratives 
 is often indicated, and even necessary, more especially in the 
 earlier stages of the disease ; they must be employed with cau- 
 tion, and their effects carefully watched. In both forms of the 
 disease, and particularly in the second, sedatives are usually 
 required, and of these opium is the chief. With the sedatives 
 may be conjoined such tonics as seem to be suited to the indi- 
 vidual habit; and as the complaint recedes, and the health 
 becomes re-established, the sedatives may gradually be with- 
 drawn. Such are the principles of the treatment I have usually 
 
 h2 
 
100 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 found most beneficial ; the details, of course, must be suited 
 to the circumstances, according to the judgment of the prac- 
 titioner. 
 
 Nearly similar remarks are applicable to the disease as it 
 occurs in young children. Rough mercurial purgatives are here 
 even more injurious than in adults ; and seldom fail to drive 
 the disease into one or other of its incurable extremes. At the 
 outset, gentle alteratives and laxatives, conjoined with a 
 carefully regulated diet, pure air, and friction over the abdo- 
 men, &c., with tepid salt water, will be found beneficial; and as 
 the complaint declines, tonics judiciously applied will secure 
 the advantages gained by the previous treatment; and thus 
 complete the cure. 
 
 The following cases are given as illustrations of the two 
 forms of the disease in adults, and of their modes of treatment. 
 
 The subject of the first case, which originally drew my at- 
 tention to the disease, was a gentleman about forty years of 
 age, whose general appearance and history coincided precisely 
 with those above given in our general description of the dis- 
 ease. He had been subject to the complaint a considerable 
 time, but latterly had become worse, and he had now a fre- 
 quent desire to pass water ; especially when under the influ- 
 ence of mental agitation, or when exposed to the cold air. 
 The urine was generally of a brown porter colour, and not 
 much more abundant than natural. The specific gravity of 
 the specimen I examined was r0237. In this specimen the 
 quantity of urea was most strikingly abundant; and there was 
 also a little lateritious sediment. He informed me that he 
 occasionally passed urine of a very pale colour ; and when this 
 happened, the quantity was greater, and the specific gravity 
 probably lower. He had no thirst; and the functions of the 
 skin appeared to be natural. He had lately, however, recovered 
 from a feverish attack, and he felt occasionally an uneasiness 
 in the region of the liver ; the tongue also was slightly furred, 
 and the bowels irregular. From these symptoms I at first 
 supposed the disease was nothing more than a common case of 
 
EXCESS OF UREA. 
 
 101 
 
 dyspepsia, connected with derangement of the hepatic system 
 and general health ; and I accordingly ordered him mercurial 
 alteratives with purgatives, and the usual means commonly 
 resorted to on such occasions. About a month afterwards I 
 again saw him. The urine was now free from sediment, and 
 its specific gravity was reduced to 1*019; but it still exhibited 
 the same brown colour, and the same great excess of urea as 
 before ; and though his general health was evidently improved, 
 the urinary complaint was in no degree diminished. He was 
 ordered a bitter infusion, containing the liquor jpotassce and 
 opium; and directed to regulate his bowels by the occasional 
 use of the alterative laxatives previously prescribed. Under 
 this plan the complaint became better in a few days; and in 
 three weeks afterwards, when I again saw him, was very con- 
 siderably improved. The urine, indeed, presented the same 
 appearance as before; but its colour was lighter; its specific 
 gravity reduced to 1*0155; and the proportion of urea, though 
 still excessive, was diminished. By persevering in the plan 
 mentioned for some time, he became almost entirely free from 
 the complaint ; and continued well for some months ; when it 
 returned again in a slight degree. Similar means were again 
 had recourse to, and the disease again yielded ; after which 
 time it returned at intervals of some months, (more frequently 
 during the winter,) but always gave way on the use of opium 
 in very moderate doses, as, for example, gutt. x. or gutt. xii. of 
 the tinct. opii in a glass of soda water once or twice a day. 
 This state of things continued for a considerable time, the urine 
 never becoming absolutely natural. He then consulted me 
 about the propriety of marrying — a step which I strongly 
 urged him to take. For several years after this I heard no- 
 thing of him ; when he called on account of some dyspeptic 
 symptoms. The urine was still unnatural, but on the whole 
 improved ; and he told me that soon after I last saw him he 
 had followed my advice and married, and had now three chil- 
 dren, with every prospect of more. 
 
 The second case I shall recite is one that occurred to Dr. 
 
102 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 Elliotson, at St. Thomas's hospital; who furnished me with 
 the urine for examination every week, so as to enable me to 
 ascertain the effects of the remedies employed. 
 
 March 6th, 1819. — Rodman, aged fifty-five. Symptoms 
 resembling those of Diabetes. There is constant craving for 
 food ; a sense of cold over the whole body ; and a frequent de- 
 sire of passing urine; which in twenty-four hours amounts to 
 sixteen pints. 
 
 The urine of this man was pale-coloured ; its specific gra- 
 vity was 1*020; and it contained a very large proportion of 
 urea; but not the least particle of saccharine matter. On 
 standing, it also deposited crystals of lithic acid. Ordered — 
 opii gr. 1 J his die.^ 
 
 March 20. — Feels much better. Urine reduced to two pints 
 in twenty-four hours. Per gat. 
 
 The urine was now somewhat deeper coloured ; and deposited 
 a copious sediment consisting partly of lithic acid crystals, 
 and partly of lateritious sediment. Its specific gravity was in- 
 creased to r0344; evidently from its having become more con- 
 centrated than natural. The quantity of urea was abundant, 
 but not in the proportion in which the urine was concentrated. 
 
 This man became so well shortly after the above date, that 
 he did not return to the hospital till 
 
 August 19. — Disease returned six weeks ago. Feels as ill 
 as ever — very weak. Bowels costive. Quantity of urine in 
 twenty -four hours about four pints. Ordered — opium as before. 
 
 The urine was now transparent. Its specific gravity was 
 r023, and urea was abundant. 
 
 Under the above plan he again speedily became better, and 
 soon afterwards ceased to attend at the hospital. In Septem- 
 ber of the following year, however, he again applied to 
 Dr. E. on account of another and very different disease. The 
 specific gravity of the urine was now r0282. It abounded in 
 lithic acid, hut contained no excess of urea; and he had been 
 
 * Opium in this case was ordered by Dr. E., on the supposition that 
 the disease was Diabetes. 
 
DEFICIENCY OF UREA. 
 
 103 
 
 quite free from his former complaint for upwards of twelve 
 months. With the subsequent history of this person I am 
 unacquainted. 
 
 These cases may be considered as 'illustrative of the two ex- 
 treme forms of this disease; which, probably for the reasons 
 already stated, appears to be rather uncommon as an idiopathic 
 affection. A variety of intermediate grades of the disease 
 have, however, occurred to me, some of which have been 
 distinctly marked ; others complicated with different complaints 
 requiring peculiar treatment. In one instance, the affection 
 occurred in a young man, whose mother and uncle had died 
 of Diabetes. In another, it accompanied a deposition of the 
 phosphates in the urine. In several instances, I have found 
 an excess of urea associated with epilepsy, and other nervous 
 affections. Hence, in whatever circumstances an excess of 
 urea in the urine may be found to occur ; whether as denoting 
 a peculiar state of disease, or as complicated with more urgent 
 derangements, it is always a symptom of such importance, 
 that it ought to be known to the physician ; who, if he has 
 duly studied its pathology, will generally be able to apply his 
 knowledge, either directly or indirectly, to the patient's advan- 
 tage. 
 
 Of Affections generally connected with a Deficiency of Urea 
 in the Urine, — If we suppose the extrication of urea from the 
 system to be as necessary to the well-being of all the more per- 
 fect animals, as the extrication of carbonic acid from the lungs; 
 it is probable that there is no state of existence compatible 
 with life, in which urea, or its equivalent, carbonate of ammo- 
 nia, does not exist in the urine. This accords with my expe- 
 rience ; for I have never found a specimen of urine, which, 
 when recently passed, did not, on examination, prove to 
 contain more or less of urea, or of its equivalent carbonate of 
 ammonia. There are, however, several forms of disease, both 
 in adults and in children, in which the proportion of urea is 
 not only absolutely, but relatively, less than in healthy urine ; 
 and though these forms of disease are rarely of that distinct 
 
104 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 character as to be pronounced idiopathic ; and in fact are often 
 referable to other forms of urinary disease, both previously, as 
 well as subsequently to be spoken of ; yet it may not be deemed 
 superfluous to bring together under one head, and in a summary 
 form, a few of the more remarkable of these forms of disease. 
 
 With very few exceptions, a prominent symptom of all the 
 different forms of disease to be now considered, is diuresis. 
 That is to say, the quantity of urine passed is not only greater 
 than natural; but often much greater than it ought to be. 
 These diseases, like the preceding, are somewhat different as 
 they occur in adults and in young children; so as to require a 
 separate notice. 
 
 Deficiency of urea, accompanied by diuresis in adults, may 
 be considered under the heads of diuresis intermittens, and diu- 
 resis continua. Perhaps the nearest approach to an entire ab- 
 sence of urea in the urinary secretion, occurs in hysteria. 
 Hysteric diuresis, however, is distinguished by being occasional; 
 while, in the intervals, urine is often passed containing a greater 
 proportion of urea than natural. Hysteric urine has often a 
 specific gravity scarcely exceeding that of spring water ; and 
 as passed, is often limpid and colourless, and nearly free from 
 sensible properties of every kind. When much concentrated, 
 however, by evaporation, hysteric urine always, according to 
 my observations, displays sensible colour and odour; and if 
 examined in this condition, not only yields traces of saline mat- 
 ters, but of urea. Hysteric urine has sometimes a disagreeable 
 odour when passed ; and in almost all instances soon acquires 
 a putrid smell, like that of cabbage water; becomes more or 
 less opake; and deposits crystals of the triple phosphate of 
 magnesia and ammonia ; especially in warm weather. Hysteric 
 urine is not exclusively passed by females ; but is occasionally 
 voided by individuals of the other sex. In general the affec- 
 tion requires no specific treatment, but yields to appropriate 
 remedies in common with the other symptoms of hysteria. 
 Many nervous individuals, also, who cannot be said to be hys- 
 teric ; or to be subject to any urinary disease, often, as is well 
 
DEFICIENCY OF UREA. 
 
 105 
 
 known, pass large quantities of limpid urine on exposure to cold, 
 and to various other exciting influences. Such urine generally 
 differs from hysteric urine in being only very dilute healthy 
 urine ; while in hysteric urine the relative proportions of the 
 ingredients are always deranged. This form of diuresis, how- 
 ever, probably runs into hysteric diuresis by such imperceptible 
 grades, that it is not possible to draw the line of distinction be- 
 tween them. 
 
 Besides hysteria, and the affections here alluded to, a variety 
 of diseases, strictly speaking of a urinary character, are like- 
 wise subject to occasional diuresis. Of some of these we have 
 already spoken ; and of those which remain to be noticed in 
 subsequent chapters, we may mention certain forms of albumi- 
 nous urine; of acidulous and alkaline urine; of urine de- 
 positing the phosphates, &;c., all of which will be fully con- 
 sidered when we come to speak of these subjects. My object 
 in mentioning them here is chiefly for the sake of analogical 
 illustration. I am not aware that the intermittent form of 
 diuresis, connected as it usually is with mental emotion, occurs 
 in young children. 
 
 The diseases confounded by authors under the general name 
 of diabetes insipidus have been probably, as already stated, very 
 various in their nature. In some instances they appear to have 
 been referable to that class of diseases connected with an ex- 
 cess of urea ; at other times they seem to have belonged to 
 forms of disease to be subsequently mentioned. Most gene- 
 rally, however, they appear to have been referable to the class 
 of diseases to be now considered ; and which may be included 
 under the general definition of diseases in which the quantity 
 of urine passed within a given time is always greater than 
 natural ; while the quantity of urea contained in the urine is 
 relatively less than in healthy urine. 
 
 In this class of diseases the urine voided in a given time is 
 constantly much above the healthy standard ; the patient usually 
 drinking in proportion. Cases are related, in which the quan- 
 tity voided in twenty-four hours has amounted to twenty pints. 
 
106 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 or even much more ; and that for a long time together. In 
 these cases the urine is almost as colourless as water ; at other 
 times it is of a very light straw colour ; and its specific gravity 
 in these instances is found to vary from the specific gravity of 
 spring water, viz. I'OOl or 1*002, to I'OOS or 1;010. The more 
 dilute specimens of urine are commonly quite neutral ; but 
 the heavier specimens have sometimes a faint acid reaction. 
 The proportion of urea, as compared with that of the other 
 ingredients, is usually less than natural ; hence such urine, 
 on being kept, often acquires a putrid or sour, rather than an 
 ammoniacal smell. There are many exceptions, however, to 
 this observation, even in the urine of the same individual ; for, 
 on account of the rapid and incessant action of the kidneys, 
 fluids taken into the stomach are absorbed, and elicited as urine 
 almost as soon as they are swallowed ; hence the qualities of 
 the urine are much liable to be influenced by those of the 
 fluids taken. 
 
 The constitutional symptoms in these diseases are subject 
 to considerable variety ; but there is always great thirst ; a 
 dry state of the skin ; and usually a constipated state of the 
 bowels. In most cases, there is an uneasy sensation referable 
 to the stomach, accompanied by a morbid craving for food ; at 
 other times this sensation merges into nausea, and there is a per- 
 fect indifference to solid matters ; which are almost immediately 
 ejected by vomiting. There are also more or less of emaciation ; 
 depression of spirits; and great muscular debility, with all 
 their consequences. 
 
 Of the causes, predisposing or proximate, of this affection, I 
 fear little can be said in addition to what has been already 
 stated. Diuresis in this, as well as in all its other forms, has 
 been supposed to occur most frequently in individuals of a 
 nervous temperament, as it is termed; and hence the present 
 form of the disease seems to have been viewed somewhat in the 
 light of a perpetual state of hysteria. There may be some 
 truth in this remark ; though I think I have seen instances of 
 the affection in which the remark has been inapplicable ; and in 
 
DEFICIENCY OF UREA. 
 
 107 
 
 which the nervous condition of the patient, if not produced, has 
 been certainly much aggravated, by the perpetual harassment 
 caused by the large flow of urine. 
 
 According to my own observation, which seems to agree 
 with that of others ; the present form of diuresis occurs equally 
 in both sexes, and is chiefly limited to the middle period of life. 
 Sometimes, as already stated, it appears to be the natural con- 
 sequence of the form of diuresis connected with an excess of 
 urea. At other times it cannot be referred to any distinct cause. 
 My belief is, that it is often connected with, or leads to, inci- 
 pient disease of the kidneys ; and if this opinion be correct, it 
 may occasionally pass into the forms of disease to be considered 
 in the next section. 
 
 The present form of diuresis, as it occurs in infants and in 
 old people, particularly in old men, requires to be briefly noticed, 
 before we speak of the prognosis and treatment. 
 
 Diuresis, with deficiency of urea, in young children, is usually 
 accompanied by symptoms very similar to those before men- 
 tioned as occurring in diuresis with an excess of urea; but the 
 symptoms are commonly much severer. Thus the thirst and 
 dryness of the skin are more troublesome; the bowels more 
 deranged ; the emaciation and debility more extreme ; the 
 quantity of the urine also is greater, and its qualities of a 
 worse character, being often more or less serous; and when 
 the disease proves fatal, as it frequently does, the kidneys, as 
 well as other organs, are found to be in a state of disease. 
 
 The diuresis of old people, and particularly of old men, is 
 often accompanied by a deficiency of urea ; but in all the in- 
 stances in which I have hitherto noticed the affection, it has 
 been associated with some apparent organic disease, either of 
 the kidneys or neck of the bladder, or both; to which, as 
 causes, the diuresis appeared to have been chiefly referable. 
 The urine in these cases is often alkalescent or slightly serous; 
 and hence the consideration of the affection, which can hardly 
 be considered as idiopathic, properly falls to be spoken of else- 
 where. 
 
108 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 Diuresis, with a deficiency of urea, from its deep-seated cha- 
 racter, is often a disease of great obstinacy, and yields with diffi- 
 culty to medical treatment ; moreover, when for a time it 
 appears to give way, it is apt to return from the slightest cause. 
 As one of the most frequent terminations of the affection seems 
 to be disease of the kidneys and its consequences ; this form 
 of diuresis generally proves fatal from dropsical effusion or 
 coma. 
 
 Treatment. — The treatment of diuresis with deficiency of 
 urea, as just stated, is exceedingly difficult, and the complaint 
 often baffles all our attempts. Many of the observations ap- 
 plicable to diabetes apply to this form of disease also, and need 
 not, therefore, be repeated ; hence we shall confine our present 
 observations to a brief recapitulation of the leading points. 
 One of the first great principles to be attended to, is, as much 
 as- possible, to restrain the patient from drinking ; for if he be 
 allowed to drink ad libitum, it is in vain to hope for benefit 
 from any plan of treatment. Another point to be kept in view, 
 is to promote cutaneous action. For this purpose the vapour 
 bath and friction, assisted by the internal use of Dover's pow- 
 der, antimony, &c. ; or, if the patient's circumstances admit, 
 removal to a warm climate ; will be found highly serviceable. 
 Tonics of every kind usually disappoint our hopes ; and the 
 more active tonics especially, often increase the thirst. As in 
 diabetes, I have seen more benefit derived from the means 
 above stated, joined to the judicious use of sound porter and 
 a system of diet chiefly consisting of animal and farinaceous 
 matters, than from any other means. The bowels should be 
 carefully regulated ; but I have obtained no permanent good 
 from active purgatives. Active purgatives for a time, in- 
 deed, divert the fluids to the bowels, and the urine conse- 
 quently is diminished in quantity; but as soon as the effects of 
 the purgatives cease, the diuresis often returns in an aggravated 
 form. It is proper to observe that the instances of this affec- 
 tion which I have seen, have differed so remarkably from each 
 other in many of their characters, as to preclude the notion of 
 
DEFICIENCY OF UREA. 
 
 109 
 
 any specific plan of treatment ; and this, I apprehend, will be 
 generally found to be the case in other instances. As illustra- 
 tions of the disease generally, and of this remark in particular, 
 I give a summary history of the two following cases. 
 
 The first case I shall relate, occurred to me several years ago. 
 The patient was a young gentleman, about twenty years of age, 
 who had laboured under the affection for a long period, during 
 which almost every means that could be devised by the most 
 celebrated of our metropolitan physicians had been resorted to 
 in vain. When I saw him, the symptoms were those of the 
 affection as before described in their well-marked form ; and 
 the urine, which varied from six to ten pints in twenty-four 
 hours, was transparent, of a pale straw colour, of very low 
 specific gravity, and deficient in urea. I tried different means 
 without any decided benefit ; but I subsequently learnt, that 
 soon after I ceased to attend him, family misfortunes reduced 
 him from a state of comparative afiluence to the necessity of 
 exerting himself for obtaining the means of subsistence ; that 
 under this misfortune, the dormant powers of his constitution 
 rallied, and his complaint gradually subsided ; and finally that 
 he became so well as to be enabled to accept a situation in 
 South America ; since which time I have not heard of him. 
 
 The second case I shall notice, occurred in a female be- 
 tween sixty and seventy years of age. The affection com- 
 menced imperceptibly during a residence in a damp situation 
 and exposure to mental anxiety. After a few weeks the quan- 
 tity of the urine became so large as to attract her notice ; the 
 thirst also began to be troublesome ; and, by indulging in the 
 use of drinks, the quantity of urine rapidly increased to six- 
 teen or eighteen pints in the twenty-four hours. In this state 
 I first saw her. The urine was limpid and colourless ; its 
 specific gravity ranged from that of spring water to about 1*005; 
 and the urea and all the urinary ingredients were deficient in 
 quantity. The symptoms were urgent thirst; a dry and 
 brown tongue, with imperspirable state of skin ; almost com- 
 plete loss of appetite, at least for solid food ; occasional nausea 
 
110 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 and vomiting ; a deranged and constipated state of the bowels ; 
 great restlessness and want of sleep, with much emaciation and 
 debility. She was put upon a plan of diet chiefly animal, 
 with the moderate use of porter, and strictly enjoined to 
 abstain from drinking watery fluids ; and by the aid of this 
 diet, and of gentle tonics and aperients, she became so much 
 better, that in a few weeks the thirst had nearly left her ; and 
 the quantity and quality of the urine had assumed their 
 natural condition. It is worthy of remark, that this patient 
 suffered much from troublesome boils during the progress of 
 this disease; though I could detect no sugar in the urine. 
 Whether the relief obtained will be permanent, must be left to 
 time to determine. 
 
 With respect to the treatment of diseases with a deficiency 
 of urea in young children, and in the aged, little need be added 
 to what has been already stated. The treatment of the disease 
 in infants and young children is similar in principle to the 
 treatment of diuresis accompanied by an excess of urea ; but 
 to ensure a chance of success, the remedies must be much 
 more carefully and sedulously applied ; and in spite of all that 
 can be done, the complaint usually goes on to a fatal termi- 
 nation. The treatment of this form of diuresis in the aged 
 will more properly fall to be considered in subsequent sections. 
 
 / 
 
ALBUMINOUS URINE. 
 
 Ill 
 
 Section h. Of Albuminous Urine. 
 
 Before the publication of the last edition of this work, the 
 subject of albuminous urine had acquired considerable noto- 
 riety in this country from the labours of Dr. Wells and Dr. 
 Blackall; but since that period, an albuminous condition of 
 the urine has attracted more than usual attention, both here 
 and on the continent, and been the subject of much discussion, 
 and of some controversy. Into this discussion it is not my in- 
 tention to enter controversially ; but, after briefly alluding to 
 what has been done in the inquiry, I shall proceed to give the 
 result of my own experience and views on the subject. 
 
 The attention of the medical public was more particularly 
 drawn to an albuminous condition of the urine and its conse- 
 quences, by the publication, in 1827, of Dr. Briglit's " Reports 
 of Medical Cases ;" in one of the chapters of which work he 
 attempted to prove, that an albuminous condition of the urine is 
 frequently connected with a peculiar organic lesion of the kid- 
 neys, giving occasion to dropsy, and rendering the system in 
 general obnoxious to various other affections, chiefly of an in- 
 flammatory nature. The inquiry was soon afterwards taken 
 up by Dr. Christison, and by the late Dr. James Gregory of 
 Edinburgh, whose observations generally corroborated those 
 of Dr. Bright. Subsequently the subject was investigated by 
 Dr. Osborne of Dublin ; by M. Bayer, and M. Solon, in 
 France ; by Professor M. C. Forget of Strasburgh, and by 
 many others both in Great Britain and on the Continent. 
 The results of these investigations were various ; some corro- 
 borating, others rendering doubtful the accuracy of Dr. Bright's 
 conclusions ; though the majority of those who published on 
 the subject decided more or less in favour of Dr. Bright. As 
 already stated, I shall not take up the question controversially ; 
 
112 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 but taking advantage of the experience of others, in addition 
 to my own, shall discuss the subject as if such controversy had 
 never existed. 
 
 In the former editions of this work, I considered the albu- 
 minous matters occurring in the urine as of two distinct kinds, 
 viz. chylous and serous ; in the first case, the albuminous 
 matters of the urine were supposed to resemble the albuminous 
 matters in the chyle ; in the second case, the albuminous mat- 
 ters in the urine were supposed to be identical with the albu- 
 minous matters of the blood. I also remarked that distinctly 
 defined instances of both these varieties of albuminous urine 
 are rather uncommon ; and that by far the most frequent form 
 which the disease assumes, seems to be of a mixed character ; 
 that is to say, the albuminous matters in the urine partake 
 more or less of both the chylous and serous characters. To 
 these opinions I still adhere ; because I do not consider that 
 the true pathology of this important class of affections can be 
 explained without some such assumptions. I shall therefore 
 consider the subject of albuminous urine generally under the 
 heads of Chylo-serous urine, and of Serous urine; premising 
 only, that these two forms of disease are supposed to gradually 
 run into each other, so that no well-marked line of distinction 
 can be drawn between them ; and that the second form of the 
 disease is of by far the most frequent occurrence. 
 
 Of Chylo-serous urine. — Chylo-serous urine, in the sense we 
 here employ the term, is distinguished by its white appearance, 
 and by its undergoing, in a greater or less degree, spontaneous 
 coagulation. The following observations comprise a summary 
 history of chylo-serous urine, and of the symptoms which 
 usually accompany it ; as well as of the principles to be kept 
 in view in its treatment. 
 
 Chylo-serous urine, when first voided, is always more or less 
 white and opake. In different individuals, however, and even 
 in the same individual at different times, the colour varies from 
 a pale opalescent white, or amber, to milk-white. Both form 
 of the secretion usually coagulate spontaneously. When the 
 
CHYLO-SEROUS URINE. 
 
 113 
 
 urine is simply opalescent, the coagulum formed is generally 
 small and partial, and occasionally occupies the centre of the 
 vessel as a contracted mass ; like the coagulum of the blood 
 in inflammation. When the urine is quite white and opake, the 
 whole coagulates into a tremulous mass like blanc mange, and 
 assumes the shape of the vessel into which it is passed. The 
 coagulum in both instances, particularly if removed [from the 
 vessel and placed on a flat inclined surface, gradually separates 
 into two portions — a fluid or serous portion more or less opales- 
 cent or milky, like the urine itself, and which when left at rest 
 for a few hours frequently throws up a sort of creamy matter 
 on its surface ; and a very delicate fibrinous mass, small in com- 
 parison with the original bulk of the coagulated mass, of a 
 flesh-like appearance, and generally tinged more or less of a 
 red colour, from the presence of the colouring matter of the 
 blood. Of these two varieties of chylo-serous urine, the first 
 or opalescent variety occurs after long fasting ; while the white 
 and milky variety occurs soon after a full meal, as some hours 
 after dinner. The serous portion of both varieties of urine 
 contains abundance of albuminous matter in various stages of 
 development ; that is to say, a large portion of the albuminous 
 matter in the white variety of urine consists of albuminous 
 matters in a hydrated or incipient state, precisely as it exists 
 in the chyle ; while the albuminous matter in the urine passed 
 after fasting is in a more developed state, that is to say, less 
 hydrated, and approaches in its properties to the albunjen of 
 the blood. In both varieties, the principle that chiefly causes 
 the opacity or whiteness, is an oily matter in an emulsive form ; 
 or, in the white variety, the colour may in some way be partly 
 associated with the incipient or hydrated albumen. The solid 
 portion of the coagulum is fibrine, in different states of deve- 
 lopment or combination with water, like the albumen ; while 
 the red colouring matter is identical with the colouring 
 matter of the blood, but in a less perfect state of development. 
 The specific gravity of the serous portions of chylous urine 
 varies in different instances fi-om I'OIO to r020, or upwards, 
 
 1 
 
114 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 and it always contains urea, and the saline matters usually 
 found in healthy urine. 
 
 The constitutional symptoms attending this peculiar condi- 
 tion of the urine, are less marked and severe than might be 
 supposed. In the slighter cases, feverish symptoms are usually 
 present ; accompanied by a sense of uneasiness in the back and 
 loins. The tongue also becomes loaded and dry, and there is 
 in consequence more or less of thirst ; a dry and unnatural 
 state of the skin ; and torpid bowels. In severe cases, the 
 symptoms approach those of diabetes ; the thirst is more op- 
 pressive ; the appetite inordinate ; and there is some degree 
 of emaciation and debility. In this form of the disease 
 also, the patient experiences difficulty in passing the urine, 
 owing to the formation of coagula in the bladder, which block 
 up the urethra ; indeed I have seen this constitute the most 
 troublesome symptom of the disease. 
 
 The present disease may be said to be of rare occurrence 
 in this country ; but in certain hot climates it is not unusual. 
 Thus I have been assured that it is by no means uncommon 
 among the negroes in some of the West India Islands.^ It is 
 stated also by M. Rayer to occur frequently in Brazil. My 
 own limited observations likewise, of which the following may 
 be considered as a summary, corroborate the remark, that the 
 disease is of greater frequency among the natives of hot cli- 
 mates. 
 
 Either in my own practice or by the favour of different 
 friends, I have now seen more or less of thirteen cases of this 
 affection ; and though little with respect to the complaint can 
 be expected to be established from such a limited experience ; 
 yet the following results may not be deemed altogether unin- 
 teresting. 
 
 First. The disease occurs in both sexes before and after 
 
 * I am indebted for this fact to Dr. Watson, who in 1835 introduced 
 me to Mr. Thomas from the Island of BarbadoeE, where he had resided 
 for ten years ; during which time, Mr. T. informed me that he had seen 
 at least a dozen well-marked cases of Chylous urine in Negroes. 
 
CHYLO-SEROUS URINE. 
 
 115 
 
 puberty. Of the thirteen cases, five were males and eight 
 females. In three cases, two males and one female, the disease 
 occurred before puberty ; of these three cases, one was a male 
 infant of about eighteen months old. 
 
 Secondly. Of the thirteen cases, seven occurred either in 
 natives of hot climates, (East and West Indies,) or in indi- 
 viduals who had resided for many years in hot climates. 
 
 Thirdly. The general health suifers much less than might 
 be expected. Two of the females, for instance, while labour- 
 ing under the affection in a marked degree, became pregnant 
 and brought forth healthy children. Hence the disease does 
 not interfere with the generative functions ; nor with the secre- 
 tion or qualities of the milk. 
 
 Fourthly. Of the thirteen cases, three are known to be 
 dead. Of the remainder, five, I believe, are alive and well. 
 Of the others I can give no account. In two of the fatal cases, 
 the patients were cut off by acute attacks of inflammation of 
 the abdominal viscera. The third patient, whose case will be 
 subsequently given as an illustration, died apparently in a state 
 of exhaustion and great emaciation, after labouring under the 
 affection for nearly twenty years. From these facts, as well as 
 from the histories of the other cases, it is evident that the 
 disease may last for a very considerable period without endan- 
 gering the existence of the patient. 
 
 Fifthly. The disease is not necessarily connected with or- 
 ganic lesion of the kidney ; at least organic lesion appreciable 
 by the senses. In one of the fatal cases which occurred under 
 the care of Dr. Roe, to whom I was indebted for the particulars 
 of the case, the body was inspected, and I had an opportunity 
 of examining the kidney, which was found to be perfectly 
 healthy; the kidney was exhibited at my Gulston Lectures, 
 delivered at the College of Physicians, in 1831. The patient 
 was a young girl of about fifteen years of age; and the imme- 
 diate cause of her death was, I understood, inflammation of 
 the bowels. In another instance, I had an opportunity of ex- 
 amining the urine passed in the morning and after dinner, 
 
 I 2 
 
116 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 within a few weeks after the disease, in its worst form, had 
 been apparently arrested by medical treatment; and to my 
 surprise / found both specimens perfectly free from albumi- 
 nous matter ; and, as far as I could determine, quite natural. 
 
 Sixthly. The causes of this affection, whether predisposing, 
 exciting, or proximate, are imperfectly understood. If we may 
 judge from the little that is known, we may say, that residence in 
 a tropical climate predisposes certain individuals to the affection. 
 The exciting cause in one of my cases, was supposed to be the 
 drinking of cold water while the person was warm ; and in 
 one or two of the other cases, exposure to cold seems to have 
 had something to do with the attacks. In the earlier stages 
 of the affection, a tendency to inflammatory action in the sys- 
 tem is sometimes present; and indeed at all times, such an 
 inflammatory state of the system appears to be easily in- 
 duced. Yet it is remarkable, that in one case which I at- 
 tended, and in which acute inflammation of the liver and phlo- 
 gistic fever took place ; the urine, during the continuance of the 
 acute symptoms, lost entirely its chylous character. The same 
 remarkable disappearance of the chylous symptoms also sub- 
 sequently occurred in the same patient, during the presence of 
 severe ptyalism fi-om mercury. But as soon as the inflamma- 
 tory action and the mercurial excitement had ceased, the 
 chylous condition of the urine returned, even worse than 
 before.^ The proximate cause of this affection seems to lie 
 partly in the assimilating organs, and partly in the kidneys. 
 The chyle, from some derangement in the processes of assimi- 
 lation, is not raised to the blood standard ; and consequently 
 being unfit for the future purposes of the economy, is, agree- 
 ably to a law of the economy, ejected through the kidneys ; but 
 these organs, instead of disorganising, or reducing it to the 
 crystallized state as usual ; (that is to say, instead of changing 
 the chyle into the lithate of ammonia,) permit it to pass through 
 
 • In these cases, the disappearance of the chyle from the urine may be 
 doubtless ascribed, in some degree, to the small quantity of chyle formed 
 during the presence of the inflamn:atory attack, and the ptyalism. 
 
CHYLO-SEROUS URINE. 
 
 117 
 
 them unchanged. That this is a just view of; the matter can- 
 not, I think, be doubted ; for if the chyle was properly converted 
 into blood, not chyle, but blood, ought to be thrown off by the 
 kidneys. On the other hand, it may be stated, in proof that 
 the kidneys are likewise affected ; that I have often found chyle 
 in the blood, when a trace of albuminous matter has not been 
 perceptible in the urine. In a healthy condition of the kid- 
 neys, therefore, even although chyle does get into the san- 
 guiferous system, it is not necessarily ejected as chyle ; but, 
 in passing through the kidneys, is subjected to the usual changes. 
 The derangement of the kidneys, however, in this affection, 
 appears to be purely functional; otherwise the urine could not 
 possibly recover, as it sometimes does, its healthy condition. 
 
 Treatment. — Of the treatment of this affection, very little 
 can be satisfactorily stated. If there be obvious inflammatory 
 symptoms present, general or local bloodletting will be pro- 
 per. In the more chronic states of the affection, local counter- 
 stimuli may be applied ; but they seldom exert much beneficial 
 effect. Thus I have known a seton, when first inserted, seem to 
 do good ; but the affection, even under its full operation, has 
 soon become as bad as ever. In the more chronic conditions of 
 the disease also, I have seen the mineral acids and astringents, 
 as alum, the acetate of lead, &c., arrest the affection for a while; 
 though it has soon returned. The same is true of opium ; 
 which sometimes causes a temporary suspension of the symp- 
 toms. On the other hand, the disease occasionally disappears 
 of its own accord for years ; and then again recurs, without any 
 apparent cause ; of which circumstance one or two instances 
 have come to my knowledge. 
 
 The following interesting case was given in the former edi- 
 tions of this work, and I now repeat it, with the sequel. The 
 patient was a married woman, about thirty years of age. The 
 disease first made its appearance in 1817, and proceeded gra- 
 dually. Her appetite was greater than natural, and she had 
 some other symptoms of diabetes; but her general health 
 seemed very little affected ; and almost the only inconvenience 
 
118 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 of which she complained, was the difficulty of passing her 
 water, owing to the coagula which formed in the bladder, 
 blocking up the urethra. 
 
 November, 1818. I received three specimens of this woman's 
 urine, namely, one voided in the morning; another a little 
 after breakfast ; and a third in the evening. 
 
 The first specimen, voided in the morning, consisted of a 
 solid jelly-like mass, or coagulum, of a pale amber colour. 
 This coagulum was of an extremely delicate texture ; and on 
 being submitted to a gentle pressure, or even allowed to drain, 
 parted with a large proportion of a serous fluid of the colour 
 above mentioned, and at the same time became exceedingly 
 reduced in bulk, and assumed the appearance of a red fleshy- 
 like mass of a fibrous texture ; which on examination was found 
 to have all the properties of the fibrine of the blood, mixed 
 with a few of the red particles of the same fluid. The specific 
 gravity of the serous portion was 1*019. Its smell was very 
 faintly urinous ; it did not affect litmus or turmeric papers ; 
 and though it contained a large proportion of albuminous 
 matter coagulable by heat ; it yielded distinct traces of the pre- 
 sence of urea. 
 
 The second specimen, voided after breakfast, resembled the 
 first in its general character ; but differed from it in some minor 
 particulars. Thus, the serum was more of a whey colour ; the 
 fibrous coagulum was less, but more compact and firm ; and 
 held, entangled in its texture, a larger proportion of the red 
 particles of the blood. The specific gravity of the serum of 
 this specimen was only 1*0124 ; and it contained a considerable 
 proportion of albuminous matter, not coagulable by heat. It 
 contained also a sensible portion of urea. 
 
 The third specimen, voided in the evening, after an early 
 dinner taken about noon, was the most remarkable, and so 
 closely resembled chyle in all respects, that I am doubtful, if 
 it had been brought to me as a specimen of that fluid, whether 
 I should have discovered the imposition. It consisted of a 
 solid coagulum of a white colour, and assuming the shape of 
 
CHYLO-SEROUS URINE. 
 
 119 
 
 the vessel like blanc mange. On being submitted to a gentle 
 pressure and permitted to drain, the residual solid portion was, 
 like that of the others, small in quantity, but whiter than the 
 coagula of the other specimens. It was, however, intermixed 
 with strings of a firmer consistence, and of a red colour. The 
 serous portion was white and opake like milk ; and on being 
 heated and permitted to stand at rest for some time, threw up 
 a substance on its surface very like the cream of milk, and 
 which, like cream, was found to contain a considerable propor- 
 tion of a butyraceous or oily principle. Its specific gravity 
 was 1-0175; and its smell was not urinous, until it had been 
 concentrated by evaporation, when it became slightly urinous ; 
 and in this concentrated state, it yielded faint, though distinct 
 traces of the presence of urea. It was not coagulable by heat, 
 though it contained abundance of albuminous matter, chiefly, 
 however, in that state in which it exists in chyle ; and which I 
 have denominated incipient or hydrated albumen. One hun- 
 dred grains of this serous fluid evaporated to dryness, left 
 about seven grains ; half a grain of which only was soluble in 
 alcohol, and consisted of urea, a little fatty matter, and the 
 other principles commonly found in all animal fluids ; while 
 the remaining six grains and a half consisted chiefly of the 
 imperfect albuminous and fatty principles above mentioned ; 
 with some salts. This residuum burnt with a flame ; yielded 
 an odour somewhat like that of cheese ; and left a coal difficult 
 to incinerate, but which when burnt was found to contain a 
 considerable proportion of earthy salts, consisting chiefly of the 
 phosphate of lime. 
 
 I had an opportunity of examining this woman's urine after 
 fasting twenty-four hours. The coagulum was now much 
 smaller in bulk, and seemed to contain more red particles. 
 The serous portion was nearly transparent, and possessed in a 
 considerable degree the colour and other sensible properties of 
 urine. Its specific gravity was 1*021 ; and it was found to 
 contain abundance of urea, and a large proportion of more 
 perfect albuminous matter than either of the other specimens. 
 
120 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 The above remarkable case occurred to my friend Dr. 
 Elliotson, to whom I was indebted for the opportunity of exa- 
 mining the urine. From particular circumstances, no plan of 
 medical treatment was adopted : and Dr. E. lost sight of her, 
 till November 1822; a period of four years. At this time she 
 appeared in good health ; but informed him that the urine had 
 remained in precisely the same state ever since he had last 
 seen her, and still continued so ; and that in the interim she 
 had become pregnant, and borne a living child. I subse- 
 quently learnt from Dr. Elliotson, that this woman continued 
 to suffer from the affection till 1836 ; when she died emaciated, 
 after labouring under the disease for nearly twenty years. 
 
 In the present state of our knowledge it has been deemed 
 proper to treat of Chylous urine separately, chiefly for the 
 reasons stated ; but I have little doubt that the affection hereafter 
 will be found to constitute a mere variety of one of the fol- 
 lowing forms of Serous urine. 
 
 Of Serous Urine. — Under this head are included the greater 
 number of the diseases which, since the publication of Dr. 
 Bright's medical reports, have attracted so much notice. 
 Strictly speaking, perhaps there are many varieties of disease 
 belonging to this head, differing not only in degree, but even 
 in kind from each other ; but as in the present state of our 
 acquaintance with these subjects, such varieties can with diffi- 
 culty be distinguished; and as the distinguishing of them 
 would perhaps lead to no practical utility ; I shall briefly con- 
 sider them as of two principal kinds or Species only ; one of 
 which may, in general terms, be said to be of an acute, the other 
 of a chronic character. The first of these species includes at 
 least two varieties, differing from each other principally in 
 degree ; the second eight ; and the whole ten varieties so 
 gradually pass into each other, that it is not easy to define 
 their exact limits. If there be, however, a distinguishing 
 feature in the character of the urine between the acute and 
 chronic species, it consists in the fact, — that in the two acute 
 varieties, the urine on cooling frequently deposits the lithate 
 
SEROUS URINE. 
 
 121 
 
 of ammonia ; while in four at least of the chronic varieties, this 
 phenomenon never occurs under any circumstances. 
 
 Before we proceed to consider this important genus of 
 nephritic diseases, which our limited space necessarily obliges 
 us to treat in a condensed form ; it is requisite to offer a few 
 explanatory remarks on the principles of our arrangement ; 
 and particularly regarding the sense in which certain terms 
 in common use are employed. 
 
 The different meanings attached to the term inflammation^ 
 or what is the same thing, to words terminating in itis, by 
 authors, are a frequent source of misconception, and conse- 
 quently of mistakes, in medical reasonings. Many of the conti- 
 nental authors, for instance, and particularly the French authors, 
 appear to consider inflammation as almost the only cause of dis- 
 organization ; at least, it is difficult to arrive at any other con- 
 clusion, provided they employ the suffix itis^ in its usual accep- 
 tation. Thus in the recent excellent work of M. Rayer, the 
 diseases to be here and elsewhere considered, are arrano'ed 
 under the heads of Nephritis, Pyelitis, Peri-nephritis, kc, 
 according as the secreting portion of the kidney, or the 
 membranes lining its internal cavities, or covering its ex- 
 ternal surface, (fee, are found, after death, to be affected with 
 signs of recent inflammation. This view of the subject has 
 always appeared to me to be imperfect. That inflammation 
 is the immediate cause of death in most of these diseases 
 is not denied ; but admitting this, I ask, does the term in- 
 flammation, even when qualified by the epithet chronic or 
 otherwise, rightly designate that comparatively quiescent state 
 of the kidneys which immediately preceded the fatal inflam- 
 matory attack? The general answer to this question must, 
 I think, be in the negative. That there is such a con- 
 dition as chronic inflammation ; and that such a state of 
 chronic inflammation does, in some instances, exist in the kid- 
 neys previously to the more acute and fatal attack, is not 
 doubted ; but my decided opinion is, that in the greater number 
 of instances, the previous state of the kidneys cannot by any 
 
122 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 justifiable latitudinarianism be designated by the term chronic 
 inflammation. My views, in sbort, on these and similar subjects 
 are the following : 
 
 All organic affections may be supposed to arise from two 
 separate, but frequently co-operating, causes, which, for the sake 
 of distinction, we may term degeneration and inflammation. By 
 degeneration I mean that slow and gradual change occurring 
 in all living structures, which appears to be connected with, or to 
 result from, the gradual decay of the vital processes in general, 
 and particularly of the processes of assimilation. Degenera- 
 tion, therefore, is the natural and universal consequence of age ; 
 but it may arise in early life from a variety of causes, among 
 which the most frequent are : first, an inherited ^.t^A. innate weak- 
 ness of the vital powers, either as they exist in the system gene- 
 rally, or as they exist in particular organs ; as for instance in the 
 kidneys : secondly, an acquired weakness of the vital powers 
 in general, or as regards the vital powers of particular or- 
 gans, produced by a variety of slowly acting causes ; such as 
 continued errors in eating and drinking ; long exposure to the 
 influence of unhealthy situations ; or of occupations unfavour- 
 able to the general health, &:c. ; and, thirdly, an acquired weak- 
 ness of the vital powers, either general or local, produced by 
 the operation of acute causes ; as acute inflammation, severe 
 accidents, &;c. 
 
 The term inflammation I employ in its admitted sense, but 
 consider the phenomenon of three kinds or grades, viz. ; acute 
 inflammation, or inflammation in its most active form ; such as it 
 more especially exists in healthy subjects and in healthy organs : 
 chronic inflammation, or that obscure state of activity, which, 
 for want of a better term, we designate inflammation ; and 
 which is almost exclusively limited to degenerated structures : 
 and congestive or adynamic inflammation, such as occasionally 
 follows acute inflammation in healthy subjects ; but much more 
 generally takes places in unhealthy subjects ; or succeeds to 
 the chronic inflammation of degenerated structures. 
 
SEROUS URINE. 
 
 123 
 
 If these views be admitted, we may deduce from them the 
 following inferences : 
 
 First. A degenerated condition of an organ, from whatever 
 cause produced, may exist for a greater or less period in a state 
 of comparative quiescence ; during which state of quiescence, 
 the system in general may accommodate itself more or less 
 perfectly to the degenerated state of such organ. 
 
 Secondly, Local degenerations are liable to become aggra- 
 vated from a variety of causes, and particularly from inflamma- 
 tion ; and when such causes have ceased to operate, as for in- 
 stance when the inflammation has subsided ; the general system, 
 as before, gradually accommodates itself, during the succeeding 
 period of quiescence, to the new order of things induced by the 
 inflammatory attack. 
 
 Thirdly. Such alternations of comparative quiescence and of 
 activity repeatedly take place ; the degeneration on the whole 
 being increased during each successive paroxysm; till finally 
 the patient is cut off" during an inflammatory attack, which 
 overwhelms his exhausted powers. 
 
 Fourthly. The patient in such cases cannot be said to die 
 of inflammation alone ; but of the conjoint eff*ects of degene- 
 ration and of inflammation. Moreover, the inflammation 
 would probably never have taken place, had degeneration not 
 existed as a predisposing cause ; or having taken place in a 
 perfectly healthy structure, the inflammation would not have 
 proved fatal. 
 
 Fifthly. The appearances presented after death under these 
 circumstances are often very unsatisfactory, and quite useless 
 in a pathological point of view ; inasmuch as by presenting the 
 conjoint effects of degeneration and of inflammation, they do 
 not enable us to distinguish what is due to degeneration, and 
 what to inflammation ; a distinction in all instances of the 
 utmost practical importance. 
 
 These inferences are not given as novelties ; but as offering 
 a brief sketch of the grounds on which, in my opinion, patho- 
 logical investigations ought to be made. They have been pro- 
 
124 PATHOLOGY OF ALBUMiyOL'S ASSIMILATION AND SECRETION. 
 
 bablv aofain and again pointed out by pathologists ; vet I do not 
 remember to have seen them any where stated totidem verbis. 
 I confess, however, that mv reading on such subjects has been 
 limited; chiefly because I have found these, and other import- 
 ant distinctions, too often neglected by authors ; and because, 
 in consequence, their works have presented a confused and 
 unphilosophical jumble : from which no practical inference 
 could be safely deduced. 
 
 Taking it for granted that the principles above contended - 
 for will be conceded ; I shall, as far as circumstances admit, 
 apply them to the elucidation of the important genus of diseases 
 now under consideration. For this purpose I shall consider 
 the leading character of the urine, namely its .serous character, 
 with reference to the kidney in a state of health (sp. a.); and 
 with reference to the kidney in a state of degeneration (sp. 5.); 
 and as fui'ther varied by the accidental circumstances of qui- 
 escence, and of injiammation. Hence our subject may be thus 
 presented : 
 
 Species a. Serous Urine; the Kidney in a \var. 1 Quiescent. 
 State of Health. ' ( car. "2 Inflamed. 
 
 Species h. Serous TTrine ; the Kidney in aivar. 1 Quiescent. 
 State of Degeneration. \rar. 2 Inflamed. 
 
 Sp. a. var. 1 — Of Serous Urine; the Kidney in a State of 
 Health; Quiescent. — In a perfectly healthy condition of 
 the kidneys, both functional and organic, perhaps it may 
 be stated, that albuminous matter is never found in the 
 urine. When, therefore, albuminous matter is found in the 
 urine, we may always safely conclude that some alteration from 
 the normal condition of the kidneys is denoted. The question 
 is, what is the nature of this aberration ? In reply to this 
 question, it is generally admitted that certain organic derangfe- 
 ments of the kidneys give occasion to serous urine ; and the 
 only point to be considered here is, do mere functional de- 
 rangements of the kidneys give occasion to serous urine ? 
 
SEROUS URINE. 
 
 125 
 
 Before we proceed to answer this question, perhaps it 
 may not be amiss to remove, as far as we are able, certain 
 sources of fallacy which occasionally prove stumbling blocks 
 to illogical reasoners ; as well as to inexperienced observers. 
 With respect to illogical reasoners, it may be observed, that 
 there are some minds so singularly constituted, that they 
 appear to be unable to comprehend the distinction between 
 a general and a universal law ; i. e. between a general law, 
 founded on experience, and therefore admitting of exceptions; 
 and a universal law, founded on reason or necessity, and 
 consequently admitting of no exceptions. Of this remark, 
 the subject of serous urine offers a striking illustration. For- 
 getting that all they know on the subject of serous urine, is 
 founded solely on experience ; and assuming as the basis of their 
 argument, the illogical grounds, that serous urine always 
 denotes disease of the kidneys ; some have deduced from the 
 admitted exceptions to the law, the opposite and equally illo- 
 gical conclusion, — that serous urine does not indicate disease of 
 the kidneys. To point out instances of such illogical reasoning 
 would be invidious ; while to attempt to refute it would be 
 waste of time. 
 
 With respect to inexperience, it may be observed that the 
 soundest reasoners are often led to conclusions which further 
 experience may prove to be erroneous ; yet, provided they rea- 
 son correctly upon what they know, such reasoners cannot be 
 said to be guilty of any breach of logic ; for no one can be sup- 
 posed to reason upon what he does not know. Such being, 
 therefore, the necessary constitution of the human mind ; the 
 truly logical reasoner will, under such circumstances, at once 
 admit and correct his errors. Accordingly we find, with regard 
 to the question now under consideration, that all the best and 
 most experienced writers on the subject, admit, that though 
 serous urine generally indicates diseased kidneys ; yet that, as 
 in all laws founded on experience, there are many exceptions 
 to this law. Now the consideration of these exceptions 
 involves the answer to the question above proposed, viz. Can a 
 
126 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 perfectly healthy kidney, from mere functional derangement, 
 give occasion to serous urine ? 
 
 The apparent, or real exceptions to the law above mentioned, 
 may be classed under three heads : 
 
 First. Substances have been mistaken for albuminous mat- 
 ters which are not albuminous: as instances we may mention, 
 that in the earlier stages of the inquiry, whenever the urine 
 became turbid on the application of heat, albumen was gene- 
 rally supposed to be present. This error has, indeed, long 
 ceased to exist among better informed inquirers ; yet there 
 is reason to believe that it has not even yet become quite obso- 
 lete. As another instance, may be mentioned, the precipitate 
 frequently produced in the urine of febrile patients by the oxy- 
 muriate of mercury; which for the most part consists, not of 
 albumen, as formerly supposed, but of the lithate of mer- 
 cury, &;c. Other similar instances might be mentioned ; but 
 these are sufficient to illustrate the point. The second class 
 of exceptions arises from the accidental presence of serum in 
 the urine, derived from other sources than the kidneys. Of 
 these, one of the most frequent is blood ; which may come from 
 any part of the urinary system as well as from the kidneys. As 
 another instance, may be mentioned that species of pseudo- 
 serum, which is often thrown out from the mucous surfaces of 
 the bladder, urethra, &;c., when in a state of inflammation ; and 
 which, when mixed with the urine, imparts to it properties 
 often difficult to distinguish from those produced by albumen 
 derived from the kidneys, &:c. The third class of exceptions 
 more immediately involves the question at issue, viz., whether 
 functional derangement alone can give occasion to albuminous 
 urine ? In the introductory remarks prefixed to this volume, 
 I have attempted to show that a distinct function of the kidney, 
 which I have named the disorganizing function, exists ; and that 
 by means of this function, the kidneys are not only enabled to 
 separate from the system inorganized and crystallizable matters 
 already existing in the blood ; but are also enabled to disor- 
 ganize (i. e. to reduce to a crystallizable condition) other mat- 
 
SEROUS URINE. 
 
 127 
 
 ters existing in the blood, which the welfare of the economy 
 requires should be removed from the sanguiferous system. 
 Now, if we suppose this disorganizing function of the kidneys 
 to be temporarily suspended; the albuminous matters of the 
 blood, which, in passing through the healthy kidneys, would 
 have been converted into the lithate of ammonia, kc, will pass 
 through these organs without suffering any change, and con- 
 sequently appear as albuminous matters in the urine ; just as 
 the chyle, under similar circumstances, was supposed, in a for- 
 mer paragraph, to pass through the kidneys unchanged. — 
 Whether such a state of simple suspension of the functions of 
 the kidneys ever takes place alone, without involving other 
 parts of the system, I am unable to decide ; but my belief at 
 present is, that it does not ; and that in all such instances, as 
 for example that of chylous urine just alluded to, not only a 
 condition of the kidneys exists, to which, for want of a better 
 name, I must apply the epithet inflammatory ; but that other 
 parts of the system (especially those connected with the assimi- 
 lating functions) are likewise more or less involved in a similar 
 condition ; and that when this supposed inflammatory condition 
 of these organs subsides, the kidneys resume, more or less per- 
 fectly, their natural disorganizing function ; and the albuminous 
 matter, as a consequence, disappears from the urine. This pe- 
 culiar condition of the system and temporary suspension of the 
 nephritic function may be apparently produced by various 
 causes; among which may be mentioned the effects of certain 
 drugs, as mercury, cantharides, &;c. A similar condition of the 
 system seems also to be occasionally produced by, or rather to 
 follow, attacks of fever ; also by a state of pregnancy, by certain 
 indigestible articles of food ; by violent mental emotions, kc. ; 
 under the operation of all which, as well as of many other simi- 
 lar causes, the urine has been found to be temporarily albumi- 
 nous. There is a point, however, of great importance connected 
 with this inquiry, to which I particularly wish to draw the atten- 
 tion of the reader, viz. that the causes mentioned do not invari- 
 ably produce serous urine in all individuals ; the inference, there - 
 
128 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 fore, must be, tliat in the persons liable to be so affected, there 
 exists a sort of latent predisposition (incipient degeneration ?) 
 to kidney disorders ; otherwise everr individual ought to be 
 similarly affected by the operation of the same causes ; which, 
 as just stated, is not, according to my observations, the case. 
 From what has been stated then, the answer to the query above 
 proposed will be, — that in some individuals, the urine is liable 
 to become albuminous from certain derangements of the system 
 in general, and of the kidney in particular, which cannot at 
 present be otherwise defined than as functional derangements ; 
 though it is not improbable, that such assumed functional de- 
 rangements may partake of the character of incipient disease 
 of the kidneys. 
 
 Sp. a. var. 2. — Of Serous Urine ; the Kidney in a State 
 of Health ; Inflamed. — The serous urine accompanied by 
 acute inflammation of the healthy kidney, is generally trans- 
 parent, or nearly so, when passed, but occasionally becomes 
 opake and turbid on cooling. Its colour is usually much deeper 
 than natural, and its specific gravity varies from 1-018 to 1*030, 
 or more. For the most part, also, the quantity of urine passed 
 bv the patient in a given time, notwithstanding the frequent 
 calls, is far below the healthy standard. At the outset of the 
 most acute instances of the disease, the urine is sometimes with- 
 out sediment ; and, in a few rare instances, mixed with blood. 
 The sediment deposited by acute serous urine, is usually of a 
 deep brownish red colour ; and consists essentially of the lithate 
 of ammonia. In all instances on the application of heat (about 
 150° or 160°) acute serous urine becomes opake, from the de- 
 position of albuminous matter. 
 
 The constitutional symptoms accompanying acute serous 
 urine are of a very formidable kind ; and are always associated 
 with a great tendency to anasarcous oedcLua, and serous inflam- 
 mation. This form of anasarca has been long distinguished in 
 this country by the name of inflammatory dropsy ; and though 
 it had been obscurely alluded to by preceding writers, may be 
 said to have been first brought into genei'al notice among 
 
SEROUS URINE. ACUTE. 
 
 129 
 
 English physicians, by the works of Dr. Wells and Dr. Black- 
 all. Inflammatory dropsy usually comes on rather suddenly, 
 and is preceded by chilliness and rigors, which are speedily fol- 
 lowed by the well-known train of feverish accompaniments, viz. 
 a full and hard pulse ; heat, dryness, and soreness of the skin ; a 
 state of anxious restlessness ; and oppressive drowsy headache. 
 The scanty and high-coloured urine above described is very 
 frequently passed in small quantities at a time ; and occasionally 
 with more or less of irritation. There is a dull heavy pain 
 in the loins, increased by pressure ; and sometimes extending 
 to the whole of the lower region of the abdomen ; particularly 
 to the groins. With these symptoms the stomach sympathizes ; 
 and there is almost always nausea, and sometimes vomiting ; 
 and pressure over the region of the stomach produces dis- 
 tressing uneasiness, or actual pain. After a few hours, or at 
 most, a day or two, the face and extremities begin to swell ; 
 and by degrees the oedema extends, more or less, over the whole 
 body. The urine is now still further diminished in quantity ; the 
 drowsiness increases ; and at length the patient becomes quite 
 comatose; in which state, if active measures have not been 
 taken in time, he usually expires ; sometimes in convulsions. In 
 other instances, serous effusion, accompanied by high inflamma- 
 tory action, takes place into the chest or other cavities. This 
 is attended by dyspnoea, &;c., according as the chest, or 
 other cavity, is affected ; and, after the most acute suffering, 
 the patient rapidly sinks under the consequences ; or, at the 
 utmost, survives only to be miserable. 
 
 This peculiar and acute form of disease may probably hap- 
 pen at all ages, and under all circumstances, from exposure to 
 the requisite exciting causes. A degenerated condition of the 
 kidneys undoubtedly predisposes to the affection ; but, as far as 
 my own observation extends, (which seems to agree with the 
 observation of others,) this form of disease occurs most fre- 
 quently in young and robust subjects in whom no such predis- 
 position could be ascertained to exist, from exposure, under 
 certain circumstances, to the combined effects of cold and 
 
130 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 moisture. Thus several instances liave occurred to me, in 
 which the patients, while in a state of intoxication, had 
 slept for sopie hours on the wet ground in the open air during 
 severe cold. Other causes mentioned by authors are, the 
 drinking of cold fluids while heated ; the sudden repulsion of 
 erysipelas ; of the acute exanthemata ; of an habitual diarrhoea, 
 &c. The proximate or immediate cause of the disease seems 
 to consist in an inflammatory condition of the system generally, 
 but involving the kidneys in particular. That some such sup- 
 position as this is necessary, appears to be evident from the 
 fact, that simple and idiopathic inflammation of the kidneys 
 gives occasion to a different train of symptoms.^ 
 
 The prognosis in this formidable disease, as above mentioned, 
 is generally unfavourable. A large proportion of the cases 
 terminate fatally, from the immediate consequences of the 
 affection ; and those who survive, generally die, sooner or 
 later, with all the symptoms of degeneration of the kidneys, 
 and serous urine in their worst forms, to be presently described. 
 
 Nearly allied to the above state of disease is the anasarca, 
 which frequently follows scarlatina, and more rarely the measles, 
 urticaria, and some other diseases particularly affecting the 
 skin. In scarlatina, this form of dropsy usually comes on after 
 the fever has begun to subside ; that is to say, between two 
 and four weeks after the first commencement of the eruptive 
 fever. The appearance of the swelling is commonly preceded or 
 accompanied by an increase of feverish symptoms, particularly 
 towards night ; the bowels having continued costive, the 
 urine scanty, and the skin harsh and dry. At this period, 
 also, frequent vomiting occasionally occurs. In a short time 
 the face, and particularly the eyelids, begin to swell, and this 
 swelling extends more or less rapidly over the whole body. 
 As the swelling increases, the patient usually becomes more 
 torpid and drowsy; and, in some cases, symptoms indicative of 
 effusion on the brain, or into the cavities of the pleura or 
 peritoneum, take place. The urine now becomes still more 
 
 * Simple nephritis will be subsequently considered. 
 
SEROtJS URINE. ACUTE. 
 
 131 
 
 scanty and high-coloured, is often turbid, and generally passed 
 at short intervals, in very small quantities at a time, with more 
 or less of pain. The colour of the urine is occasionally brown, 
 or is quite red ; and in this case the colour obviously depends 
 upon the colouring matter of the blood. In almost all instan- 
 ces, however, whether it contains the colouring matter of the 
 blood or not, the urine coagulates more or less perfectly by heat, 
 showing that it contains albuminous matter in solution. 
 
 The exciting cause of this anasarcous affection has been 
 supposed by some to depend, like the preceding, on exposure 
 to cold and moisture; but, in many instances, it cannot be 
 referred to this or any other satisfactory cause. The imme- 
 diate cause seems to consist in an inflammatory state of the 
 whole system, involving the kidneys in particular. The affec- 
 tion, to whatever cause it is to be ascribed, occurs much more 
 frequently in children than in adults ; and it is usually so much 
 the more severe, as the preceding eruptive fever and sore-throat 
 have been mild and favourable. 
 
 With respect to the treatment of inflammatory anasarca, 
 accompanied by inflammation of the kidney, it may be observed 
 generally, that active antiphlogistic measures are absolutely 
 necessary. Blood-letting, general and local, must be resorted 
 to according to circumstances, and particularly according to 
 the period, degree, and seat of the inflammatory action. If 
 the patient be a young and robust individual, of sound con- 
 stitution, blood-letting from the arm, and cupping over the 
 loins, may be usually repeated with excellent effect. If 
 the patient be a person of previously dissolute habits and 
 of broken constitution, with probably unsound viscera, gene- 
 ral blood-letting must be applied with greater caution, and 
 cupping and leeches will be more appropriate. Much may be 
 learned on this point by a careful inspection of the blood first 
 drawn. If the blood be dense, and abounding in colouring 
 matter, blood-letting in general may be safely repeated; if, 
 on the contrary, the colouring matter be obviously deficient, 
 and the blood be poor and watery, further depletion will hardly 
 
 K 2 
 
132 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 be proper. Another class of remedies to be resorted to, after, 
 or in conjunction with, depletion, and which has been particu- 
 larly recommended in this affection, is diaphoretics. Of these, 
 perhaps, the Dover's powder is the most efficient ; with which 
 may be conjoined the use of the warm bath, or, what is better 
 in some instances, of the vapour or hot air bath. The patient, 
 also, in the intervals, should be most carefully protected from 
 the influence of cold by warm clothing ; and particularly by 
 flannel next the skin. Other diaphoretics, as the various 
 antimonials, the acetate of ammonia, kc, may be also occa- 
 sionally resorted to with advantage. Calomel is a doubtful 
 remedy ; but in some instances may be advantageously com- 
 bined with Dover's powder, kc. Stimulating diuretics act 
 unfavourably ; particularly in the early stages of the affection. 
 When the active symptoms of the complaint have been sub- 
 dued by blood-letting ; and the urine, as is generally the case, 
 from the employment of this active remedy, has become im- 
 proved in quality and increased in quantity ; the more gentle 
 diuretics may be often resorted to with advantage ; such are 
 the acetate, citrate, or nitrate of potash, with the spir. cetheris 
 nitrici, &c. The bowels should be kept open, and occasionally 
 a Brisk purgative may be given ; but there seems to be no 
 good attainable by constant purgatives ; which may, in those 
 instances in which the kidneys are severely affected, lead to 
 that harassing diarrhoea too commonly proving fatal in 
 this class of diseases. When the patient, by these and other 
 appropriate means, has been fortunate enough to recover from 
 the immediate attack, it will be absolutely necessary for him, 
 for a long time, perhaps during the remainder of his life, to 
 consider himself as an invalid ; to live abstemiously and care- 
 fully ; to take regular and moderate exercise ; and, above all 
 things, to avoid exposure to cold and wet. Indeed, if his cir- 
 cumstances admit, he may advantageously spend the winter 
 months in a warmer climate. 
 
 The treatment of the anasarca occurring after scarlatina, 
 &:c., resembles in principle the treatment of the acute form of 
 
SEROUS URINE. CHRONIC. 
 
 133 
 
 inflammatory dropsy above described. If there be urgent 
 symptoms of inflammation, or of congestion, cupping or leeches, 
 near the part affected, should be resorted to ; and these means 
 may be followed by the application of blisters, or other appro- 
 priate counter stimuli. If the head be particularly affected, 
 active depletion and cathartics will be proper. The diarrhoea 
 which occasionally supervenes should be moderated, but not 
 suddenly checked. If this diarrhoea, as is sometimes the case, 
 appears to depend on an inflammatory condition of the mucous 
 membrane of the intestines, recourse may be had to leeches, 
 followed by fomentations, &c., to the abdomen. If the 
 diarrhoea be the immediate effect of the irritation occasioned by 
 faecal accumulation, mild and efficient purgatives, as castor oil, 
 (fee, should be administered ; so as to completely get rid of the 
 offending cause. When the more acute symptoms have sub- 
 sided, diuretics may be usually employed with good effect ; such 
 as digitalis conjoined with the syrup of squills, the acetate of 
 potash, ammonia, &c., according to the circumstances of the 
 case, and the judgment of the practitioner. 
 
 The consideration of the two preceding forms of disease 
 scarcely falls within our present design. I have been in- 
 duced to give the above sketch of their history, with the view 
 of pointing out their connexion and analogy with the chronic 
 forms of serous urine, to be next considered ; many cases of 
 which I have been distinctly able to trace to acute attacks 
 upon the kidney, similar to those first described ; as well 
 as to the analogous attacks following scarlet fever. In 
 those cases originating in attacks of scarlet fever, the ana- 
 sarcous symptoms following that disease have been usually 
 severe, and in some instances treated by large and active doses 
 of calomel; which, no doubt, contributed its share towards 
 the production of the chronic forms of the disease under 
 which the patients laboured. 
 
 Species h. — Of Serous Urine ; the Kidney in a state of Dege- 
 neration. — The relations between the various forms of serous 
 urine, and the corresponding conditions of the degenerated ki^- 
 
134 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 ney to be now considered, are not so well understood as they 
 deserve to be. The study, also, of the various forms assumed 
 by the degenerated kidney, has not yet been prosecuted with that 
 philosophic spirit of inquiry which the importance of the subject 
 demands. To both these deficiencies many causes have contri- 
 buted ; some of which are incidental to the nature of the subject 
 itself ; while others are referable to the carelessness or inadver- 
 tence of observers. Among the causes incidental to the subject 
 itself, may be mentioned the recent period since it began to 
 attract much notice ; and the fact that, in their quiescent state, 
 degenerated conditions of the kidney comparatively seldom 
 prove fatal ; so that few opportunities have been afforded of 
 examining the conditions of the kidney with reference to the 
 urine ; while the few opportunities that have occurred, have 
 been often neglected, on account of the attention of the observer 
 being otherwise directed. Among the causes referable to the 
 inadvertence of the observer, may be mentioned the circum- 
 stance formerly alluded to, viz. the confounding of inflamma- 
 tion with degeneration ; that is to say, the mistaking the in- 
 flamed and degenerated condition of the kidneys, seen after 
 death, for the quiescent degenerated condition of the kidneys, 
 which had probably existed up to the moment immediately 
 preceding the supervention of the fatal inflammation on the 
 already degenerated structure. On account of these, and many 
 other circumstances which might be mentioned, the reader 
 is not to consider the following attempt to arrange and classify 
 these important diseases as complete or final ; but as offering 
 the best view of the subject which my present experience (cor- 
 rected and illustrated by the experience of others, as far as 
 known to me) will admit. 
 
 The circumstance, perhaps, of all others constituting a 
 natural boundary or land-mark among nephritic diseases, is the 
 age of the patient. Before the age of forty, there is no natural 
 reason why the kidneys in a perfectly healthy individual, who 
 has lived regularly, should in any degree or mode suffer 
 degeneration. But about the age of forty, and particularly 
 
SEROUS URINE. CHRONIC. 
 
 135 
 
 afterwards, many causes often co-operate to induce a certain 
 change of condition ; some of which may be considered as inci- 
 dental to age ; while others are the natural consequence of 
 long-continued habits unfavourable to health, but sanctioned 
 by the usages of society ; such as the daily use of a full and sti- 
 mulating diet, the free use of wine, kc. Of all other causes, 
 however, particularly in large towns, venereal affections and 
 their remedies lay the foundation of kidney diseases in every 
 class of society, and perhaps at all ages, more frequently 
 than any other cause. Few, in early life, so situated, escape 
 these loathsome affections in some form or other ; and what 
 with the excitement of fermented liquors, and, among the lower 
 classes, the constant use of ardent spirits, the wonder is, not 
 that the urinary organs suffer, but that they do not suffer even 
 more severely than at present. Although, however, the effects 
 of youthful excesses apparently subside for the time, they 
 are too often felt in advanced life, when the vital powers 
 become enfeebled ; and thus contribute to render old age 
 miserable. The gay and thoughtless, therefore, little think 
 of the remote consequences of their dissipation ; and that 
 they are, in fact, to use a mercantile simile, drawing bills at 
 twenty, which will certainly be demanded, at some future period 
 of their lives, with fearful interest. Another fertile source of 
 kidney disorders, as stated in a former paragraph, is exposure 
 to cold ; the acute inflammatory attacks arising from which 
 cause, are usually followed by chronic affections of these organs, 
 continuing through life. The effects of cold, also, are severely 
 felt when it co-operates with any of the causes above enume- 
 rated; and particularly with the mercury and other active 
 remedies too often required to eradicate syphilitic poisons from 
 the constitution. 
 
 Among the causes predisposing to affections of the urinary 
 organs in general, and to kidney affections in particular, is the 
 often -mentioned inherited tendency. I do not mean to assert 
 that the children of parents subject to these affections invari- 
 ably suffer ; but I have seen repeated instances, in which they 
 
136 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION 
 
 have suffered from urinary disorders, at an age when, and from 
 exciting causes under which, a perfectly healthy individual 
 would probably have escaped with impunity. Another of the 
 most fertile of the causes predisposing to urinary diseases at all 
 ages, but particularly in early life, is the strumous diathesis. 
 When any of the above-mentioned causes, whether of an ex- 
 citing or predisposing character, co-operate with a strumous 
 tendency, their effects in general are much more decidedly 
 marked and obstinate ; and the treatment, of course, of such 
 unfortunate complications is rendered proportionately difficult. 
 Occasionally the other predisposing causes are complicated 
 with a gouty or rheumatic tendency, especially in middle and 
 advanced life ; and such complications must be treated accord- 
 ingly. 
 
 From these and other causes, it too often happens that in 
 early life, and very frequently in later life, symptoms of degene- 
 ration of the kidneys, accompanied by a corresponding derange- 
 ment of the urinary secretion, begin to manifest themselves. 
 Of these derangements of the urinary secretion, the presence 
 in th^ urine of albuminous matter is one of the most striking ; 
 probably for the reasons formerly assigned for an analogous 
 phenomenon, viz. the suspension or partial destruction of that 
 peculiar function of the kidney, by which, in its healthy state, 
 albuminous matters become disorganized ; in other words, by 
 which albuminous matters are converted into the lithate of 
 ammonia, and the other ingredients of healthy urine. 
 
 As the causes producing albuminous urine have been shown 
 to be so various, the obvious inference will scarcely be ques- 
 tioned, that the properties of the urine, as well as the cor- 
 responding states of the system, must vary likewise. This, 
 in fact, is found to be the case ; and we come now to point out 
 the principal varieties of albuminous urine, and, as far as we 
 are able, the corresponding conditions of the kidneys and 
 constitution ; premising, as before, that our remarks have refe- 
 rence almost solely to practical purposes. 
 
 We have stated that the age of the patient affords a means of 
 
SEROUS URINE. CHRONIC. 
 
 137 
 
 distinction, or natural boundary, among the various urinary 
 diseases to be spoken of ; and at the same time pointed out 
 sufficient grounds to prove the general truth of this remark ; 
 the practical application of which, comes to be considered in 
 the next place. 
 
 When diseases of the kidneys occur before the age of forty, 
 they may almost always be considered as acquired de novo ; or 
 as resulting from an inherited predisposition ; or from a stru- 
 mous diathesis. On the contrary, after the age of forty, kid- 
 ney diseases partly result from long-continued and slowly 
 acting causes, giving occasion to gout, &c. ; and partly from 
 that natural decay of the vital powers which necessarily takes 
 place in advanced life. These facts lead to the general infe- 
 rences, that from premature disease, and consequent imperfect 
 nutrition, ancemotrophy of the kidneys will constitute the leading 
 feature of their diseases in early life ; while, in middle and ad- 
 vanced life, that hcemotrophy of these organs will result from the 
 constant plethora produced by the daily use of a generous and 
 stimulating diet.^ Now these inferences, on the whole, appear 
 to accord with experience ; and though there are numerous ex- 
 ceptions to them, yet it will be found, on close examination, that 
 many of the exceptions are more apparent than real. Thus, the 
 
 * It need scarcely be mentioned, that the terms ancdmotrophy and hcsmo^ 
 trophy simply imply a deficiency, and an excess, of sanguineous nourish- 
 ment. Atrophy and hypertrophy, as commonly understood, include the 
 idea of diminished and increased magnitude ; and do not, therefore, ex- 
 actly express the meaning intended to be conveyed. On the other hand, 
 ancemia and hypercBmia have reference only to the quantity of blood present, 
 without regard to its nutritive properties. For these reasons, as well as 
 for the sake of distinction, I have adopted the terms in the text to desig- 
 nate those peculiar conditions of degenerated organs, chiefly characterized 
 by the absence or presence of (red) blood ; and which conditions apparently 
 depend on the individual contraction or expansion, or on the numerical 
 diminution or increase (or both) of the blood-vessels supplying such de- 
 generated parts. That some such distinction is requisite for describing 
 the condition of degenerated structures, is evident from the fact, that an 
 organ may be ansemotrophied or haemotrophied, without being diminished 
 or increased in bulk ; or without the presence of general anjemia or hyper- 
 aemia ; and vice versa. 
 
138 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 hsemotrophy of early life, and the anaemotrophy of middle and 
 advanced life, are rarely absolutely identical with the haemotro- 
 phy of middle and advanced life, and the anaemotrophy of early 
 life ; that is to say, in the hsemotrophy of early life and the anae- 
 motrophy of advanced life, the kidneys are almost always disor- 
 ganized, as well as too much or too little nourished. Nor are 
 the general conditions of the urine in these two primary forms 
 of disease much less strongly marked. Thus, in the simple 
 anaemotrophy of early life, the urine is usually pale-coloured ; of 
 moderate specific gravity ; and rather copious : while, in the 
 simple haemotrophy of middle and advanced life, the urine is 
 generally deeper coloured ; of higher specific gravity ; and less 
 copious. The exceptions, however, to these general remarks 
 are numerous ; though, as before mentioned, many of these ex- 
 ceptions are apparent only. Thus the urine of the early haemo- 
 trophied kidney is often deep-coloured, of high specific gravity, 
 and deficient in quantity ; but as the early haemotrophied kid- 
 ney is usually more or less disorganized, the other properties 
 of the urine become likewise deranged ; and the practised eye 
 will accordingly readily discriminate, by the presence of such 
 derangements, between the urine of the disorganized haemo- 
 trophied kidney, and the urine of the simple haemotrophied 
 kidney. In like manner, the anaemotrophied kidney of middle 
 and advanced age is almost always more or less disorganized ; 
 and as the urine suffers a corresponding change, it may, in 
 most instances, be distinguished by such changes, from the 
 urine secreted by the simple anaemotrophied kidney. 
 
 The general inference, then, from these remarks is, that the 
 terms ancemotrophy and hcemotrophy, in the senses to which we 
 have restricted them, may be supposed to represent two pri- 
 mary conditions of the system giving occasion to, or at least 
 connected with, two distinct forms (or sections) of degenera- 
 tion — an inference of so much practical importance, that 
 we shall make it the basis of our arrangement of renal affec- 
 tions connected with serous urine. In conformity, there- 
 fore, with this plan, we shall separately consider, in their chro- 
 
SEROUS URINE. CHRONIC. 
 
 139 
 
 nic or quiescent state, and afterwards in their acute or in- 
 flamed state, the diseases connected with these two sections 
 of disease ; each of which may, for the sake of convenience, 
 be divided into two subspecies, chiefly differing from each 
 other in degree. This arrangement may be represented in 
 the following tabular form ; — 
 
 <5i / 
 
 o 
 
 TO a 
 
 C/2 
 
 Subspecies «. The kidney in a state of j Var. 1. Quiescent. 
 
 organic change; but without any visible^ „ ^ ^ ^ 
 
 , ^ . r 1^- ' * * ; 2. Inflamed. 
 
 derangement of its ultimate structure. [ 
 
 Subspecies fi. The kidney in a state of | y^^^ 3 Quiescent, 
 disorganization, i. e. having its ultimate <^ 
 structure more or less visibly destroyed. Var. 4. Inflamed. 
 
 Subspecies 7. The kidney in a state of [ 3 Q^i^^cen^. 
 organic change ; but without any visible <j 
 derangement of its ultimate structure. Var. 6. Inflamed. 
 
 Subspecies 5. The kidney in a state of [^^^^^ 
 disorganization, i. e. having its ultimate -< 
 structure more or less visibly destroyed. Var. 8. Inflamed. 
 
 In treating of the above srarieties of renal affections con- 
 nected with serous urine, we shall first separately describe the 
 condition of the urine ; the state of the kidneys ; the causes predis- 
 posing and exciting peculiarly belonging to the two quiescent 
 varieties, 1 and 3, of the two subspecies « and /3, of section i ; 
 and afterwards the same phenomena particularly belonging 
 to the two quiescent varieties 5 and 7, of the two subspecies 
 7 and ^ of SECTION 11. We shall then proceed to consider the 
 diagnosis; the prognosis ; and the treatment of the four quiescent 
 varieties in connexion. In treating of the four inflamed varie- 
 ties, 2, 4, 6, and 8, an order somewhat different will be followed. 
 This mode of arrangement has been adopted, not because it is 
 the most philosophic ; but for the sake of distinctness, as far as 
 the properties of the urine, &c., are concerned ; and for the sake 
 of convenience, and to avoid repetition, as far as regards the 
 diagnosis, prognosis, and treatment. 
 
140 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 Species h. Section i. Of Serous Urine ; Kidney in a state of 
 Ancemotrophy ; quiescent. — The important section of diseases 
 to be now considered, comprises a large portion of those 
 nephritic affections which have of late so much occupied the 
 attention of the medical world ; and which are characterized 
 by a serous condition of the urine. They are distinguished 
 by ancemotrophy, natural or produced, not only of the kidney, 
 but, for the most part, of the whole system ; and by their pre- 
 valence before the middle period of life. They exist under a 
 great variety of forms, many of which will be found described 
 by authors on these diseases ; but for all practical purposes, in 
 the present state of our knowledge at least, they may be includ- 
 ed under the two subspecies above mentioned, viz. subsp. a, dis- 
 eases in which the urine, from slight causes, frequently becomes 
 more or less serous ; and in which, therefore, the kidneys must 
 be in some incipient condition of organic change ; though their 
 ultimate structure be not visibly deranged : and, subsp. /3, dis- 
 eases in which the urine is always serous ; and in which the 
 ultimate structure of the kidney is either visibly disorganized 
 or destroyed. 
 
 Section i. Subsp. a. Var. 1. State of the Urine. — In this 
 incipient stage of ancemotrophy, the action of the kidney is ca- 
 pricious and uncertain ; so that from no assignable cause, or 
 from such slight causes as would not affect a person in health, 
 the urine exhibits more or less of the following phenomena : 
 
 The colour of the urine is usually paler than natural ; occa- 
 sionally deeper ; and frequently it is acid, even in a greater 
 degree than in health ; and in this case there is often deposited 
 on cooling, especially after meals, a pale-coloured, or occasion- 
 ally a bright pink-coloured sediment, of lithate of ammonia. 
 At other times the urine is nearly neutral, and becomes turbid 
 on the application of heat, from the deposition of the earthy 
 phosphates. Sometimes it is alkalescent when passed, particu- 
 larly if alkalis have been injudiciously administered ; and 
 generally, from the great susceptibility of the system, and 
 especially of the kidneys, the qualities of the urine are liable 
 
SEROUS URINE. CHRONIC. 
 
 141 
 
 to be changed in this affection by almost every thing taken in 
 the shape of food or medicine ; hence the sensible qualities of 
 such articles may be more speedily and decidedly detected in 
 this secretion, than in the urine of a healthy individual ; and 
 hence, also, from this great susceptibility of change, the 
 urine is sometimes serous. The quantity of the urine partakes of 
 the same variable characters as the qualities. When the urine 
 is high-coloured and acid, it is usually scanty and of great 
 specific gravity. When the quantity is copious, as is often the 
 case, — particularly during the latter part of the night and morn- 
 ing, the specific gravity is below the healthy standard. Ge- 
 nerally speaking, the quantity passed in a given time is above 
 the average ; while the specific gravity is sometimes below ; but 
 frequently above the average standard of health. 
 
 Section i. Subsp. /3, Var. 3. State of the Urine. — Much of 
 what has been just stated respecting the conditions of the 
 urine in the incipient stages of kidney anaemotrophy, is equally 
 applicable to the earlier stages of the actually disorganized 
 kidney. When the kidney has become disorganized, however, 
 not only the urinary symptoms are more strongly marked ; 
 but, as the disease proceeds, they assume the following forms : 
 
 In the earlier stages of the confirmed disease, the colour of 
 the urine is either ordinary, or paler than natural; rarely 
 deeper. It is generally acid; in a few rare cases alkalescent, or 
 speedily becoming so. It is seldom perfectly transparent, owing 
 to the presence of floating flocculi of mucus, or muco-albu- 
 minous matter ; though it very rarely becomes turbid on cooling, 
 by the deposition of the lithate of ammonia. On the applica- 
 tion of heat and nitric acid, the urine always becomes turbid ; 
 the secretion, therefore, is permanently serous. In the ear- 
 lier stages, the quantity of the urine differs but little from 
 that of health ; though, perhaps, on the whole, the quantity is 
 above, rather than below, the natural standard. Nearly the 
 same remarks apply to the specific gravity ; which, in the earlier 
 stages, does not differ much from the healthy standard ; though 
 in general, perhaps, it will be found rather below the average. 
 
1 42 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 These observations, however, are subject to some variety ; as the 
 quantities and qualities of the urine usually partake of the 
 capricious characters of the incipient stages of the affection. 
 As the disease advances, the properties of the urine frequently 
 undergo remarkable changes; and, in the fully formed and 
 latter stages of the affection, the following, with occasional 
 modifications, may be said to be the leading characters of this 
 secretion : 
 
 The colour of the urine is almost uniformly paler than in 
 health, and sometimes it is nearly devoid of colour altogether. 
 Generally speaking, it retains its acid character ; and though, as 
 before, an alkaline condition of the secretion occurs, this is un- 
 usual. From an increase of the mucous matter formerly 
 mentioned, the urine is opalescent when passed ; but it never 
 becomes turbid, on cooling, by the deposition of the lithate of 
 ammonia. Heat and nitric acid always produce turbidity ; 
 though the absolute quantity of albuminous matter present is 
 much less than in the preceding stages ; and sometimes is very 
 trifling. The quantity of urine is rarely below, often as much 
 as thr.ee or four times above, the average standard ; and in such 
 cases the specific gravity descends to 1*010, or even to 1*006 
 or 1*008; and in a few rare cases I have found the specific 
 gravity as low as 1*001 or 1*002; or barely above the specific 
 gravity of spring water. In such cases the quantity has been 
 usually much above the natural standard. 
 
 From the above properties of the urine, it will be generally 
 found that both the positive and relative proportions of its in- 
 gredients are much diminished. Thus, even in the earlier 
 stages, when the specific gravity is not remarkably low, and 
 the albuminous matter is abundant ; on the separation of the 
 albuminous matter by heat, it will be found that the specific gra- 
 vity is often reduced four, or even as much as seven, units. 
 Hence, if the quantity of urine be taken into account, the abso- 
 lute weight of the other solid ingredients passed in twenty-four 
 hours is very deficient. In the latter stages, this deficiency is 
 still more remarkable ; so that the proportion of solid ingredi- 
 
SEROUS URINE. CHRONIC. 
 
 143 
 
 ents voided in a given time, sinks to a fifth (even to one-twelfth) 
 of the healthy average.* With respect to the relative pro- 
 portions of the ingredients, according to my observations in 
 such cases, the lithates are most strikingly deficient ; and next 
 to them the urea and saline matters. 
 
 In the very last stages, immediately preceding dissolution, 
 the quantity of the urine often becomes remarkably diminished ; 
 while its specific gravity is but little increased. This state of 
 things often ushers in, and accompanies, a fatal coma. 
 
 Section I. Subsp. a, Var.l. State of the Kidneys, — The pre- 
 cise condition of the kidneys in the first stage of ansemotrophy is 
 but imperfectly understood ; since, as before stated, few indivi- 
 duals die of the aff*ection in this stage ; and it is only by accident 
 that opportunities occur of examining the organs. As far as my 
 limited experience, assisted by analogy, extends, the following 
 may be considered as a brief outline of the condition of the 
 kidneys under the circumstances at present contemplated : 
 
 The size of the kidneys is sometimes below the average, 
 or normal ; not unfrequently even hypertrophied. The colour, 
 both external and internal, is usually paler than natural. 
 The ultimate structure is not sensibly changed, yet often pre- 
 sents an appearance undefinably unnatural. The texture is not 
 unfrequently firmer than in health ; sometimes irregularly firm, 
 or lumpy. At other times, though more rarely, the texture is 
 softer than natural; and, generally, the kidney may be said to 
 partake of that w^ant of natural appearance and development 
 which can hardly be verbally expressed ; but which obviously 
 prevails in certain individuals, originally of delicate constitu- 
 tion ; or who have become diseased in early life from unhealthy 
 occupations, or from dissipated habits. 
 
 Section I. Suhsp. /3, Var. 3. State of the Kidneys. — From 
 the shortness of the period since kidney diseases have begun to 
 attract attention, and from the consequent limited number of 
 facts from which to draw conclusions ; from the different descrip- 
 tions also given by authors apparently of the same subject, as well 
 
 * Dr. Christison on renal granular degeneration, pp. 47. 54. 
 
144 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 as the different opinions they have expressed regarding them, the 
 following observations are necessarily less perfect than could 
 be desired, and in fact are confined to a few of the best ascer- 
 tained points. In illustration of our subject, we shall princi- 
 pally limit our attention to the phenomena presented by the 
 granulated kidney of Dr. Bright ; not only because this con- 
 dition of the kidney has been best studied ; but because it con- 
 stitutes one of the most common and remarkable instances of 
 the aneemotrophied form of disease, now under consideration. 
 
 In the early stages of granular degeneration, the size of the 
 kidneys rarely surpasses, and is often below, the average. — 
 As the disease proceeds, the size usually diminishes ; and in the 
 latter stages, the size is sometimes reduced to one-third, or even 
 less, of the natural bulk. In the early stages, the external 
 colour is generally paler than natural, and often presents a 
 mottled appearance, caused by a mixture of gray granules with 
 the natural (but paler) colour of the organ. As the disease 
 proceeds, the gray, or yellowish-gray, predominates; and in 
 the latter stages, the organ generally assumes altogether 
 more ' or less of a grapsh-yellow tint. The general texture or 
 consistence of the kidneys is very variable. In the early stages 
 the consistence is sometimes nearly natural ; at other times 
 firmer. The external surface also is often distinctly rough, or 
 has a granulated feel. As the disease advances, the firmness 
 usually increases, and the organ feels not only rough, but 
 becomes irregularly lobulated ; so that, in the last stages, the 
 hardness varies from that of the healthy, to that of the tuber- 
 culated, liver. Indeed, Dr. Bright has sometimes found the 
 organ so hard as to cut almost like cartilage. In the last stages, 
 also, the general appearance of the kidney is not only lobu- 
 lated, but sometimes even botryoidal. 
 
 On making a longitudinal section of the kidney, the following 
 among other phenomena are presented. In the early stages the 
 external or cortical structure scarcely retains its natural breadth, 
 and is frequently contracted. This portion of the kidney also, 
 instead of appearing of its usual colour and appearance, is often 
 
SEROUS URINE. CHRONIC. 
 
 145 
 
 of a greyish-yellow colour, and presents more or less of a gra- 
 nulated texture. A similar section of the kidney, in the more 
 advanced stages, assumes various appearances. The cortical 
 portion of the kidney is now generally much contracted in 
 breadth, so that the entire extremities of the tubular masses are 
 pushed, as it were, towards the external surface ; and there 
 is also granulated matter usually deposited among the tubuli. 
 In the latter stages, the kidney is sometimes seen converted 
 into one entire mass of uniform granular or homogeneous 
 degeneration, with the exception, perhaps, of a single tubulus at 
 one or both extremities. In general one kidney is found much 
 further advanced in disease than the other ; and sometimes, even 
 in the last stages, one kidney is only partially advanced, while 
 the other is quite destroyed. In the present form of the disease, 
 however, when one kidney is destroyed, the other is rarely 
 found quite healthy. 
 
 Section i. Subsp. a. Var. 1. Constitutional Symptoms. — The 
 constitutional symptoms accompanying the first variety of kid- 
 ney degeneration in early life, are usually marked by three pro- 
 minent features, viz. derangement of the assimilating organs ; 
 susceptibility to cold and moisture ; and malaise, with more or 
 less of debility. The stomach is easily nauseated, or becomes 
 acescent or flatulent. The appetite is usually capricious and 
 morbid ; the bowels sluggish, or alternately sluggish and irri- 
 table. The biliary secretion is modified in its qualities, and 
 alternately deficient or excessive, kc. The skin is generally dry 
 and harsh, sometimes unnaturally relaxed ; and the patient is 
 so susceptible of the influence of cold and moisture, that on the 
 slightest exposure, he is apt to get catarrh and bronchial irri- 
 tation. To these derangements and tendencies, there are almost 
 always superadded a sense of general malaise and nervous sus- 
 ceptibility, inclining generally on the side of despondency ; a 
 pale and haggard expression of countenance ; and often more 
 or less of emaciation and debility. 
 
 Such are the usual derangements accompanying the pre- 
 sence of, or disposition to, the first variety of kidney dege- 
 
 L 
 
146 PATHOLOGY OF ALBUMKfOUS ASSIMILATION AND SECRETION. 
 
 neration in early life ; and of these and many similar derange- 
 ments, the kidney degeneration has been usually considered as 
 the mere effect. The truth is, however, that the constitutional 
 and local affections form a closely connected group, depending 
 alike, in most instances, on the same cause; and that it 
 is, in consequence, difficult or impossible to say, that the one 
 set of derangements produces, or is derived from, the other. 
 
 Section i. Subsp./3, Var.3. Constitutional Symptoms. — In the 
 earlier stages of this variety, the constitutional symptoms differ 
 little, perhaps, except in degree, from those above mentioned as 
 occurring in the first variety ; and the disease usually creeps on 
 so insidiously, that the patient can seldom give any satisfactory 
 account, either of its cause or commencement. In such in- 
 stances, therefore, the physician has seldom an opportunity of 
 seeing the affection at the outset ; and not, perhaps, until it 
 has become suddenly aggravated by some accidental circum- 
 stance, in consequence of which the patient has been induced 
 to apply for medical assistance. On inquiry it will be very 
 generally found, in addition to the preceding symptoms, that 
 diuresis in the horizontal position, or during the night, has, in 
 such cases, been also present; and that for months, and even for 
 years, the patient has been in the habit of getting up once or 
 oftener to pass his urine, particularly towards the morning ; 
 while during the day he has not been more troubled than for- 
 merly. The patient also, if closely questioned, will in almost 
 all instances acknowledge a consciousness of some uneasiness 
 about the back and loins, occasionally extending to the groins 
 and thighs ; while in many cases these symptoms are ur- 
 gent, and accompanied by a distressing feeling of debility. 
 For the most part, also, there is a sense of uneasiness about the 
 urinary organs, and in men in particular, a pain or irritation 
 in that part of the urethra occupying the perinseum ; which pain 
 or irritation sometimes extends to the point of the penis. 
 When the affection has existed in the chronic form for a con- 
 siderable time, there is always more or less debility, and gene- 
 rally, but not always, of emaciation ; the skin, also, is usually 
 
SEROUS URINE. CHRONIC. 
 
 147 
 
 dry ; and the general surface, and especially the face, acquires a 
 peculiarly pallid and exsanguine aspect. The functions of 
 the digestive organs, and particularly of the stomach, become 
 more and more impaired ; and on assuming the erect position 
 in the morning, nausea and vomiting sometimes take place. 
 There is more or less of thirst ; and the patient in consequence 
 usually prefers fluid to solid aliments. The bowels are irregu- 
 lar ; frequently constipated ; at other times, from very slight 
 causes, relaxed ; and the patient is harassed with a troublesome 
 diarrhoea. There is great susceptibility to cold, and during 
 the winter months, indeed at all times, from the slightest ex- 
 posure, the patient is apt to get cold, as it is termed ; hence 
 he not unfrequently labours under a sort of chronic catarrh ; 
 particularly during the winter months. This state of things 
 not unusually leads to, or is associated with, inflammation 
 and dropsical eff'usion into the cavities of the chest or abdomen ; 
 particularly if the heart or liver, as is frequently the case, are 
 unsound. Under the same circumstances, also, there is com- 
 monly anasarcous oedema of the lower extremities ; though, in 
 some cases, this is less remarkable than might have been ex- 
 pected ; and in a few, dropsy in every form is entirely absent. 
 After a greater or less period and degree of sufiering from these 
 or other concomitant affections, during which the powers of life 
 rapidly give way, diarrhoea usually takes place, and still fur- 
 ther reduces the patient; who at length becomes oppressed 
 with drowsiness, and finally dies in a comatose state. 
 
 Such is the usual history of the constitutional symptoms 
 attending that form of degenerated kidney, termed the granu- 
 lated kidney. The disease, however, is liable to considerable 
 modifications, from the prevalence of one or more of the affec- 
 tions which usually accompany it ; some of which have been, 
 while others remain to be, noticed ; though the nature of the 
 present work prevents us from entering into details. 
 
 Under the head of concomitant diseases, Dr. Christison has 
 enumerated the following list, comprising some of the most 
 formidable affections to which humanity is liable : viz. Dropsy ; 
 
 L 2 
 
148 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 Diarrhoea ; Pleurisy and Peritonitis ; Pneumonia ; Catarrh ; 
 Dyspepsia and Chronic Vomiting ; Coma, with other affections 
 of the head; Chronic Rheumatism; Organic diseases of the 
 Heart ; and Organic diseases of the Liver. 
 
 Of all these affections, dropsy of the cellular membrane, or 
 anasarca, is the most frequent ; and indeed, as is well known ^ 
 this concomitant disease first drew the attention of Dr. 
 Bright to granular degeneration of the kidney. A few 
 instances of granular affection have been found, unaccompanied 
 by cellular effusion throughout the whole progress, as above 
 stated ; but it so very rarely happens that anasarca does not 
 occur at some period or other of the affection, that it has been 
 considered as one of the essential symptoms of the disease. 
 The other forms of dropsy occur more rarely, and in most 
 instances, when present, are accompanied by organic disease of 
 the heart, lungs, or liver. Dr. Christison lays down the fol- 
 lowing four rules, with reference to the connexion between 
 granular disease of the kidney and anasarca, with which, in 
 general, I perfectly agree. 1. " A very great proportion of 
 cases of inflammatory dropsy depend on organic disease of the 
 kidneys." 2. " All cases of anasarca, where the oedematous 
 parts do not pit on pressure, are connected with granular de- 
 generation of the kidneys." With respect to this rule I am 
 not able to give a very decided opinion either way ; but I be- 
 lieve it to be true in general. 3. " All dropsies, when the 
 urine is steadily above the healthy standard in point of quantity, 
 [and at the same time of low specific gravity,] occur in 
 connexion with granular kidney ; except in the instances of 
 dropsy attending the advanced stage of diabetes." This rule, 
 as far as my observation extends, is generally correct. 4. " All 
 dropsies, where the urine not being above the healthy standard 
 in quantity, is also below 1*010 in density, are connected with 
 granular disorganization of the kidneys ; whether the urine be 
 albuminous or not." Dr. C. does not speak confidently with 
 respect to this rule, and it may be liable to exceptions ; yet I 
 have every reason to believe it to be generally correct. I fully 
 
SEROUS URINE. CHRONIC. 
 
 149 
 
 concur, also, with his concluding observations on this subject. 
 The " presence of dropsy in general exasperates all other 
 secondary disorders, and the removal of it usually relieves them. 
 There are, perhaps, however, some exceptions. At least it has 
 repeatedly occurred to me to remark, that coma or chronic 
 vomiting has been exasperated, or has begun to show itself for 
 the first time, immediately on the disappearance of extensive 
 anasarca. Dropsy is in most cases removed with tolerable 
 certainty, though not always quickly." 
 
 Dyspepsia in its severer forms, and chronic vomiting, are 
 placed by Dr. C. as next in point of frequency to anasarca, 
 and perhaps correctly, as far as regards " the middle and final 
 stages of the disease. They may be frequently palliated ; but 
 for the most part with difficulty removed." 
 
 After dyspepsia, diarrhoea is the disease noticed by Dr. Chris- 
 tison, as most frequently occurring in connexion with renal dis- 
 ease. Like Dr. Bright, however, I have not met with it so 
 often as a symptom in the earlier stages of the affection, as 
 Dr. C. appears to have done in Edinburgh ; though in the last 
 stages of the affection, diarrhoea is very common, and frequently 
 the immediate forerunner of death. 
 
 Pleurisy and Pneumonia occasionally occur as secondary dis- 
 eases in renal diseases ; as does Peritonitis ; but not nearly so 
 frequently as bronchial affections, both acute and chronic. In- 
 deed, as Dr. C. has remarked, few cases of renal affection occur 
 in the winter months, without more or less of catarrh ; which 
 often assumes a severe and unfavourable form. 
 
 Coma seems, as we have stated, to be the natural termination 
 of the disease, and is usually preceded by more or less 
 of urinary suppression. Sanguineous apoplexy is much more 
 rare. The comatose state is usually preceded by drowsiness ; 
 which should be averted by every possible means, as one of the 
 most dangerous premonitory symptoms. When the drowsi- 
 ness, as Dr. C. remarks, " has fairly passed into coma, a fatal 
 result is almost inevitable." 
 
 Chronic rheumatism, I have observed with Dr. C, to be a 
 
150 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 common and very troublesome concomitant of renal affections ; 
 especially during the winter and spring months. 
 
 Diseases of the heart have been noticed by most writers as 
 frequently accompanying renal affections^ though the connexion 
 between the two sets of diseases is not obvious. 
 
 Diseases of the liver are not uncommon, and are, perhaps, 
 not difficult to be accounted for, when we consider that by 
 far the greater number of renal affections owe their origin 
 to intemperance ; which is likewise the most frequent cause 
 of hepatic affections. 
 
 On the perusal of this formidable list of diseases, too often 
 found in connexion with kidney affections, the question natu- 
 rally arises, — what is the bond of union among them ? In reply 
 to this question, Dr. C. remarks, that kidney diseases " seem 
 to engender an infirmity of constitution, which renders the body 
 prone to disease in general." That this observation is quite 
 correct there cannot be a doubt ; yet I think it inadequate, as 
 it stands, to explain the phenomena ; and that the more general 
 proposition is requisite for this purpose, viz, that certain causes 
 (dram-drinking for instance) produce an infimiity of the con- 
 stitution in general, and of the m-inary organs, as the kidneys, 
 (fee, in particular, — in other words, that the affection of 
 the kidneys is but one of the consequences of a generally ope- 
 rating cause ; but that such affection of the kidneys, when esta- 
 blished, acts in its turn as a secondary cause, and still fui'ther 
 predisposes the constitution to mischief. The point, however, 
 is hardly worth contesting, and I fully concur in the import- 
 ant observations with which Dr. Christison concludes his sec- 
 tion on the subject, when thus slightly modified,^ viz. that in- 
 dividuals labourino' under " o-ranular dea'eneration of the kid- 
 
 c c o 
 
 neys at a moderately advanced period of its progress, are pe- 
 culiarly liable to the invasion of some epidemic diseases." 
 
 * The proposition as advanced by Dr. C. stands thus : — " It would ap- 
 pear that granular degeneration of the kidneys, at a moderately advanced 
 period of its progress, renders the body peculiarly open to the mvasion of 
 some epidemic diseases," &c. — Page 75 — 106. 
 
SEROUS URINE. CHRONIC. 
 
 151 
 
 In illustration of which proposition, he continues. "These 
 organs have been frequently found advanced in granular dis- 
 organization in cases of death from typhus fever, which for 
 some years has been extensively epidemic in this city. (Edin- 
 burgh). And the same morbid appearance was found in a 
 considerable proportion of the cases of malignant cholera." 
 
 Section i. Subsp. a and /3, Var. 1 and 3. — Of the causes pre- 
 disposing and exciting — For the sake of convenience, as well 
 perhaps as of propriety, we shall consider the predisposing 
 causes, with reference more especially to var. 1 ; and the exciting 
 causes, as those more immediately inducing var. 3. 
 
 Var. 1. — The primary predisposing causes to most renal 
 affections, are inherent ; and, in the present forms of dis- 
 ease, the chief primary predisposing cause is nearly allied to, or 
 at least is usually associated with, the strumous diathesis. Besides 
 this general predisposing cause, there cannot be a doubt that, in 
 many instances, a peculiar predisposition to this affection, as well 
 as to other affections of the urinary organs, exists. Of this 
 peculiar predisposition, I think I have seen instances in the 
 children of old drunkards and debauchees, who had died of 
 renal affections ; many of whom have applied to me for similar 
 complaints, at an age, and under circumstances, in which it 
 was difficult to account for their maladies on any other prin- 
 ciple. Thus, a slight gonorrhoea, for instance, which, in a 
 healthy person, and under ordinary circumstances, would have 
 subsided, without leaving a trace of evil, has, in such indi- 
 viduals, ended in a troublesome stricture, and finally disor- 
 ganization, in a greater or less degree, of the whole 
 urinary system. Hence, all causes predisposing to affections 
 of the urinary organs in general, may predispose to kidney 
 diseases in particular ; and hence the reason why many of the 
 affections treated of in preceding chapters, as well as those to 
 be spoken of hereafter, finally become complicated with this 
 peculiar affection, and, through its means, immediately prove 
 fatal. As instances of these diseases already spoken of, we may 
 mention a predisposition in the system to form oxalic acid ; or an 
 
152 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 excess of urea ; or lactic acid, (rheumatism) ; also the acute 
 forms of the affection described in the preceding pages, 
 arising from exposure to cold, from scarlatina, &;c. ; in short 
 all diseases either already described, or to be described here- 
 after, particularly affecting the urinary organs, strongly dis- 
 pose the kidneys to take on the present, or some other formida- 
 ble, malady. 
 
 Var. 3. — With such predispositions to nephritic affections 
 as those above enumerated, it is not, perhaps, difficult to account 
 for the operation of the various exciting causes to be now con- 
 sidered ; for daily experience teaches us, that when a strong 
 predisposition to organic disease exists, and particularly if it be 
 actually established, such organic disease is prone enough to 
 advance in spite of every care. Even the ordinary modes 
 of living, for instance, often co-operate and act as exciting- 
 causes under such circumstances : thus a deficient and un- 
 wholesome diet, conjoined with unhealthy and sedentary occu- 
 pations, develope and confirm the strumous diathesis in gene- 
 ral; and when in early life, as is too often the case among the 
 lower classes of society, the abuse of spirituous liquors is super- 
 added, the kidneys in particular suffer ; and the present varie- 
 ties of renal disease, in their worst forms, are speedily esta- 
 blished. Indeed, as already stated, and as will be more parti- 
 cularly shown hereafter, the abuse of ardent spirits is, in this 
 country of all others, the most frequent exciting cause of the 
 kidney affections. Among the other exciting causes, exposure 
 to cold is one of the most common. This cause operates alike 
 on all classes of society, but the poor and ill-fed are necessarily 
 exposed to its more dire effects. Another exciting cause which 
 has been stated in large towns more especially to co-operate in 
 the production of the present diseases among all classes, are 
 venereal affections ; as well as the remedies employed to eradi- 
 cate the various forms of this multiform scourge. These affec- 
 tions, by establishing inflammatory and organic disease in the 
 urinary organs, are exceedingly liable to institute and excite 
 similar mischief in the predisposed kidneys. The stimulating 
 
SEROUS URINE. CHRONIC. 153 
 
 remedies also, as well as the mercury employed to cure vene- 
 real affections, especially if incautiously used, as is too often the 
 case, contribute their ample share towards the same end. 
 Other exciting causes enumerated by authors, are blows or in- 
 juries in the neighbourhood of the kidneys ; the suppression of 
 cutaneous affections ; Sec; all of which, and many others acting 
 upon, or co-operating with, strong predisposition, rarely fail to 
 develope, in some form or other, the diseases now under con- 
 sideration. 
 
 Agreeably to our plan of arrangement, before we proceed to 
 consider the diagnosis, prognosis, and treatment of the present 
 SECTION of renal diseases; we shall briefly describe the 
 condition of the urine, and of the kidneys, the constitutional 
 symptoms, and the causes, of the second section of renal affec- 
 tions ; those, namely, connected with hsemotrophy. 
 
 Species h. Section ii. Of Serous Urine; the Kidney in a 
 State of Hcemotrophy ; quiescent, — Under this second gene- 
 ral division of nephritic affections, distinguished by a serous 
 condition of the urine, we include, as formerly mentioned, those 
 diseases more especially occurring about the middle and subse- 
 quent periods of life, in over-fed and plethoric individuals ; and 
 which, in consequence, are usually accompanied by excessive 
 development, or haemotrophy of the different organs. These 
 diseases, like the diseases accompanied by ansemotrophy, we 
 divide into two subspecies, chiefly distinguished from each other 
 by degree, viz. subsp. y, in which the kidney is supposed to 
 be in a state of organic change, but without any visible derange- 
 ment of its ultimate structure ; and subsp. ^, in which the 
 kidney is in a state of visible disorganization. 
 
 Section ii. Subsp. y, Var. 5. State of the Urine. — About the 
 age of forty, and in more advanced life, the properties of the 
 urine often become considerably modified in individuals who 
 had not previously considered themselves in bad health. The 
 general action of the kidneys, indeed, often partakes of the ca* 
 priciousness accompanying the diseases of early life ; but the 
 variations in general are less marked, and from slight causes. 
 
154 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 and sometimes from no assignable cause, the urine assumes 
 the following characters : 
 
 The colour of the urine is usually natural ; sometimes deeper 
 than natural. It is almost uniformly acid; and is, when passed, 
 transparent, or nearly so ; but on cooling frequently becomes 
 opake, and deposits a copious sediment of lithate of ammonia, 
 the colour of which varies, in different instances, from a reddish 
 brown, to a dirty clay colour. This sediment usually, after 
 a time, subsides to the bottom of the vessel, and leaves 
 the urine clear ; but in certain cases a portion is apt to remain 
 suspended, so that the urine seldom becomes transparent by 
 mere subsidence ; and occasionally even remains turbid after 
 filtering. The application of a gentle heat, however, renders it 
 transparent; but if the heat be raised to 130° or 140°, the urine 
 under the above circumstances frequently again becomes turbid 
 from the deposition of albuminous matter — a series of changes 
 characteristic of this variety of urine. The quantity of the 
 urine seldom exceeds the average, and is often below it ; hence 
 the specific gravity is high, and varies from 1*018 to 1*025, or 
 more. Occasionally the action of the kidney is capricious, 
 and the quantity for a short time surpasses the average ; and in 
 this case the specific gravity generally sufiers a corresponding 
 reduction ; but this is rare. 
 
 Section ii. Subsp. ^. Var. 7. State of the Urine. — In the ear- 
 lier stages of the established disease, the colour of the urine still 
 remains natural, or is deeper than in health ; very seldom paler, 
 at lesist, permanently paler. The urine is generally acid, and 
 occasionally deposits the lithate of ammonia, which is more or 
 less of a lateritious colour. The secretion, also, is almost always 
 albuminous, particularly after meals ; though, in some instances, 
 albuminous matter appears only after considerable intervals. 
 The quantity is variable, but generally not surpassing, fre- 
 quently below, the natural standard. Hence the specific gra- 
 vity is high, even in the advanced stages, and, indeed, is sel- 
 dom very low, that is, below 1*010. In the more advanced 
 stages it becomes impossible to lay down rules generally appli- 
 
SEROUS URINE. CHRONIC. 
 
 155 
 
 cable ; as this form of kidney affection is liable, as it proceeds, 
 to become complicated with a great variety of other diseases 
 which considerably modify the properties of the urine. In none 
 of these complications, however, except in the complication 
 with granulated kidney, or in a few instances with strumous 
 abscess, does the urine ever become permanently pale coloured, 
 large in quantity, and of low specific gravity. Thus, in the 
 complication with lithic acid gravel, or with calculous abscess, 
 &c., in the kidney, the urine is often serous and even bloody 
 or purulent ; but rarely at the same time permanently pale 
 coloured, copious, or of low specific gravity. Even when the 
 urine becomes alkalescent, and deposits the phosphates, though 
 the colour may become paler, the quantity is not permanently 
 excessive ; nor the specific gravity very low. Indeed, the very 
 presence of these complications, which will be elsewhere spoken 
 of in detail, is no bad diagnostic mark of the peculiar condition 
 of the kidney now under consideration, as more immediately 
 contrasted with the granulated form of disease ; in which, ac- 
 cording to my observations, actual calculous depositions, and 
 even abscesses, may be said to be rare. 
 
 Section ii. Subsp. y, Var, 5. State of the Kidneys.-— The ^ve- 
 cise condition of the kidneys in this form of incipient disease, 
 like that of incipient ansemotrophy, has not been studied so 
 carefully as it deserves, and principally for the same reasons. 
 As before, I offer the following general remarks as the result 
 of a limited observation and analogy : 
 
 Size of the kidney normal ; frequently above the average, 
 hypertrophied ; more rarely atrophied, or below the average. 
 Colour^ both external and internal, often deeper than natural. 
 Ultimate structure not intelligibly changed, yet for the most 
 part obviously varying from that of health. Texture, frequently 
 loose and flabby, more rarely firmer than the natural condition ; 
 and generally the kidneys seem to partake of that unnatural 
 character, and forced or excessive development which hardly 
 admits of description, but which may readily be supposed to be 
 produced by long-continued full diet, and the free use of vinous 
 
156 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 liquors on the system in general, and upon the congested ab- 
 dominal viscera in particular — circumstances which, as we 
 shall show hereafter, appear to act as the most frequent causes 
 of this form of disease. 
 
 Section ii. Subsp. Var. 7. State of the Kidney. — In the ear- 
 lier stages of the established disease, the size of the kidney is 
 usually normal, occasionally larger than natural ; but as the dis- 
 ease proceeds, the size usually increases, so that in the advanced 
 stages, the organ has been found twice, or even thrice, the natural 
 magnitude. The colour of the kidneys is often darker than natu- 
 ral, as if from vascular congestion, a condition that seems to pre- 
 vail more or less throughout ; hence, in the last stages the 
 colour of the organ becomes very dark, or even reddish black. 
 The general texture or consistence in the earlier stages of the 
 confirmed disease is still flabby, and softer than natural, a ten- 
 dency that increases as the disease proceeds ; and in the last 
 stages, the organ often becomes quite soft and friable. On 
 making a longitudinal section of the kidney, the following, 
 among other phenomena, are presented. The cortical sub- 
 stance of the kidney is almost always broader than in health, 
 and generally gorged with blood. Sometimes, also, this part 
 of the kidney presents a distinct granular appearance, which 
 occasionally becomes more evident in the advanced stages ; 
 though this appearance is often entirely wanting, and the 
 whole mass assumes a uniform homogeneous appearance, like 
 that of the brain ; or occasionally like that of the fatty degene- 
 rated liver, although no fatty matter is present. In the last 
 stages, the natural structure becomes more or less obliterated 
 and useless ; and in this case, as in some other diseases of the 
 organ, the whole substance of the kidneys is sometimes entirely 
 removed by absorption or otherwise ; so that ultimately, not a 
 vestige of the cortical or tubular structure of the organ remains ; 
 and the once enlarged organ is reduced to a small, flabby, 
 irregular capsule. In such cases, the other kidney remains 
 more or less entire ; so as to protract for a time the patient's 
 existence. 
 
SEROUS URINE. CHRONIC. 
 
 157 
 
 Besides these terminations of the present form of renal disease, 
 which are the most usual, this form of affection, as before no- 
 ticed, is often complicated with lithic acid gravel ; with calculous 
 abscess; and with various other morbid derangements, from 
 which the anaemotrophied kidney seems to be wholly exempted. 
 
 Section ii. Subsp. y. Var. 5. Constitutional Symptoms. — We 
 have stated that in early life dyspeptic derangements, more es- 
 pecially of the stomach, constitute the prevalent diseases usually 
 connected with renal affections ; and we may now remark, that 
 about the age of forty and afterwards, affections of the stomach 
 become gradually less frequent, or at least, less troublesome ; and 
 the organs heloio the stomach usually assume the greatest appear- 
 ance of derangement ; the attacks also at this period of life 
 have usually more or less of the periodical or paroxysmal form ; 
 while in the intervals between the paroxysms, the patient fre- 
 quently enjoys tolerable health, and the urine is quite free from 
 albuminous matter. These preliminary remarks being borne 
 in mind, the reader will better appreciate the force of the 
 following observations. The constitutional symptoms accom- 
 panying the confirmed nephritic diseases now under consider- 
 ation, are more or less severe in different instances, and vary 
 considerably according to the nature of the organs parti- 
 cularly affected, as well as according to the degree in which 
 the organs are implicated. A deranged state of the bowels, 
 drowsiness, and other symptoms usually denoting a congested 
 state of the system, and particularly of the hepatic system, 
 commonly precede the attack, which for the most part is 
 immediately ushered in by what is denominated a cold; that 
 is to say, a disposition to chilliness, followed by dull pain in the 
 loins, and more or less of feverish excitement. The subse- 
 quent symptoms vary, and depend in a great degree on the 
 individual predispositions and peculiarities of the patient. 
 Sometimes bronchitis or other thoracic symptoms make their 
 appearance, and constitute the leading features of the attack. 
 At other times the abdominal viscera are more immediately 
 involved, and a slight yellow tinge appears in the eyes or on 
 
158 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 the skin, kc. In the more unfavourable cases, there is a strong 
 tendency to apoplexy and paralysis ; or to an erysipelatous erup- 
 tion on some part of the surface of the body ; the lower extre- 
 mities, also, are apt to become oedematous, and pit on pres- 
 sure ; particularly towards night. There is generally with 
 these symptoms a dull heavy pain or of uneasiness about the 
 region of the kidneys, accompanied in most instances by more 
 or less of irritation about the urinary organs ; particularly if 
 the organs are in any way predisposed to derangement. Hence 
 there is often a frequent desire to pass the urine in small quan- 
 tities at a time ; which on the v/hole is scanty, and presents the 
 phenomena before described. 
 
 Section ii. Subsp. Var. 7. Constitutional Symptoms. — The 
 symptoms attending the subsequent, and particularly the latter 
 stages of the affection, depend almost entirely upon the turn the 
 disease may take, either from the predisposition of the patient, or 
 from the accidental exciting causes to which he is subjected. If 
 the patient in middle or advanced life becomes a drunkard, and 
 more especially if he becomes addicted to the use of ardent 
 spirits, the granulated form of disease of the kidney before de- 
 scribed may be superinduced on the haemotrophied kidney ; 
 which, as already stated, may from this cause finally assume an 
 ansemotrophied condition. If the patient be gouty, or has receiv- 
 ed some blow or other injury about the region of the kidney, the 
 formation of lithic acid calculi may take place. If he has been 
 subject to cutaneous affections of the scaly kind, the oxalate of 
 lime calculus will be most likely to occur ; or finally, if he 
 labour under chronic disease of the bladder, prostate, &;c., his 
 case will be likely to become complicated, with a deposition of 
 the phosphates in the urine ; neither of which forms of disease, 
 as already stated, are, according to my observations, of fre- 
 quent (on the contrary are of most rare) occurrence in the 
 granulated and ansemotrophied diseases of early life. It is pro- 
 per, however, to remind the reader of the fact already stated, 
 that many of the affections accompanying the ansemotrophied 
 state of the kidneys, also accompany, though in modified forms, 
 
SEROUS URINE. CHRONIC. 
 
 159 
 
 the hsemotropliied forms of disease ; such as dyspeptic, bron- 
 chial, rheumatic and gouty affections, in the earlier stages ; and 
 in the latter stages, dropsy, diarrhoea, and coma — the two last 
 of which, as in the ansemotrophied forms of nephritic affection, 
 often immediately precede the fatal termination.^ 
 
 Section ii. Subsp. y and ^. Var. 5 and 7. Of the Causes pre- 
 disposing and exciting. — We shall, as before, for the sake of con- 
 venience, consider the predisposing causes, with reference more 
 especially to var. 5 ; and the exciting causes as those more 
 immediately giving occasion to var. 7. 
 
 Var. 5. — Besides many of the causes predisposing to renal 
 affections in early life formerly enumerated, about the age of 
 forty and in subsequent life, there are commonly superadded a 
 variety of others, such as the rheumatic and gouty diathesis, 
 the effects of a long-continued use of a full diet and free use of 
 wine, and especially of malt liquors ; of sedentary habits, or 
 their reverse, severe horse exercise, &:c. ; but more especially of 
 the gradual organic diseases incidental to age, all of which and 
 a variety of analogous circumstances give occasion, in middle 
 and advanced life, to congestion of the abdominal, and particu- 
 larly of the hepatic system, the natural result of which is 
 congestion and tendency to hypertrophy of the kidneys, 
 prostate gland, bladder, &;c., while the hsemorrhoidal veins, 
 and sometimes the veins of the lower extremities, become 
 more or less varicose. In this state of congestion, the particu- 
 lar organ affected is often determined by the action of exciting 
 causes to be next enumerated. 
 
 Var. 7. — Of all the accidental circumstances acting as ex- 
 citing causes in the above highly charged condition of the 
 system, errors in diet and exposure to cold are the most fre- 
 quent. The patient partakes of something which he imagines 
 disagrees with him ; or he gets a cold ; or both these occurrences 
 take place simultaneously ; he has, in short, what he denomi- 
 nates a severe bilious attack, accompanied by more or less of 
 fever, and inflammatory congestion of the thoracic and abdo- 
 
 * See page 149. 
 
160 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 minal viscera, or both, and the urine assumes the conditions 
 before mentioned, that is to say, it becomes scanty, turbid, and 
 serous. For the reasons stated, the gouty and indolent, who 
 live fully, are most subject to these attacks ; but in advanced 
 life, and in the strongly predisposed, they too often afflict 
 the abstemious and active. From the peculiar effects of cold, 
 it happens in general that these attacks are more frequent in 
 winter than in summer; hence many individuals often get 
 repeated attacks every winter, who pass the summer compara- 
 tively well ; and in such cases, as formerly stated, the urine, in 
 the earlier stages of the affection, is often free from albuminous 
 matter. Among other exciting causes of a general nature, one 
 of the most fi-equent is mental anxiety or grief ; or indeed any 
 sudden or great reverse of fortune, subverting the habits and 
 constitution altogether ; while among particular exciting causes, 
 the use of surgical instruments, arising from the necessity in- 
 duced by mechanical or other impediments about the urethra 
 or bladder, is, of all others, perhaps the most fi-equent. A long 
 list of other excitino- causes mio-ht be enumerated ; but those 
 mentioned amply illustrate the point in question ; and therefore 
 are quite sufficient for our present purpose. 
 
 Section i. Subsp. a and ^3. Var. 1 and 3. 
 
 Section ii. Subsp. y and I, Var. 5 and 7. 
 
 For the reasons formerly stated, we shall consider the diag- 
 nosis of the two great sections of renal affections distin- 
 guished by a serous condition of the urine in early and in ad- 
 vanced life ; as well as the two subspecies into which we have 
 divided each of these sections, under one general head. We 
 commence with a few remarks on the phenomena presented by 
 the blood in these affections ; phenomena which not only 
 afford a striking means of diagnosis ; but throw no inconsider- 
 able light on the properties of the urine, as well as on the con- 
 stitutional symptoms above described. 
 
 As my own observations on the properties of the blood in 
 renal affections nearly agree with those of Dr. Christison, I 
 shall content myself with referring to his recent work on the 
 
SEROUS URINE. CHRONIC. 
 
 161 
 
 subject, for details ; my observations, therefore, will be chiefly 
 confined to the leading facts. In the earlier stages both of 
 anaemotrophy and hsemotrophy, neither the absolute nor rela- 
 tive proportions of the constituent principles of the blood seem 
 to be much affected ; while the last stages of both conditions of 
 the kidney, and particularly of anaemotrophy, appear to be cha- 
 racterised by anaemia, or a general deficiency of the sanguineous 
 principles. In the progress and different stages and conditions 
 of the affection, however, various circumstances conspire to alter 
 or disturb the relative proportions of the ingredients of the blood, 
 particularly when anaemotrophy exists. Of these disturbances, 
 the following are among the most remarkable : 
 
 Soon after the commencement of these affections, the albu- 
 minous (and perhaps the saline) portion of the blood is appa- 
 rently diminished in quantity — an observation first made by 
 Dr. Bostock during L)r. Bright's researches ; and confirmed by 
 Drs. Christison and Gregory. According to the same authori- 
 ties also, and the fact has been confirmed by others, urea at 
 this period of the affection exists in the blood in greater or 
 less proportions ; sometimes in remarkable quantity. At this 
 period also, the proportion of fibrine is usually increased, while 
 the proportion of the colouring matter, or haematosin, remains 
 nearly natural. These observations apply, it will be remem- 
 bered, to attacks of inflammatory excitement occurring in the 
 early stages of the affection. How far they are really appli- 
 cable to the quiescent conditions of the organs in the early 
 stages, I am unable to state ; but I strongly suspect that they 
 do not hold true; and that, in the quiescent state, neither the 
 albuminous matters of the blood are so much diminished, nor 
 the fibrinous portion so much increased, as above represented ; 
 and that such apparent diminution and increase are rather 
 referable to the inflamed, than to the mere degenerated, con- 
 dition of the kidney. 
 
 In the progress of the disease (particularly of anaemotrophy,) 
 the relative proportions of the different ingredients of the blood 
 seem to undergo some changes. In the first place, as the 
 
 M 
 
162 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 proportions of albuminous and saline matters diminish in the 
 urine, they apparently increase in the blood. The proportion 
 of fibrine varies, but for the most part is relatively (sometimes 
 absolutely) greater than natural in the middle stages ; but, in the 
 last stages, the proportion, under all circumstances, usually falls 
 short of the healthy standard. The proportion of hsematosin 
 in the blood seems to go on steadily decreasing as the degene- 
 rating process advances ; so that in the last stages, the quan- 
 tity of this ingredient is sometimes reduced to less than one 
 third of the healthy average proportion. These observations 
 apply, as before, to the inflamed state of the kidneys more 
 especially ; and it is probable, as above remarked, that, in the 
 quiescent state of these organs, the whole of the sanguineous 
 ingredients are nearly equally diminished : for, as Dr. Christi- 
 son observes, the blood in the last stages of these complaints, 
 on coagulating, forms a diminutive clot, scarcely constituting 
 a fourth part of the whole weight of the blood ; even when 
 the buffy coat, the result of reaction, is entirely absent. 
 
 The conditions of the blood in hsemotrophy of the kidneys 
 have not been so carefully noticed as those above mentioned in 
 anaemotrophy. As far as my own observations extend, I should 
 say that hyperaemia, rather than anaemia, exists in haemo- 
 trophy of the kidneys ; certainly at least in the earlier stages 
 of the affection. In the latter stages, when, as we have said, 
 haemotrophy sometimes gradually gives way to anaemotrophy, 
 it is probable that the blood undergoes corresponding changes ; 
 and that ultimately anaemia takes the place of hyperaemia. 
 
 Such are the most remarkable phenomena hitherto noticed 
 with respect to the constituent principles of the blood in these 
 affections — phenomena which show most evidently that the 
 affections of the kidney do not constitute the whole disease ; but 
 that, in fact, the disease lies much deeper in the system, and in- 
 volves more or less the whole of the great assimilating pro- 
 cesses. The phenomena presented by the blood, moreover, are 
 in strict accordance with the phenomena presented by the urine ; 
 that is to say, in the last stages of the disease, the deficient 
 
SEROUS URINE. CHRONIC. 
 
 163 
 
 principles in the urine correspond with, or depend on, the 
 deficient principles in the blood from which the urine is formed. 
 Further, the diseased state of the kidneys in anaemotrophy en- 
 ables us to explain the presence of urea in the blood, and of 
 albumen in the urine ; as well as the general absence of the 
 lithate of ammonia, and of the other definite principles of 
 the urine ; while the supposition that, in the earlier stages of 
 hsemotrophy, the function of the kidneys is partly suspended, 
 but not totally destroyed, offers a plausible explanation of the 
 mixture of the alkaline lithates with the unchanged albumi- 
 nous principles in that secretion. Lastly, the deficiency of 
 fibrine and of hgematosin in the blood sufficiently explains the 
 debility, general paleness, and emaciation which characterise the 
 latter stages of anaemotrophy ; while the greater abundance, 
 or even excess, of these principles in the opposite form of the 
 disease, elucidate many of the phenomena of haemotrophy. 
 Those who feel an interest in these observations, and reflect 
 on them, will be readily enabled to carry the diagnostic differ- 
 ences and explanations connected with the properties of the 
 blood, further ; and indeed to illustrate by their means, many 
 of the minute details of the phenomena presented by the 
 urine. 
 
 We come now to make a few brief remarks, chiefly by way 
 of recapitulation, on the diagnostic differences presented by 
 other circumstances, and particularly by serous urine, in the 
 different forms of nephritic affection accompanied by that pe- 
 culiarity. 
 
 The disposition to anaemotrophy in early life, and to haemo- 
 trophy in middle and the subsequent periods of life ; and conse- 
 quently the disposition to the diseases connected with these pecu- 
 liar conditions of the system, furnish us with general diagnostic 
 distinctions, of so striking a character, that we have made them 
 the basis of our arrangement of these affections. Now most 
 intimately connected with these conditions of the system are, 
 as we have stated, the properties and characters of the urine. 
 We shall not enter into details, but merely remind the 
 
 M 2 
 
164 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 reader, that in the ansemotrophy of early life, the urine 
 and its sediments are usually pale-coloured, and present a 
 peculiar crudity of texture and aspect, which, to those who 
 have been accustomed to observe on the point, are quite suffi- 
 cient to distinguish them ; while, on the contrary, the urine 
 and sediments connected with haemotrophy are usually deep- 
 coloured, and more decidedly marked. The quantity of the 
 urine, as well as its specific gravity, will frequently present a 
 striking contrast; the quantity being capricious, but on the whole 
 generally abundant, and the specific gravity, of low average 
 in ansemotrophy ; while, in haemotrophy, the quantity is more 
 uniform, generally below the average ; and the specific gravity 
 is higher. When the serous character has been once established 
 in ansemotrophy, it is seldom entirely absent ; even in the earlier 
 stages of degeneration ; and if for a short time it disappears, it 
 is reproduced by the slightest causes. On the contrary, the 
 serous urine of hsemotrophy is often transient only, and in the 
 earlier stages, under favourable circumstances, sometimes dis- 
 appears for many months together. Again, among the consti- 
 tutional symptoms, the dyspepsia of ansemotrophy is generally 
 distinguished by troublesome stomachic derangements ; while 
 the dyspepsia of hsemotrophy is more frequently connected 
 with a congested state of the hepatic system, and of the abdo- 
 minal viscera in general. Even the dropsies so frequently 
 attending the two different forms of disease present to the 
 observant eye many strong points of contrast ; the anasarca, 
 for instance, of ansemotrophy is frequently cold and passive ; 
 while the anasarca of hsemotrophy, particularly in the earlier 
 stages, is often associated with activity ; and the swelling is 
 tender to the touch. In the more advanced stages of the 
 diseases, the dropsies of hsemotrophy seem to take place earlier 
 and more frequently in the great cavities, particularly of the 
 chest and abdomen, than the dropsies of ansemotrophy ; which 
 for a long period are often almost entirely confined to the ana- 
 sarcous form of the disease. In ansemotrophy of the kidney, se- 
 rous effusion is the most frequent cerebral disorder ; while in 
 
SEROUS URINE. CHRONIC. 
 
 165 
 
 hgemotropliy there is greater tendency to sanguineous apoplexy. 
 The list of diagnostic marks between these two great sections 
 of disease might be easily extended ; but the above are suffi- 
 cient to illustrate the subject. To enter into the diagnostic 
 characteristics of the minor symptoms, would carry us far be- 
 yond our design, and, after all, serve no useful purpose ; for 
 those who wish to become acquainted with these diseases, 
 must study them closely, and to such, trifling diagnostic dis- 
 tinctions will be superfluous ; while those who have not studied 
 these diseases would be only perplexed by minute details. 
 
 Section i. Subsp. a and /3. Var. 1 and 3.) 
 
 Section ii. Subsp. y and ^\ Var, 5 and 7./ '^^gnosis. 
 
 In illustration of the prognosis in these diseases, we shall, in 
 the first place, make a few remarks on the comparative fre- 
 quency of renal affections, accompanied by a serous condition 
 of the urine. 
 
 Of the comparative frequency of kidney diseases, and parti- 
 cularly of the forms now under consideration, it may be stated, 
 that, on a certain occasion, in Guy's Hospital, Dr. Bright 
 found one in eleven, and on another, one in six of the pa- 
 tients taken indiscriminately, with symptoms of kidney disease ; 
 while in Edinburgh the proportion seems to be still greater. 
 With respect to the comparative frequency of renal diseases 
 at different ages, Dr. B. states that of seventy-four cases, four 
 only occurred above the age of sixty ; thirteen above the age 
 of fifty ; fifty under the age of forty-five ; and nineteen under 
 the age of thirty. I have seen several instances under puberty, 
 and in extreme old age ; and others have noticed the same oc- 
 currence. Many of the cases occurring before puberty seemed 
 to have resulted from scarlatina ; while the cases occurring in 
 extreme old age have been generally associated with prostate and 
 bladder disease. In adolescent and middle age, at least three- 
 fourths (in Edinburgh, according to Dr. Christison, four-fifths) 
 of the whole number of cases are caused by the abuse of ardent 
 spirits. Kidney diseases attack both sexes ; but are more 
 frequent in males than in females; probably because males 
 
166 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 are more liable to be subjected to the exciting causes. These 
 observations, it will be understood, more especially apply to 
 the lower classes in large towns ; who usually constitute the 
 most frequent inmates of public hospitals. Among the middle 
 and higher circles, the proportions are probably different ; and 
 among ale and wine drinkers in particular, the relative pro- 
 portion of cases is probably greater in middle and advanced 
 life ; that is to say, in such individuals the diseases connected 
 with hsemotrophy probably exceed those connected with anse- 
 motrophy. It may however, be observed, that as a habit of 
 drinking too often increases with age ; and as the longer it is 
 indulged, the stronger is the stimulus required to produce 
 the same effect ; many individuals who in early life had been 
 satisfied with weaker potations, resort to the stronger ones 
 as they grow older ; and on this principle we may probably 
 account for the late development, in many instances, of the 
 granulated form of renal affection ; which as we have stated, 
 may be thus even superinduced on a previously heemotrophied 
 organ, and thus form a mixed kind of disease. In such in- 
 stances, the hsemotrophied kidney may finally become ange- 
 motrophied ; but it is exceedingly improbable that the converse 
 change should take place, viz. that the ansemotrophied kidney 
 should ever become hsemotrophied. Moreover, when ansemo- 
 trophy of the kidney is once fairly established in early life, 
 especially by the abuse of ardent spirits, the individual rarely 
 survives the middle age ; so that there is no time for a hse- 
 motrophied condition of the kidney to be developed from the 
 opposite condition ; even if it were possible to suppose such a 
 change to take place. But although the general prognosis in 
 renal diseases be thus unfavourable, particularly when con- 
 nected with ansemotrophy ; it is not to be considered that they 
 are, under all circumstances, absolutely and necessarily fatal. 
 We come now, therefore, to take a short view of those symp- 
 toms which may be considered as more especially favourable, or 
 unfavourable. On this subject, as the following remarks will 
 show, our views nearly coincide with those of Dr. Christison. 
 
SEROUS URINE. CHRONIC. 
 
 167 
 
 First, as regards the properties of the Uood. When the posi- 
 tive, as well as the relative proportions of the ingredients of the 
 blood are not materially changed ; or when they are no further 
 changed than what results from the inflammatory condition of 
 that fluid ; an early stage of the affection, controllable by appro- 
 priate means, is usually indicated. On the contrary, when the 
 proportion of colouring matter is deficient, and its deficiency 
 cannot be referred to previous depletion ; and when all the in- 
 gredients of the blood, in short, are much below the standard 
 of health ; an advanced and generally irremediable state of 
 ansemotrophy is denoted. 
 
 Secondly, as regards the urine. Among the favourable 
 symptoms indicating a generally controllable state of disease, 
 as well as of its concomitant affections, may be mentioned the 
 high specific gravity ; the deep colour ; the moderate or rather 
 diminished quantity ; the abundance of albuminous matter ; and 
 presence of lithate of ammonia ; all of which, particularly if 
 they co-exist, denote in most instances an incipient stage of 
 disease, (both as regards an8emotrophy and hsemotrophy,) con- 
 trollable by means to be presently stated. Even when the 
 urine is of moderate specific gravity and pale-coloured ; pro- 
 vided the quantity equals or surpasses the average, the progno- 
 sis is not very unfavourable. On the contrary, when the specific 
 gravity of the urine is low (below TO 10); when its colour at the 
 same time is pale ; and its quantity limited ; when the albumi- 
 nous matter, in common with the other urinary ingredients, is 
 very scanty ; and the lithate of ammonia in particular, is entirely 
 absent ; an advanced state of ansemotrophy of the kidney is 
 usually denoted ; from which complete recovery is impossible. 
 
 Thirdly, as regards the concomitant diseases, much depends 
 upon the stage of the kidney affection. In the early stages, 
 many of the concomitant diseases partake of an inflammatory 
 character, and are thus controllable by the usual means ; such 
 are inflammation of the serous membranes, inflammatory 
 dropsy, &;c. The dyspeptic, rheumatic, and gouty symptoms, 
 also occasionally occurring at this early period of the affection, 
 
168 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 though frequently of an obstinate character, are usually capable 
 of mitigation. On the contrary, in the advanced stages of these 
 affections, the same diseases, when accompanied, as is often the 
 case, with organic lesions of the liver, heart, &c., become abso- 
 lutely unmanageable ; while colliquative diarrhoea, and coma, 
 when fully established, prove inevitably and speedily fatal. 
 
 Finally, with reference to the general question, — how far dis- 
 eases of the kidneys are entirely removable ; or, if not remov- 
 able, how far they are compatible with life ; we may remark — 
 
 First, as to their removal. — We have stated that in the very 
 early stages, the disorder appears to be chiefly functional, and 
 therefore removable. Indeed, if any thing can be inferred from 
 the mere condition of the urine, as far as the presence of albumi- 
 nous matters is concerned, even the more advanced stages of 
 the affection are occasionally so far removed or superseded as 
 to be hardly distinguishable by the urine ; or to be inconveni- 
 ently felt by the patient. As instances, the condition of the 
 organs usually resulting from early hgemotrophy, or from scar- 
 latina, may be adduced ; after which, the urine is often found 
 quite free from albuminous matter. Such a state of recovery we 
 may consider, with Dr. Christison, to be analogous to a state of 
 recovery from inflammation of the lungs or other organs — a state 
 of recovery so far perfect as regards immediate symptoms ; and 
 becoming so much further corroborated by time, as to give 
 little inconvenience to the patient ; though it may leave him, on 
 the whole, perhaps throughout the remainder of his life, more 
 predisposed to similar attacks, than those who had not pre- 
 viously experienced them. 
 
 Secondly, as to the compatibility of renal diseases with life. 
 The great risk in renal diseases, throughout all the stages, arises 
 from a disposition to take on inflammatory action. In the 
 early stages, as above stated, these inflammatory attacks, if 
 promptly met, are usually subduable ; while, in the latter stages, 
 they too often prove fatal, in spite of all we can do to arrest them. 
 Now, as the chief exciting causes to inflammatory action in 
 renal affections are exposure to cold ; intemperance, particu- 
 
SEROUS URINE. CHRONIC. 169 
 
 larly in the use of ardent spirits ; mental excitement ; severe 
 bodily exertion, &;c. ; the chance of life, in these affections, 
 very much depends on the peculiar circumstances in which 
 individuals labouring under them are placed ; and on their 
 habits, occupations, &c. ; and if these be all favourable, I am 
 decidedly of opinion that a very large proportion of those who 
 labour under renal affections, may live for many years, and 
 enjoy tolerable health — indeed better health and more comfort 
 than are compatible with many other chronic and incurable 
 diseases. This remark applies more especially to affections 
 connected with haemotrophy, and to certain forms of strumous 
 disease ; in some of which it is often remarkable how long life 
 is protracted under conditions that one would almost conceive 
 to be impossible. Thus I knew an instance of a gentleman, 
 who, before the age of twenty, laboured under distinct symp- 
 toms of an abscess in the kidney ; who lived to the age of 
 seventy ; and who almost daily, throughout that long period, 
 passed more or less of purulent matter in the urine. His ap- 
 pearance and state of health were never robust ; yet he enjoyed 
 tolerable health and comfort ; and only felt greater annoyance 
 than usual, when the purulent matter, as it would occasionally 
 do, almost disappeared from the urine. On such occasions 
 the stomach became deranged ; and he had an attack of fever- 
 ish excitement ; which usually terminated after a short time, 
 in the sudden discharge of an enormous quantity of pus with 
 the urine ; after which he speedily recovered his former state of 
 health. Such attacks were usually brought on by exposure to 
 cold, or by inattention to the state of the bowels, diet, &c. ; 
 and he finally sank under an unusually severe attack of this 
 kind."^ Similar remarks have been made by other writers, as 
 for instance by Dr. Baillie ; and indeed it is well understood 
 that one kidney, like one eye or other duplicate organ, may be 
 entirely obliterated ; while the other is quite sufficient to carry 
 
 * It is remarkable that dropsy rarely appears under this form of dis- 
 ease ; the gentleman alluded to in the text, even to the last, never suffered 
 from oedema. 
 
170 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 on the functions of life. On the other hand, in diseases of the 
 kidneys, connected with anaemotrophy, when the patient is 
 placed in unfavourable circumstances ; when he persists in his 
 intemperate habits; and, from the nature of his occupation, 
 is exposed to cold and moisture, &c. ; the chance of a pro- 
 tracted existence is very trifling ; indeed, as already stated, 
 such individuals seldom survive the age of forty, and they 
 often die much earlier. Some further remarks on the prognos- 
 tics indicated by certain symptoms, will be more conveniently 
 considered, when we speak of the effects of inflammatory at- 
 tacks upon the kidneys in a state of disease. 
 
 Section i. Subsp. a and fi. Var. 1 and 3. 
 
 Section ii. Subsp. y and ^. Var, 5 and 7. 
 
 The treatment of incipient nephritic degeneration in its 
 comparatively chronic and quiescent condition, will vary con- 
 siderably according to the age and circumstances of the pa- 
 tient. In early life, the complaint, as we have stated, often 
 assumes more or less of the characters of dyspepsia, as well as 
 of derangement of the urinary system, and the practice must 
 be directed accordingly. The symptoms of dyspepsia are so 
 varied and numerous, that it is impossible to lay down rules 
 with respect to them all. The practitioner, however, will find, 
 w^hatever his experience in the treatment of dyspeptic affectiohs 
 may be, that in cases of the present description, the dyspeptic 
 symptoms are infinitely more obstinate than usual ; and that very 
 often, whether he considers the dyspepsia as the cause or effect 
 of the concomitant urinary derangements, he will be equally 
 unsuccessful in the treatment of both. The three great points 
 to be constantly borne in mind in the management of these 
 cases are, — attention to diet and regimen ; the guarding against 
 the influence of cold and moisture ; and the avoiding all vio- 
 lent remedies. With respect to diet and regimen, it may be 
 observed generally, that the diet should be light and nutritious, 
 and free from stimulating matters ; the purest water should be 
 selected for use ; and of fermented liquors, the less there is 
 taken the better ; though much will depend on this point 
 
 I Treatment. 
 
SEROUS URINE. CHRONIC. 
 
 171 
 
 on the previous habits of the patient. The clothing should 
 be warm, and consist of flannel next the skin throughout 
 the year ; and during the winter and spring months, the 
 addition of leather will, in many instances, be useful. The 
 exercise should be moderate, and short of fatigue ; and if the 
 patient's circumstances admit, easy travelling both by sea and 
 land, warm sea-bathing, (fee, may be often recommended with 
 advantage. By violent remedies, I mean more especially the 
 abuse of mercury, and of stimulating articles ; such as copaiba, 
 cubebs, turpentine, &;c., all of which, when injudiciously ad- 
 ministered in exciting doses and in excited habits, are capable of 
 doing infinite mischief. Indeed, I believe a large number of 
 the cases of kidney disease in early and middle life, among the 
 higher classes, are often referable, in no small degree, to the 
 abuse of these remedies. 
 
 In the treatment of kidney diseases in early life, it will be 
 sometimes proper, at the outset, to abstract blood by leeches or 
 cupping from the loins or perinaeum in small quantity ; and 
 if the hepatic system be congested, to administer mild but effi- 
 cient purgatives and alteratives. Of purgatives, perhaps the 
 best is castor oil, if the stomach will tolerate it ; the simple ex- 
 tract of colocynth, conjoined with some aromatic, as the oil of 
 aniseed, &;c., often suits well. Rhubarb is apt to irritate from 
 its getting into the urine ; but if it does not irritate, it is in 
 other respects well suited as an aperient. The symptoms more 
 immediately connected with the stomach, are acidity, flatu- 
 lence, and nausea, which often, in various degrees, co-exist or 
 alternate. One of the best remedies for all these symptoms is 
 hydrocyanic acid, either alone or associated with small doses 
 of the fixed alkalies ; to ensure their good effect, however, the 
 alkalies must be carefully and judiciously administered ; other- 
 wise they do more harm than good. Some of the lighter bit- 
 ters and tonics, such as the infus. humuli or infus. cinclionce, 
 prepared with cold distilled water, are occasionally beneficial. 
 When the kidneys and bladder are more than usually irritable, 
 as is sometimes the case, the uva ursi conjoined with hyos- 
 
172 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 cyamus, hop, &c., is often useful ; particularly after the other 
 symptoms have been attended to and removed as far as possible. 
 The same may be said of the diosma and pareira hrava, either 
 alone or conjoined with acids, &;c., as the properties of the 
 urine may indicate. In this particular state and form of the 
 disease, however, I doubt if any remedy surpasses the uva 
 ursi when judiciously directed. 
 
 The treatment of incipient nephritic degeneration, and its 
 usual accompaniments as they occur in advanced life, requires, 
 of course, to be varied according to the degree of the disease 
 and the organs more immediately affected. In the acute forms 
 of the affection, when the urine and its sediments are extremely 
 high coloured, and the hepatic system obviously involved in 
 the aflection ; when, also, there is a tendency to apoplexy, and 
 existing or threatened effusion into the cavities of the chest, 
 peritonaeum, &:c., blood-letting, general or local, or both, as the 
 case may indicate, will be frequently proper at the outset, with 
 which may be conjoined the judicious use of mercurials, and 
 the more active diuretics ; and the patient must, at any rate, 
 and by almost any means, be saved from the imminent danger 
 awaiting him. In the milder forms of the disease, however, 
 when the urine is less scanty, and the sediments of a paler 
 colour, there is seldom much occasion for active mercurial 
 treatment. Indeed active mercurial treatment, as before ob- 
 served, is in a great many cases calculated to do positive mis- 
 chief ; and to confirm, if not to produce, nephritic disease, which, 
 under proper treatment, would have remained stationary at 
 least, or perhaps would never have existed. But while mercu- 
 rial treatment should be thus carefully avoided, there can be 
 no objection to the use of mild alterative doses of this remedy, 
 either alone, or if gouty irritation exists in the system, conjoined 
 with the acetous extract of colchicum, &;c. With these may be 
 associated mild purgatives, and the saline diuretics, such as the 
 supertartrate, citrate, or nitrate of potash, the spir. cetheris 
 nitric^ &;c. The diet of the patient should be light and mode- 
 rate; and when the more active symptoms have abated, the 
 
SEROUS URINE. CHRONIC. 
 
 173 
 
 diuretic effects of the remedies may be occasionally assisted by 
 the use of the effervescing waters ; to which may be added, if 
 the patient has been accustomed to wine or spirits, a little sound 
 sherry or hock ; or a little hollands, if preferred. This plan 
 must be pursued as long as it may appear necessary, or until 
 the urine has acquired its natural appearance and transparency ; 
 and when this has taken place, it will be often found on ex- 
 amination, as above stated, that in a great many of the more 
 favourable cases the urine has entirely lost its albuminous 
 character ; so as to lead to the conclusion that formidable dis- 
 ease of the kidney has never existed. 
 
 Nearly the same observations are applicable to the confirmed 
 and advanced stages of renal affections accompanied by serous 
 urine. The diet and regimen, in particular, must be still more 
 rigidly and carefully attended to, and all the barbarous crudi- 
 ties which a vitiated appetite or depraved taste has introduced 
 into modern cookery, should, without exception, be avoided ; 
 for whatever affects the stomach, which in most instances is 
 exceedingly liable to be affected by slight causes, is sure to ex- 
 ert an unfavourable influence on the urinary organs. It is im- 
 possible to lay down rules which shall be universally applicable, 
 but if the patient confines himself to mutton, poultry, and 
 some of the lighter kinds of fish, among animal matters ; and to 
 farinaceous substances, such as bread, rice, sago, &c., together 
 with the occasional use of the lighter herbaceous or legumi- 
 nous substances, he can scarcely go wrong. In most cases, 
 also, it will be proper to abstain from sugar. With respect to 
 drinks, in addition to what has been above stated, we may 
 observe, that though fermented liquors of all sorts had better 
 be shunned, yet cases will occasionally occur in which it will 
 be proper to break through this rule ; for as the greater num- 
 ber of individuals affected by the ansemotrophied forms of 
 disease more especially, have brought on, or at least aggra- 
 vated their complaints, by the excessive use of fermented 
 liquors, it may not be prudent, or perhaps possible, in all in- 
 stances to abstract fermented liquors entirely, and at once ; 
 
174 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 and hence it may be necessary, in some instances, to continue 
 their use for a time, and diminish the quantity taken by de- 
 grees. In such cases, those fermented liquors which have a 
 tendency to keep up a moderate flow of urine, will in general 
 be found most useful. 
 
 In the confirmed and advanced stages, the exercise must be 
 moderate, and always short of excessive fatigue ; and per- 
 haps, on the whole, gentle walking exercise is the best. 
 Hough riding, either on horseback or in carriages, appears to 
 aggravate the symptoms ; and is apt either to cause bloody 
 urine ; or in some instances to produce a tendency to urinary 
 suppression. Sailing, when it does not produce too great and 
 long-continued sickness, which it is sometimes apt to do in 
 these affections, is also particularly desirable. All violent ex- 
 ertions, particularly calling the dorsal or lumbar muscles into 
 play, such as lifting heavy weights, &;c., should be avoided. 
 The effects of cold should be more than ever guarded against 
 by warm clothing ; and the getting of wet feet, or the expo- 
 sure in any way of the lower extremities or back to the 
 effects of cold or moisture, is particularly dangerous. Hence, 
 whenever the circumstances of the patient admit, he should 
 be recommended to migrate during the winter months to a 
 warmer climate. 
 
 In addition to what has been stated respecting the treatment 
 of renal affections in their incipient state, the following obser- 
 vations may be made respecting the medical treatment of them 
 in their confirmed and later stages. One of the first points 
 to be attended to, is the regulation of the bowels ; and for 
 this purpose, as formerly stated, castor oil is better adapted 
 than most other expedients. When castor oil disagrees, in ad- 
 dition to the remedies formerly suggested, we may recommend 
 the extract of colocynth combined with the extract of hen- 
 bane, as advised by Dr. Christison — a combination long in 
 use here, and often very effective. Mercurial remedies, for the 
 reasons we have already so frequently alluded to, are seldom 
 required or proper in the variety of complaints attended by 
 
SEROUS URINE. CHRONIC. 
 
 175 
 
 ansemotrophy, now more particularly occupying our attention. 
 When their use appears to be absolutely indicated, they must 
 be employed with great caution, as a most troublesome ptya- 
 lism is apt to be speedily induced by mercury, even in small 
 doses, in these affections ; while the affections themselves are 
 commonly much aggravated by its use. A class of remedies 
 which has been much recommended in the confirmed and 
 chronic forms of the affections, is diaphoretics ; the steady use of 
 some of which is often beneficial, provided their action be at 
 the same time directed to the kidneys ; or at least be not calcu- 
 lated to unduly suppress the action of these organs. One of 
 the best I know is the citrate of ammonia; which may be 
 variously associated, either with ipecacuanha and the syrup of 
 poppies ; or with Dover's powder ; the extract of sarsaparilla, 
 Sec. I have also found the infus. diosmce with sarsaparilla 
 useful, when steadily employed. Urgent vomiting is best 
 allayed by the hydrocyanic acid, or creasote. Much benefit is 
 sometimes derived from the establishment of an issue or seton 
 over the region of the kidneys — not, perhaps, of a curative kind, 
 but the external inflammatory action has seemed to act as a 
 divertisement to the internal; and the tendency to mischief 
 in the kidneys has, in consequence, been not only much dimi- 
 nished, but the attacks, when they have occurred, have been less 
 severe : in short, the complaint for the time has appeared to 
 be arrested in its progress. When the issue or seton has 
 reduced the tendency to inflammatory excitement, remedies of 
 a more decidedly tonic or astringent character may be some- 
 times employed with advantage ; such are the uva ursi, the 
 pareira brava, and even some of the milder preparations of 
 iron; particularly if conjoined with henbane orconium; but 
 their use requires caution, and they must be immediately dis- 
 continued if they cause excitement. 
 
 In the early stages of chronic hsemotrophy of the kidneys, 
 the treatment required is almost always more or less of the 
 depletory or antiphlogistic kind. Occasional cupping over the 
 loins ; the keeping of the bowels freely open ; the use of the 
 
176 PATHOLOGY OF ALBUMINOUS ASSIMILATIOX AND SECRETIOV. 
 
 alkalies ; or neutral saline compounds with vegetable acids, as 
 the citrate or tartrate of potash, will be beneficial. If the 
 urine be scanty, the spiritus cetheris nitrici may be added to the 
 saline mixture. If hepatic or gouty congestion prevails, altera- 
 tive doses of mercurials, either alone or combined with purga- 
 tives, or with the acetous extract of colchicum, may be given at 
 short intervals ; so as to meet, or to keep under such symptoms, 
 when threatening, or actually present. Hence, in this form 
 of disease, it will always be proper to pay strict attention to 
 the quantity and quality of the urinary secretion, by which 
 means a coming attack can be often anticipated, and sometimes 
 warded off, by cupping, appropriate purgatives, and other means 
 calculated to obviate local congestion. In the intervals of ap- 
 parently perfect health, which often exist in the earlier stages 
 of this form of disease, especially during the summer months, 
 little medical treatment of any kind, except gentle purgatives, 
 when requisite, will be necessary : and the patient will have 
 scarcely more to attend to, than the prophylactic means above 
 described. In the more advanced stages of diseases connected 
 with haemotrophy, in which the symptoms usually approximate 
 more or less nearly to those connected with anaemotrophy, the 
 23lan of treatment will be of a mixed character, and more nearly 
 resemble that laid down above, as adapted for this form of 
 affection. 
 
 With respect to remedies calculated to remove renal affec- 
 tions altogether, I know of none. Even obstinate functional 
 disorders, depending on lesions of the nervous system imper- 
 ceptible by our senses, too often resist all our attempts to re- 
 move them ; how then can we hope to remove diseases de- 
 pending on obvious destruction of the organs ? 
 
 Finally, in the treatment of renal affections in general, we 
 cannot do better than remind the reader of the maxim often 
 mentioned in these pages, and which should be constantly 
 kept in view ; viz. that in all the forms and stages of renal 
 affections, and particularly in the advanced stages, it is much 
 easier to do mischief than to do good ; and that the great prin- 
 
SEROUS URINE. CHRONIC. 
 
 177 
 
 ciples to be kept in view are, to prevent evil as much as pos- 
 sible on the one hand ; and on the other, to meet promptly 
 symptoms as they arise, particularly when of an inflammatory 
 character. 
 
 Species h. | ^ection i. | Kidney inflamed. 
 ^ ( Section ii. J 
 
 We have already pointed out the importance of considering 
 separately those attacks of an inflammatory kind, to which all 
 organic affections of the kidney are liable, and which in fact 
 constitutes one of their most dangerous features. At the 
 same time, however, it must be noticed that these inflamma- 
 tory attacks are so insidious in their approach, and differ by 
 such imperceptible grades in their early stages from the 
 common quiescent conditions of the organs, that it is difficult, 
 in many instances, to say where one ends and the other 
 begins. Hence, for the sake of distinctness, and to avoid 
 repetition, I have thought it proper, in describing these inflam- 
 matory attacks, to adopt a different plan of arrangement, and 
 to speak of the whole in connexion. Moreover, as the inflam- 
 matory attacks upon the haemotrophied kidney are the most 
 strongly marked, I have reversed the order followed in speak- 
 ing of these diseases in their chronic forms ; and commenced 
 with inflammation of the haemotrophied organ. 
 
 The leading changes in the properties of the urine induced by 
 an inflammatory attack, may be thus briefly stated. In inflam- 
 matory attacks of almost every form of diseased kidney, one of 
 the first observable symptoms, as far as the urine is concerned, 
 is a diminution in its quantity ; accompanied, of course, by a 
 corresponding deepening of its colour, and an increase in its 
 specific gravity. These changes are usually most remarkable 
 in inflammation of the haemotrophied kidney ; in the early 
 stages of which, the urine is often much diminished in quan- 
 tity, of a deep brown or red colour, and is not only loaded with 
 albuminous matter, but usually, on cooling, deposits large 
 quantities of the lateritious lithates. In this stage of the affec- 
 tion also, blood occasionally makes its appearance in the excre- 
 
 N 
 
178 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 tion. As the inflammatory action proceeds, the urine still re- 
 mains, or even becomes more, scanty ; though its colour and 
 specific gravity do not always increase in the same proportion ; 
 and in the latter stages, purulent matter is occasionally present. 
 Immediately preceding dissolution, when the affection cannot 
 be arrested, the secretion of urine sometimes ceases almost en- 
 tirely. Analogous phenomena, though of a much less marked 
 kind, are usually presented by the urine in the ansemotrophied 
 conditions of the kidneys. The quantity, which is usually 
 much more copious than in the hsemotrophied form of dis- 
 ease, becomes more or less diminished at the commencement 
 of the inflammatory attack ; the turbidity and colour, also, are 
 sometimes increased ; but the lithate of ammonia is rarely, if 
 ever, present. In the latter stages, the quantity usually be- 
 comes further diminished ; and blood, mixed with mucous and 
 purulent matters, sometimes make their appearance. In the 
 very last stages, when vomiting, diarrhoea, and coma usually 
 supervene, the secretion of urine as before, is nearly sus- 
 pended altogether. Another property of the urine which 
 sometimes undergoes remarkable changes during inflammatory 
 attacks, is its acidity. Iii the early stages of hsemotrophy, when 
 inflammation supervenes, the urine often becomes preterna- 
 turally acid ; and even in the anaemotrophied forms of the 
 disease, and in cases in which the urine is neutral or alkales- 
 cent, it will occasionally, under acute attacks, assume an acid 
 character. 
 
 When there is abscess in the kidney, particularly of the 
 strumous or chronic kind, the purulent matter almost con- 
 stantly present, sometimes disappears during the earlier and 
 acute stages ; but towards the termination, after the excite- 
 ment has given way, the purulent matter is often discharged 
 in greatly increased quantity, to the apparent relief of the 
 patient. In such cases, probably, either the pus has not 
 been secreted ; or having been secreted, it has not been able 
 to escape by its usual exit, on account of the increased swell- 
 ing, &c., produced by the inflammatory attack. Such is a 
 
SEROUS URINE. CHRONIC. 
 
 179 
 
 brief account of the chief variations which the urine undergoes 
 during acute attacks of inflammation supervening on diseased 
 kidneys. There are many other modifications of these and 
 other symptoms, incidental to different constitutions and forms 
 of disease, which we cannot here notice ; but which those who 
 are conversant with the subject will, no doubt, easily recog- 
 nise. We proceed, therefore, to consider the effects arising 
 from inflammatory action on previously existing disease in 
 the kidneys. 
 
 State of the Kidneys. — As by far the greater proportion of 
 kidney diseases prove immediately fatal by the supervention of 
 inflammatory action on their degenerated structure, the appear- 
 ances described by authors as occurring after death, present, 
 in general, faithful pictures of the phenomena now under con- 
 sideration. Under these circumstances, it will not be necessary 
 for me to enter into details ; and I shall content myself with 
 referring for such details to the works of Dr. Bright, and 
 more especially to the Atlas of Mr. Rayer on diseases of the 
 kidney ; where everything that has been observed will be found 
 delineated. The following general remarks, therefore, are all 
 I shall offer on this part of the inquiry. 
 
 The appearances produced by inflammatory action on the 
 haemotrophied and ansemotrophied diseases of the kidney, are 
 liable to modifications, the most remarkable of which may be 
 thus summarily stated : 
 
 The effects of inflammation on the haemotrophied kidney 
 are usually displayed by enlargement and engorgement of the 
 structure of the organ, which exhibits, both externally and in- 
 ternally, a dark red or brown colour ; sometimes general ; at 
 other times in patches ; occasionally in small spots only ; and 
 when a section is made of the kidney, blood usually flows from 
 it freely, on gentle pressure. If the patient has survived to a 
 more advanced stage of the disease, there may be generally 
 seen purulent depositions of all sizes, from that of a pin's head, 
 to that of a pea, or larger. These are more especially distri- 
 buted through the cortical part of the organ ; and are usually sur- 
 
 n2 
 
180 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 rounded by a highly injected vascular structure. These puru- 
 lent deposites are often visible on the surface of the organ, and 
 in some instances they may be traced down from the surface, 
 between the natural structure of the kidney, so as to give it the 
 appearance of being infiltrated with pus ; and the parts thus in- 
 filtrated are usually softer than the other portions of the organ. 
 Other effects of inflammation on the haemotrophied kidneys, 
 more especially of the chronic, gouty, or rheumatic kinds, are 
 the various forms of urinary deposites, e. g., the lithic acid, the 
 oxalate, carbonate, and phosphate of lime ; the triple phosphate 
 of magnesia and ammonia, &c. ; certain forms of all which, but 
 more especially of the lithic acid, are deposited in the natural 
 cavities of the kidneys, during the presence of a peculiar action, 
 which, for want of a better name, we must call inflammatory. 
 Most usually these concretions, as we have before stated, are de- 
 posited in the natural cavities of the kidney, from whence they 
 make their escape ; but occasionally they are retained, and by 
 gradually increasing in bulk, at length cause the destruction 
 of the organ in a greater or less degree. 
 
 In the aneemotrophied forms of disease, the following are 
 some of the most remarkable effects of acute and chronic inflam- 
 mation. We formerly stated, that in this condition of the kid- 
 ney, on account of the deposition of foreign matter in the tex- 
 ture of the organ, its natural structure becomes more or less 
 obliterated ; hence, instead of the universal engorgement and 
 redness found after death from inflammation in the haemotro- 
 phied kidney, the angemotrophied organ is only partially en- 
 gorged and red ; that is to say, the obliterated portions of the 
 kidney retain more or less of their pale colour ; and thus give to 
 the external surface of the organ a marbled appearance, which 
 is often rendered the more remarkable by the rough tubercu- 
 lated or botryoidal inequalities formerly described. Similar 
 appearances, modified in a variety of ways, are presented by 
 sections of the kidney after fatal inflammation. The formation 
 of pus is less frequent, or rather less abundant, than in the 
 inflamed haemotrophied organ ; while the deposition of lithic or 
 
SEROUS URINE. CHRONIC. 
 
 181 
 
 calcareous deposits, as the results of chronic inflammation, is ex- 
 tremely rare, or altogether wanting. In the few instances in 
 which they do occur, they usually consist of the carbonate or 
 phosphate of lime. Gangrene is a rare termination of inflam- 
 mation of the kidney ; and its occurrence seems to be chiefly 
 limited to the haemotrophied forms of disease. 
 
 In inflammation of the haemotrophied kidney, the capsule of 
 the organs is usually vascular, but otherwise natural ; and in 
 general it may be very easily separated in its entire state from 
 the kidney. In inflammation of the ansemotrophied kidney, on 
 the contrary, the capsular membrane is often disorganized, 
 thickened, and more or less firmly adherent. 
 
 Constitutional Symptoms. — Inflammatory attacks of the kid- 
 neys, in all the forms and stages of degeneration, are usually 
 ushered in by the common symptoms of fever. These symp- 
 toms, however, are varied, in an infinite number of modes and 
 degrees, according to the constitution of the patient, and to the 
 original character of the renal affection. The symptoms are 
 usually most strongly marked in the haemotrophied kidney, 
 and may be thus sumniarily stated. After exposure to some of 
 the common exciting causes of inflammation, as cold, &c. ; and, 
 in bladder diseases, after the use of instruments, more especially 
 if incautiously employed, the patient experiences a shivering fit 
 more or less decidedly marked, which is soon followed by the 
 usual consequences, fever, pain in the back and head, restless- 
 ness, loss of appetite, &c. As these indications proceed, they be- 
 come associated with symptoms more especially denoting kidney 
 irritation, such as vomiting, hiccup, and various other forms of 
 gastric derangement ; also pain and uneasiness about the re- 
 gion of the kidneys, bladder, &c. There is in general, thirst; 
 and the tongue becomes furred, then red, and afterwards brown 
 and dry ; and while these changes are going on, which they do 
 sometimes very rapidly, the affection gradually assumes more 
 or less of the typhoid character ; diarrhoea supervenes ; the 
 urine becomes high coloured and scanty, and the patient dies 
 comatose. These symptoms vary considerably, as we have 
 
182 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 stated, according to the patient's age and strength, and accord- 
 ing to the stage of the renal disease ; the symptoms being usu- 
 ally less acute in the old and debilitated, who have long suf- 
 fered from urinary and bladder diseases ; than in the middle- 
 aged, in whom the constitution has not yet been materially im- 
 paired, and in whom the affection is in its incipient state. 
 
 The constitutional symptoms denoting increased action of an 
 inflammatory character in the ansemotrophied kidney, some- 
 what resemble the preceding, but are less decidedly defined, 
 and, moreover, are subject to considerable modifications. The 
 rigor, for instance, at the commencement, is commonly less 
 distinct, and the attack more frequently begins with obvious 
 derangement of the assimilating organs ; exhibited either in the 
 form of dyspepsia, hepatic congestion, or disordered state of the 
 bowels, or all these combined, or associated with others. In 
 this state of things, any little error of diet will often give occa- 
 sion to the attack, which is not unfrequently aggravated by 
 vomiting or diarrhoea, or occasionally by both. In some in- 
 stances, the urine, under the above circumstances, becomes more 
 scanty than usual, and the attack is ushered in by a drowsy 
 listlessness ; and, on account of the diminished quantity of urine 
 secreted, there is a temporary lulling of the ordinary bladder 
 irritation. In a variety of instances, particularly during the 
 winter months, the attacks commence with a common cold, 
 which is accompanied by a strong tendency to bronchitis 
 or pneumonia., In some instances, diarrhoea, in others, ana- 
 sarca, are among the first symptoms that attract the patient's 
 notice, and indicate increased disease in the kidneys ; in short, 
 any of the concomitant symptoms previously mentioned, as 
 well as many others depending on accidental causes, and the 
 peculiar circumstances of the patient's constitution, often deter- 
 mine both the kind and degree of the immediate attack, and 
 consequently the risk accompanying it ; as well as in a great 
 degree the principles of treatment. 
 
 With respect to the termination and consequences of inflam- 
 matory attacks of the degenerated kidney, not proving imme- 
 
SEROUS URINE. CHRONIC. 
 
 183 
 
 diately fatal, it may be noticed generally, in conclusion, that 
 they difter materially in the two forms of the affection now 
 under consideration, as well as in the same form, under the dif- 
 ferent modes of attack above alluded to. In the hsemotrophied 
 kidney, the attack is sometimes terminated by a discharge of 
 blood from the organ ; not unfrequently by a discharge of pus ; 
 occasionally by neither ; but in almost all instances it will be 
 found that after every attack the patient is left in a worse and 
 more susceptible state than before ; and that it is long before 
 he recovers his former condition, and frequently never. Simi- 
 lar remarks may be made respecting acute attacks of the ansemo- 
 trophied kidney. They are occasionally resolved by an attack 
 of haemorrhage ; or a discharge of pus ; but the patient, 
 is much more apt to get into a general cachectic state, ter- 
 minating in phthisis, or some of the chronic affections above 
 described. Irritable and diseased bladder is another very 
 frequent termination ; which, added to the constitutional de- 
 rangement, increases infinitely the distress of the patient, and 
 generally abridges his existence. 
 
 With respect to the causes of inflammatory attacks on the 
 degenerated kidney, as well as the diagnosis and jjrognosis, we 
 need not, after what has been stated, enter into details. We 
 shall, therefore, content ourselves with refering the reader to 
 what has been said on these subjects when treating of the dis- 
 ease in its quiescent state ;^ and proceed at once to make a few 
 remarks on the plan of treatment. 
 
 Section i. Subsp. a and /3, Var. 2 and 4. 
 Section ii. Subsp. y and o, Var. 6 and 8. 
 We need scarcely state that the principles, as well as many 
 of the details of the treatment to be pursued in inflammatory 
 attacks of the degenerated kidney, have, like those of the causes, 
 diagnosis, and prognosis, been already anticipated ; under these 
 circumstances, we shall principally confine ourselves to a reca- 
 pitulation of the leading facts. 
 
 Inflammatory attacks on the hsemotrophied kidney should 
 * See pp. 131, 159. 
 
 XTreatment. 
 
184 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 be promptly met at the very outset by active antiphlogistic 
 treatment. Few cases, perhaps, will require general blood- 
 letting, but almost all will be much benefited by local deple- 
 tion ; such as by free cupping or leeching over the loins, &c. 
 Blisters are doubtful remedies ; though if not kept on too long, 
 they may be sometimes useful ; but strong mustard poultices, or 
 other effective counter-stimulants, producing speedy and decided 
 effects, are preferable. Internally, active aperients may be 
 usually administered ; among which calomel and colchicum 
 may be included ; especially, as is often the case, if gouty 
 irritation be suspected or present. When the more active 
 symptoms have subsided, the purgatives may be associated with 
 diuretics ; or diuretics may be given alone, as the case may 
 appear to indicate. Of diuretics, the citrate, tartrate, or super- 
 tartrate of potash, conjoined with nitre and the spir, cetheris 
 nitrici, are among the best, and may constitute a part, at least, 
 of the prescription. When the urine has assumed its usual 
 quantity and properties, we may conclude in general that the 
 inflammatory attack has subsided; though the urine will be. 
 generally found to contain more or less serum for a considerable 
 time (sometimes always) subsequent to the attack ; particularly 
 after meals. The above remarks apply more immediately to 
 the earlier and acute attacks ; but a similar plan of treatment, 
 modified according to circumstances, is usually indicated 
 throughout all the stages of the affection. In the latter stages, 
 purgatives must be sometimes given with more caution ; but 
 diuretics are occasionally required to the last, to remove the 
 increased or sudden dropsical effusion, which frequently takes 
 place, either into the cellular membrane, or into the thoracic 
 or abdominal cavities, during subacute inflammatory action, 
 produced more especially by exposure to cold. 
 
 In the inflammatory attacks of the anaemotrophied kidney, 
 the symptoms, though of a still more formidable character than 
 those attending inflammation of the hsemotrophied kidney, are 
 seldom so acute ; that is, are seldom -of the high phlogistic cha- 
 racter of those exhibited by the haemotrophied kidney. Hence 
 
SEROUS URINE. RAYEr's CLASSIFICATION. 
 
 185 
 
 general depletion must be cautiously resorted to ; and local 
 blood-letting, by leeches or by cupping over the loins, if blood- 
 letting be at all indicated, will be safer than general depletion. 
 In inflammation of the anaemotrophied, as well indeed as of the 
 hsemotrophied kidney, the application of leeches to the peri- 
 ngeum and anus will be often found particularly useful ; and the 
 bleeding may be encouraged according to circumstances, by 
 applying a large warm poultice to the part. In the latter 
 stages of the affection, bleeding in every form is quite out of 
 the question ; and the symptoms, which are usually of a colli- 
 quative kind, must be combated as they arise, according to their 
 nature and degree. Diarrhoea is a frequent and formidable 
 symptom, and usually resists any attempt to abate it ; diarrhoea 
 sometimes precedes effusion on the brain and coma ; a tendency 
 to which the sudden checking of the diarrhoea, either spontane- 
 ously or by opiates, seems to promote. In short, the treatment 
 of the latter stages of inflammatory attacks, both of the hsemotro- 
 phiedand ansemotrophied kidney, when the more acute symptoms 
 -have abated, differs in no respect from the treatment of those 
 diseases in their chronic and quiescent forms, as before detailed. 
 
 It would be foreign to the objects of this volume to enter 
 minutely into the treatment of all the various secondary dis- 
 eases which we have enumerated as occasionally accompanying 
 renal affections ; the general principles of which treatment are 
 supposed to be well understood by every medical practitioner. 
 
 While these sheets were passing through the press, the 
 second volume of M. Eayer's Traite des Maladies des Reins 
 came into my hands. This volume is principally devoted to 
 the diseases we have been considering ; and which M. Eayer 
 
186 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 comprises under the general appellation of Nephrite Albumi- 
 neuse. He divides these diseases into the acute or febrile ; and 
 the chronic or non-febrile ; and relying chiefly on the appear- 
 ances found after death, further subdivides them into six va- 
 rieties ; two of vrhich varieties belong to the acute^ and four to 
 the chronic, forms of the affection. The following is his account 
 of these six varieties : 
 
 First Variety. (See M. Bayer's Atlas, pi. vi. fig. 1 ; and 
 pi. X. fig. 3.) The size of the kidneys is augmented ; in the 
 adult, the weight of one of the kidneys is increased to eight or 
 even twelve ounces, instead of four ounces the average weight. 
 Their consistence is firm without hardness ; somewhat resem- 
 bling that state of the organ which is produced by injecting it 
 with a watery fluid. Their surface, which is more or less unna- 
 turally red, appears studded over with a great number of little 
 points, of a deeper red than the general tint of the organs. On 
 making a section, the augmentation of volume is found to chiefly 
 depend on the distension of the cortical portion of the kidney, 
 which presents internally a great number of red points similar to 
 those which are observed on the surface of the organ. These red 
 points M. Rayer thinks to be the glandules of Malpighi, strongly 
 injected with, blood. The tubular structure of the kidney, com- 
 pressed between the tumified prolongations of the cortical struc- 
 ture which extend between the pyramids, is of a more ill- 
 defined red, and its striae are less apparent than in the healthy 
 state. Lastly, the mucous membrane, lining the calices and 
 pelvis of the organ, is more vascular than natural. This con- 
 dition of the kidney is considered as rare ; since death seldom 
 takes place till the affection is further advanced. 
 
 Second Variety. (See M. Rayer's Atlas, pi. vi. figs. 2 and 
 3 ; and pi. vii. fig. 5.) The size and weight of the organs, as 
 in the preceding variety, are augmented. The consistence is a 
 little less firm. The lobules are frequently more distinct than 
 in health; but the point that particularly distinguishes this 
 variety is a remarkable admixture of ansemia and hypersemia ; 
 a marbled aspect of the surface of the kidneys produced by red 
 
SEROUS URINE. RAYEr'S CLASSIFICATION. 
 
 187 
 
 spots disseminated over a ground of a whitish yellow tint. 
 When cut open, the cortical portion of the organ is found en- 
 larged, and of a pale yellow tint, spotted with red, which is 
 strongly contrasted with the tubular structure ; the colour of 
 this being of a decided reddish brown. 
 
 Third Variety. (See M. Eayer's Atlas, pi. vi. fig 4.) The 
 size of the kidneys is increased as before ; but the appearance 
 of the surface is neither spotted nor marbled. The cortical sub- 
 stance of the organ, both external and internal, is of a pale 
 uniform rose or yellowish tint ; or occasionally the colour is still 
 less marked, and resembles that of the flesh of the eel. {Atlas, 
 pi. X. fig. 5.) Minute vessels, injected with blood, appear here 
 and there. {Atlas, pi. vii. figs. 2 and 5 ; pi. ix. fig. 9 ; pi. x. fig. 
 10.) More rarely, small red or brown spots, or large white 
 granulations, denote a former deposition of lymph {Atlas, pi. vi. 
 fig. 6.) or depressions. Occasionally redness and hardness of the 
 mamillary processes of the tubular structure are observed ; as 
 well as a slight thickening of the mucous membrane lining the 
 calices and pelvis, the vessels of which are sometimes in- 
 jected. These phenomena are not, however, to be considered 
 as characteristic, as they are sometimes seen in common ne- 
 phritis. 
 
 Fourth Variety. This has been designated by Dr. Bright as 
 the granulated texture of the kidney. {Atlas, pi. viii. figs. 1, 2, 
 3, 4, 5, 6 ; pi. ix. fig. 1, 8.) As in all the preceding varieties, 
 the kidneys are larger and heavier than in a state of health. 
 Their external surface most frequently is of a pale yellow, and 
 sprinkled, and sometimes covered, with small spots of a miUi 
 white or slightly yellow colour^ of the size of a small pin-head. 
 The spots are occasionally elongated, and somewhat resemble 
 the light curdy deposit from whey, and are scattered more or 
 less irregularly over the surface of the organs. In general the 
 
 * M. Rayer observes that the term yellowish granular matter, generally- 
 adopted in this country to designate this morbid phenomenon does not 
 convey an exact notion of the most frequent appearance assumed by the 
 granular degeneration. 
 
188 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 gTanulations are more numerous and striking at the extremi- 
 ties of the kidneys. They are all covered with an extremely 
 thin membrane, through which they appear as if overlaid with 
 a coat of varnish. The surface of the organs is perfectly smooth, 
 and of a milk-white colour. The granulations of Bright are 
 found in the cortical substance of the kidney. When the kid- 
 neys are divided on their convex side towards their scissure, the 
 cortical substance offers, as in the second and third varieties, a 
 general pale yellowish tint, which is strongly contrasted with 
 the red colour of the tubular structure. The distended cortical 
 portion occupies a larger space than in health, particularly in 
 the prolongations between the pyramids. The minute points 
 of a milk-white colour, instead of being more or less round and 
 separated, as is most frequently the case on the surface of the 
 organs, (Atlas, ipl. ix. fig. 1.) appear under the form of irregular 
 flocklike lines, which seem continuous with the diverging striae of 
 the tubular pyramids. (Atlas, pi. viii. figs. 1 and 5.) When the 
 section is carefully made in the direction of the striae of the tu- 
 bular substance, the above distribution is very apparent; parti- 
 cularly at the periphery of the kidney, and at the bases of the 
 pyramids; where the granular alteration is in general the most 
 strongly marked. 
 
 Sometimes the granular deposit is scanty or entirely wanting 
 in the interior of the cortical substance, although it may be 
 very abundant on the surface of the kidney. In other cases, 
 on the contrary, the granular degeneration occupies all the 
 depth of the cortical substance, and extends to the little pro- 
 longations which penetrate to the base of the tubular pyramids ; 
 the striae of which are jammed and depressed on their sides, 
 so as with their floating extremities to somewhat resemble a 
 wheat-sheaf (Atlas, pi. ix. fig. 8.) 
 
 When a granulated kidney is macerated in water for some 
 time, the granular deposits become more apparent. Their 
 dead-white colour, also, strikingly contrasts them with the 
 surrounding cortical substance. (Atlas, pi. ix. fig. 1.) 
 
 Fifth Variety. This form, more rare than the preceding. 
 
SEROUS URINE. RAYER's CLASSIFICATION. 
 
 189 
 
 is, like them, sometimes accompanied by dropsy. The kidneys 
 are, as in the former instances, more enlarged and heavy, and 
 have a more decidedly lobulated appearance than in health. I 
 cannot, says M. Rayer, give a better idea of the appearance 
 presented by the organ in this variety, than by saying that it 
 resembles an infinite number of minute grains of oatmeal, de- 
 posited under the investing cellular membrane. These little 
 grains are quite distinct from the grains of sabulous matter 
 sometimes deposited in the cortical substance ; as they are also 
 from the little lymph granules, which are occasionally seen 
 in this, as well as in other varieties of nephritis. 
 
 Sixth Variety. This variety appears to correspond with Dr. 
 Bright's third variety. The kidneys are sometimes larger, 
 frequently smaller, than in health. {Atlas, pi. vi. fig. 5; pi. vii. 
 fig. 6; pi. X. figs. 8 and 10.) They are hard, and present mamme- 
 lated inequalities on their surface. There are few or no milk 
 coloured spots externally; but on making a section of the 
 organ, granulations are almost always seen in the cortical 
 substance. I have also seen a kidney in this state of indura- 
 tion and unnatural form, present a great number of granula- 
 tions on its surface. {Atlas, pi. vii. fig. 6.) 
 
 In cases in all respects resembling the preceding, in which 
 the patient has died some months or years after a first attack 
 of serous urine, I have in vain, says M. Rayer, searched in the in- 
 durated, rugose, and mammelated kidneys, the true granulations 
 of Bright ; for we cannot give that name to the minute projec- 
 tions or asperities with which the surface of the organ is ordi- 
 narily scattered. The kidneys are most frequently discoloured, 
 either generally or partially ; and, anatomically speaking, they 
 so resemble the kidneys as altered by simple chronic nephritis, 
 that it would not be possible to point out the distinction without 
 a knowledge of the phenomena which occurred during the life- 
 time of the patient. 
 
 In this advanced stage of the disease the exterior membranes 
 of the kidneys are almost always thickened, at least partially ; 
 and are strongly adherent to the surface of the organs. 
 
190 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION* 
 
 The following are some of the most frequent morbid ap- 
 pearances occurring in conjunction with the present forms of 
 diseased kidney. 
 
 1. The glandules of Malpighi are red or dark-coloured, and 
 much enlarged ; (First form of the disease, Atlas, pi. vi. fig. 1 ; 
 pi. X. fig. 3 ;) and this discoloration is remarkable, when 
 anaemia pervades the cortical substance of the kidney. In the 
 advanced stage of the disease, the renal glandules assume the 
 form of minute serous vesicles ; {Atlas, pi. ix. figs. 6 and 7,) in- 
 termingled with others of a larger size, which, as the disease 
 proceeds, become real cysts. 
 
 2. The little red ecchymosed or petechial spots which are 
 sometimes observed in the first form of the disease, may be 
 subsequently replaced by yellow or slate-coloured spots. 
 (Atlas, pi. vi. fig. 6.) 
 
 3. The renal veins may present fibrinous concretions adher- 
 ing to their sides, {Atlas, pi. vii. fig. 3,) and extending to their 
 principal ramifications. In this case a section of the cortical 
 substance appears more moist than when this condition of the 
 veins is absent. The lymphatic glands of the renal scissure 
 are sometimes enlarged ; but this is very rare. 
 
 4. The calices and pelvis have several times shown traces of 
 inflammation both acute and chronic ; acute inflammation has 
 been indicated by vascular arborisations or red spots ; chronic 
 inflammation by a dull or bluish-white appearance of the 
 mucous membrane ; which in two cases has been seen partially 
 ulcerated. {Atlas, pi. x. fig. 1.) 
 
 M. Rayer supposes organic derangements of the bladder, 
 prostate, kc, to be only accidentally associated with kidney 
 disease ; while he considers organic afiections of the lungs, 
 heart, stomach, &;c., to be more intimately connected with renal 
 affections, either as causes or consequences. Anasarca he 
 views almost as a necessary consequence ; and observes, that 
 instead of mere serosity, a gelatinous fluid is sometimes deposited 
 in the cellular tissue.^ 
 
 * Traite des Maladies des ReiiiS;, vol. ii. pp. 99 — 104. 
 
SEROUS URINE. CHRISTISON's CLASSIFICATION. 191 
 
 The following is Dr. Christison's arrangement of the present 
 diseases. 
 
 " On comparing," says Dr. Christison, " with my own ob- 
 servations, the experience of Dr. Bright, Dr. Gregory, M. 
 Solon, and M. Rayer, as well as the more limited facts pub- 
 lished in the journals by other authors, it appears to me that 
 the following appearances ought, in the mean time, to be distin- 
 guished, with the view of afterwards tracing their relationship : 
 1. Congestion of the kidneys, with or without some granular 
 deposit in their substance. 2. True granular degeneration of 
 the cortical or tubular structure ; a. finely granular ; h. bo- 
 tryoidal. 3. Degeneration by a smooth homogeneous yellowish 
 gray mass, intermediate in consistence between that of the 
 liver and that of the brain. 4. Disseminated tubercles. 5. In- 
 duration, of semicartilaginous hardness. 6. Atrophy, with 
 disappearance of the proper renal structure, and with or with- 
 out one of the previous morbid states. 7. Simple aneemia. 
 The last is of doubtful existence as a local affection, or inde- 
 pendently of general anaemia ; and in all probability the cases 
 which have been considered such, were really cases of anaemia 
 with granular deposit."^ 
 
 The above classifications of renal diseases, founded, as they 
 chiefly are, onpost mortem phenomena, necessarily comprise not 
 only the effects of degeneration, but also the effects, upon the 
 degenerated structure, of the inflammatory attack, which 
 usually precedes, and proves the immediate cause of, death. In 
 a practical point of view, therefore, as formerly stated, arrange- 
 ments of this kind are of little comparative value, since they do 
 not enable us to distinguish what is due to degeneration, and 
 what to inflammation. It is admitted, indeed, that the dif- 
 ferences between these two classes of phenomena are, in many 
 instances, exceedingly difficult to be defined ; yet, when we 
 consider that in three-fourths of the cases which come before 
 us, (before me at least,) the sufferings of the patient arise, not 
 from inflammation, but from the mere degenerated condition 
 
 * On Granular Degeneration of the Kidneys, p. 91. 
 
192 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION, 
 
 of the kidneys, the separation of the phenomena and symptoms 
 of degeneration from those of inflammation must be admitted 
 to be a point of first-rate importance. Indeed, of so much im- 
 portance has this point appeared to me, that I have at all 
 hazards risked the preceding attempt at such a practical ar- 
 rangement ; not only with the hope that it will hereafter lead 
 to something more complete ; but that even in its present im- 
 perfect state it will not prove entirely valueless. 
 
 The reader is not to understand from the preceding remarks, 
 that post mortem examinations are to be disparaged. On the 
 contrary, they cannot be too much practised : my regret is, 
 that such inquiries are not more generally prosecuted in a 
 philosophical and practical spirit ; than as a mere matter of 
 picture-making. Of the value of post mortem inquiries we 
 have a striking instance in the second great practical distinc- 
 tion among kidney diseases, which we ha^e attempted to point 
 out in the preceding pages ; namely, the differences distin- 
 guished by the terms ancemotropihy and hcemotrophy These 
 two great sections of disease gradually run into each other, 
 or are so commixed as to cease to be distinguishable ; yet, 
 in their well-marked forms, the contrast between them is 
 so striking that they can scarcely be overlooked. Indeed, 
 most writers on the subject have noticed these distinctions ; 
 though I do not find that any one has generalised them, or 
 drawn from them iho^e practical inferences to which they seem to 
 lead. The point, like the preceding, is one of difficulty, and 
 requires further elucidation ; the reader will therefore, I trust, 
 concede the usual indulgence to a first attempt. 
 
 * Fifteen years ago, when the last edition of this volume was published, 
 I had recognised the striking differences assumed by the urine in these 
 two forms of disease ; but the conditions of the kidneys with which they 
 were connected, were unknown to me. Dr. Bright pointed out the state 
 of the kidney (anaemotrophy) more especially connected with the first 
 form of diseased urine. The connexion of the peculiar condition of the 
 kidney (hgemotrophy) with the second form of diseased urine, as far as I 
 know, has only been recognised by myself. See Second Edition of this 
 work, p. 48. 
 
SEROUS URINE. 
 
 193 
 
 There is one point connected with this part of the subject 
 requiring some remark. M. Rayer describes the kidney 
 as enlarged in all the varieties of the affection he has 
 noticed : an observation, I believe, that does not accord with 
 experience in this country; where, as Dr. Christison justly 
 remarks, the organ is often found diminished in magnitude, 
 particularly in granular degeneration. M. Rayer seems to 
 consider atrophy of the kidney as the result of simple chronic 
 inflammation : an opinion in which, with Dr. C, I cannot 
 acquiesce. The truth appears to be, that real granular disease 
 of the kidneys is much less common in France than in this 
 country ; probably from the more temperate habits of the 
 people, as regards the abuse of ardent spirits. 
 
 Lastly, there is yet one other point, chiefly arising from 
 the concomitant affections attending kidney disease, de- 
 manding a brief notice ; viz. that the renal disease, the source 
 of all the mischief, is often lost sight of amidst the other 
 apparently more prominent symptoms. On such occasions, 
 I have more than once had the mortification of being 
 superseded by a practitioner, who has disregarded, even de- 
 spised, the renal disease, and prescribed and acted as if no such 
 disease existed. I do not mean to say that lives have been 
 sacrificed in this way ; but I have certainly seen instances in 
 which the fatal event has been accelerated and rendered inevit- 
 able under such circumstances. I make these remarks chiefly 
 with the view of inculcating the maxim — that when kidney 
 disease exists, it shoidd not only he known, hut never for a moment 
 he lost sight of; whatever may be the nature of the concomitant 
 affection. 
 
 o 
 
194 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 Section c. — Of Lithic Acid. 
 
 The next great class of substances existing in the urine, and 
 formed from albuminous principles, is Lithic Acid and its 
 various compounds. These have been described in the intro- 
 duction ; after briefly reminding the reader, therefore, of their 
 general nature, we shall proceed at once to consider the sub- 
 ject in a pathological point of view. 
 
 The conditions of the urine, of which derangements of the 
 Lithic Acid principle constitute the leading feature, differ 
 considerably according to the modes in which the Lithic Acid 
 is associated in the secretion. Moreover the modes in which 
 the Lithic Acid is associated, determines the modes or forms 
 in which it is precipitated, and produces the characteristic 
 sediments to be at present considered. Now Lithic Acid sedi- 
 ments, as we formerly stated, assume two distinct general 
 forms, viz. the form of amorphous and impalpable sediments ; 
 and the form of crystallized and massive concretions. Further, 
 each of these general forms of sediment is deposited under at 
 least three different modifications : that is to say, the amorphous 
 sediments assume the forms of the yellow, the red, and the pink 
 sediments ; the crystallized, or massive concretions, the forms 
 of crystallized sand or gravel, amorphous concretions, and pisi- 
 form concretions. 
 
 We have stated that in a perfectly healthy condition of the 
 urine, this secretion not only remains transparent after 
 cooling, but continues transparent, until it begins to suffer 
 
LITHIC ACID. AMORPHOUS SEDIMEN'J'8. 
 
 195 
 
 those spontaneous changes incidental to all fluids containing 
 organised matters in solution. From a variety of circumstances, 
 however, affecting the general health in every mode and de- 
 gree, the urine undergoes certain changes by which the Lithic 
 Acid is rendered incapable of being retained in solution ; under 
 these circumstances, when the urine becomes cold, and even 
 sometimes before, the Lithic Acid is deposited, either in a 
 state of combination with ammonia or soda, or nearly pure ; 
 and thus forms the two great classes of sediments we have now 
 to consider. 
 
 Of Amorphous and Impalpable Sediments. — The amorphous 
 and impalpable Lithic Acid sediments consist in general of the 
 Lithic Acid in combination with ammonia. The yellow sedi- 
 ments of this variety consist of the lithate of ammonia tinged 
 more or less by the yellow colouring principle of the urine ; 
 the red sediments, or lateritious sediments, as they are frequently 
 termed, consist of the lithate of ammonia tinged by a mixture 
 of the yellow colouring principle of the urine, and by a pecu- 
 liar red colouring principle (purpurate of ammonia) developed 
 by the kidneys in certain forms of disease ; the pink sediments 
 consist of the lithate of ammonia, tinged chiefly by the red 
 colouring principle or principles above alluded to, with little 
 or no admixture of the natural yellow colouring principle of 
 the secretion. 
 
 Urine depositing the yellow sediments, like the sediments 
 themselves, ranges through all the shades of colour peculiar to 
 the variety. It is always acid, sometimes acid in a high de- 
 gree. The quantity and specific gravity also are liable to con- 
 siderable variety ; but are generally confined within the 
 extreme limits of health ; that is to say, the specific gravity 
 usually lies between 1*015 and 1*025; and the quantity varies 
 accordingly. Urine depositing the yellow sediments is rarely 
 serous; nor does it present any other remarkable deviation 
 from the normal state. 
 
 Urine depositing the red sediments is usually more or less 
 of a deep brown or red colour. It is generally more acid than 
 
 () 2 
 
196 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 the urine of health ; and while the quantity passed in a given 
 time is almost always below the normal standard, the specific 
 gravity as often exceeds, and commonly ranges between 1*025 
 and 1*035. Urine depositing the red sediments is sometimes 
 serous, and not unfrequently presents other anomalous pro- 
 perties which it would be foreign to our present purpose to 
 notice here. The yellow and the red are the most common of 
 urinary sediments. Urine depositing the pink sediments is 
 usually more or less of a red or purplish tint. It is acid, 
 and often passed in considerable quantity. Hence its specific 
 gravity seldom surpasses 1 '030, and is often considerably below 
 this point. I do not remember to have seen urine depositing 
 the pink sediments serous ; though it may be occasionally so. 
 Pink sediments in a well-marked form are not very common.* 
 With respect to the constitutional symptoms and causes ac- 
 companying and producing these three varieties of amorphous 
 sediments, it maybe observed, — First, that the different varieties 
 of yellow sediments may be called the sediments of health, if 
 such a term be allowable. That is to say, the different varieties 
 of yellow sediments are such as are produced in the urine of 
 healthy or slightly dyspeptic individuals by errors of diet, 
 atmospheric changes, and numerous other circumstances, which 
 seem, independently of fever, to produce certain derangements 
 of the digestive functions, and a turbid state of the urine. 
 Perhaps there is no healthy individual whose urine does not 
 occasionally deposit this variety of sediment. There are some, 
 however, much more liable to these deposits than others, and 
 
 * During nearly thirty years since urinary diseases have attracted my 
 notice, I have not seen a dozen well-marked cases of pink sediment. Even 
 the less strongly-marked cases are not very common. I mention this, 
 because it has been asserted that such sediments are common in hospitals. 
 The last specimen of a well-marked pink sediment that occurred to me, 
 now several years since, was sent me by Dr. Elliotson ; of whom I took 
 the opportunity of inquiring whether such sediments were really common 
 at the hospital to which he belonged. He assured me that they were 
 very rare ; and if I remember rightly, that he had not seen more than 
 three or four such instances during the long period of his connexion with 
 hospitals. 
 
LITHIC ACID. AMORPHOUS SEDIMENTS. 
 
 197 
 
 such individuals have turbid urine from the slightest causes, 
 more especially during the colder seasons of the year. In in- 
 stances of this kind, the extremes of the scale of colours may 
 be often noticed at very short intervals ; that is to say, the 
 colour of the sediment one day will be pale and almost white ; 
 the next day of a deep yellow bordering on red. This variety 
 of sediment is very common in the urine of children. 
 
 Secondly, The varieties of red sediments usually indicate the 
 presence in the system of feverish or inflammatory action ; 
 indeed this law is so general, that I have scarcely seen an ex- 
 ception to it. The deeper the colour of the sediment, and the 
 more approaching to red, the more severe in general the in- 
 flammatory symptoms. The urine of all persons labouring 
 under feverish and inflammatory affiections, and whose urine 
 is naturally healthy, is liable to deposit this variety of sedi- 
 ment. Those, however, whose urine is most liable to de- 
 posit the yellow sediments, seem most liable to the paler 
 varieties of the red sediments; from which the deeper varieties 
 of yellow sediments differ by imperceptible grades only. 
 Such persons appear to be naturally of an irritable feverish 
 habit, and are apt to be affected by the slightest causes ; as 
 by trifling errors in diet, a chilly state of the atmosphere, 
 &;c. They are often subject to gout or rheumatism ; in which 
 diseases, more than in any others, these sediments may be 
 seen in their most strongly marked forms. 
 
 Thirdly, The varieties of pink sediments usually indicate the 
 presence in the system of certain chronic visceral affections, 
 more especially of the liver. These sediments occur also in 
 hectic or irritative fever ; but in this case they often partake 
 more or less of the character of red sediments ; into which, on 
 the one hand, they gradually merge by imperceptible degrees. 
 The most perfect specimens of the pink sediment I have seen, 
 have been unaccompanied by fever ; and have occurred in drop- 
 sical cases connected with hepatic disease. In a few cases of 
 obstinate dyspepsia connected with formidable visceral obstruc- 
 tion, I have seen the urine not only passed of a bright pink 
 
198 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 colour, but remain so on cooling, without depositing any sedi- 
 ment. In these cases the iithate of ammonia appeared to be 
 absent, and the colouring matter in consequence remained in 
 solution. 
 
 After what has been stated, we need not enter on the sub- 
 jects of diagnosis ^.ndi prognosis, vfith reference to these sedi- 
 ments. Moreover, as these sediments are, for the most part, 
 symptomatic only of other diseases, and rarely or never of 
 themselves give occasion to secondary complaints, we are 
 scarcely called upon to consider their mode of treatment. 
 Hence the little we have to say on this part of the subject 
 will be deferred till Vt e come to speak of the treatment of the 
 lithic acid diathesis in general. We pass on, therefore, to 
 consider the second general form of lithic acid sediments, viz. 
 crystallized or massive sediments. Massive sediments com- 
 posed of the Lithic Acid appear, as we have stated, under at 
 least three distinct forms, viz. crystallized sand or gravel; amor- 
 jjhous concretions ; Siiid pisiform concretions; on each of which 
 we shall make a few remarks. 
 
 Crystallized Sediments, or Red Gravel, consist of Lithic Acid 
 nearly pure. Lithic acid, as has been before stated, exists 
 in healthy urine, in such a state of combination, and in such a 
 proportion, as to be held in solution at all ordinary tempe- 
 ratures. In certain conditions of the system, however, the 
 constituent principles of the urine are so arranged that the 
 lithic acid is precipitated from that secretion in a crystallized 
 and nearly pure state — a phenomenon easily imitated artificially, 
 as is well known, by the addition of a few drops of any acid to 
 healthy urine. The precipitation of crystallized lithic acid 
 does not, therefore, necessarily indicate an excess of lithic acid 
 in the urine, but only the peculiar arrangements of the urinary 
 principles above mentioned ; and so completely is the urine 
 divested of lithic acid by this peculiar arrangement, that on 
 adding to it an excess of a mineral acid, not another particle of 
 lithic acid is usually deposited. Crystallized sediments vary 
 considerably in their colour and appearance according to cir- 
 
LITHIC ACID. RED GRAVEL, &C. 
 
 199 
 
 cumstances. When unaccompanied by fever, their colour is 
 usually identical with the deeper tints of the yellow amorphous 
 sediments above described. When they are accompanied by 
 fever, they are generally more or less of a red or lateritious 
 colour. I have never seen crystallized sediments of a pink 
 colour ; but I have seen them of so dark a shade of brown or 
 red, as to appear, at first sight, almost black. 
 
 The urine depositing the yellow crystallized gravel is com- 
 monly more transparent than usual, and of a peculiar copper 
 colour. It is always acid, sometimes in a preternatural de- 
 gree. The quantity voided is often considerable ; and in this 
 case the specific gravity is seldom much above 1*020. At 
 other times the quantity is less, and the specific gravity consi- 
 derably higher. 
 
 Urine depositing the red crystallized gravel is commonly 
 transparent, of a deep red or brown colour, and strongly acid. 
 The quantity passed in a given time is generally below the 
 average, and hence its specific gravity almost always exceeds 
 that of health. Between these two extremes, the colour and 
 other properties of the urine, above described, like the ana- 
 logous properties of the crystallized gravel, vary in every 
 possible degree. 
 
 Amorphous Lithic Concretions are generally deposited in the 
 kidneys, and, perhaps more frequently than any other cause, 
 give occasion to that peculiar train of symptoms constituting a 
 nephritic attack, to be hereafter described. They may be 
 considered as of two kinds, the coloured and the white. The 
 coloured varieties are by far the most common. They vary in 
 size, from that of a pin's head to that of an almond. Their 
 form is irregular, but generally elongated. The surface is 
 usually rough ; and the texture of their central parts at least is 
 neither crystallized nor lamellated, but presents the appearance 
 of being formed from a number of irregular smaller masses 
 agglutinated together. Their colour varies considerably, being 
 sometimes of a bright yellow ; at other times of a dark brown- 
 ish red ; in other instances, they present externally a whitish 
 
200 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 appearance, at least in their dry state. All these varieties 
 consist of the lithic acid nearly pure ; and tinged only with the 
 colouring matters of the urine. The white varieties, which 
 are very rare, consist chiefly of the lithate of soda. They are 
 of various sizes and shapes, and are usually soft and friable. 
 Their texture is amorphous, never crystallized ; and they have 
 often the appearance of having been moulded, while in a plastic 
 state, into the forms they present. 
 
 The urine accompanying the coloured varieties of the lithic 
 acid concretions differs but little from the state it presents 
 when it deposits the lithic acid gravel before mentioned. In- 
 deed, crystallized gravel, as well as amorphous sediments, 
 often alternate with, or accompany, the formation of the yellow 
 varieties of amorphous lithic concretions now under consider- 
 ation. Such crystallized gravel or amorphous sediments, 
 however, appear more especially at those periods when 
 there is a greater than ordinary tendency in the system to 
 form lithic acid ; on which occasions the urine is generally 
 deep coloured, scanty, of high specific gravity, and strongly 
 acid. On the contrary, the urine in the few cases I have seen 
 of the white lithate of soda concretions, has been of a pale 
 whey-like colour, copious, of low specific gravity, and occasion- 
 ally serous. 
 
 Of Pisiform Lithic Concretions. — The primary nucleus of 
 this form of concretion is usually formed in the kidney ; though 
 for the most part the concretion descends into the bladder before 
 it has acquired such a magnitude as to give uneasiness, either 
 in the kidney, or during its passage down the ureter. A re- 
 markable feature attending the formation of this variety of con- 
 cretion, is the great number in which they are usually generated ; 
 a circumstance which may be said to be characteristic of them. 
 Their great number occasions them to accumulate occasionally 
 in the pelvis of the kidney ; or in the lower portion of the ureters, 
 where they terminate in the cavity of the bladder ; and on such 
 occasions severe nephritic attacks are sometimes the conse- 
 quence. These secretions vary in size, from that of a pin's head 
 
LITHIC ACID. RED GRAVEL, &;C. 
 
 201 
 
 to that of a pea or marble. Their form is always more or less 
 globular ; though they sometimes present flattened or facetted 
 surfaces, produced by their contact or attrition with each other. 
 Their surface is usually smooth, sometimes even porcelainous 
 or polished ; and their internal texture is almost invariably crys- 
 tallized, and usually lamellated. Their colour ranges through 
 all the shades of yellow ; and occasionally, though more rarely, 
 they assume a dark brown or reddish colour. 
 
 The urine, in this form of concretion, approaches in its pro- 
 perties the state of the urine which deposits the lithic acid 
 gravel ; that is to say, it is usually transparent, of a light yel- 
 low colour, distinctly acid, rather copious, and of moderate 
 specific gravity.* Yet it is remarkable that this form of urine 
 rarely deposits crystallized gravel or amorphous sediments ; 
 and in the few instances in which these sediments occur, they 
 usually belong to the yellow, rather than to the red varieties. 
 
 The symptoms local and constitutional accompanying the 
 deposition of lithic acid in the massive condition from the 
 urine, are more or less of pain or uneasiness in the region of 
 the kidneys ; with irritation and sense of heat about the neck 
 of the bladder and urethra. There is also a frequent desire to 
 pass the urine, which is voided in small quantities at a time, 
 and Vv itliout affording the usual relief ; the sensation still con- 
 tinuing of something being left behind in the bladder. The 
 digestive functions also, as in most cases where urinary depo- 
 sits are concerned, are considerably deranged, or very liable to 
 become so ; and the patient is frequently troubled with acidity of 
 the stomach, flatulence, &c., particularly after any little error 
 in diet ; as the use of fruits, acescent wines, &c. We have 
 seen, however, that massive lithic sediments assume very differ- 
 ent forms ; and we may remark that these different forms of 
 
 * The urine, in this form of lithic acid concretion, as well as in the 
 amorphous form of concretion, is frequently of low specific gravity, per- 
 fectly transparent, and strongly serous ; particularly in those who have 
 been accustomed to the daily use of large doses of strong wines ; and who 
 are at the same time of a gouty habit. See Hiemotrophy of the Kidney in 
 the preceding section. 
 
202 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 litllic massive sediment, are not only associated with very differ- 
 ent periods of life, but with very different constitutional symp- 
 toms and consequences. We shall consider the subject, there- 
 fore, with reference to four periods of life ; viz., before puberty ; 
 between puberty and the age of forty ; between forty and sixty ; 
 and in old age. 
 
 Children in general, and particularly the children of dyspep- 
 tic and gouty individuals, or who inherit a tendency to urinary 
 affections, are exceedingly liable to crystallized lithic deposits 
 from the urine. These appear not only under the form of 
 amorphous sediments as before mentioned, when there is sel- 
 dom much irritation in the urinary organs ; but frequently also 
 in the form of crystallized gravel. In this case, symptoms of 
 irritation about the urinary organs may be always more or less 
 observed, if the child be attended to. Thus there will be found 
 to be a frequent desire to pass urine, which is voided in very 
 small quantities, and with manifest uneasiness. The irritation 
 about the urinary organs also sometimes induces the child to 
 wet the bed by night, &:c. In such instances, if the urine be 
 examined, it will ^always be found to be very unnatural, and 
 frequently loaded with lithic acid ; and should this prove to be 
 the case, the matter requires immediate attention, as there is 
 much greater risk at this period of life than any other, of the 
 formation of stone in the bladder ; as will be more particularly 
 shown hereafter. 
 
 Between the age of puberty and forty, there is, perhaps, 
 generally speaking, less disposition to the formation of lithic 
 acid deposits than at any other period of life. In individuals, 
 however, who have a strong disposition to urinary affections, 
 these sediments not only frequently occur even during this 
 period, but go on almost constantly in some form or other, and 
 in different degrees, according to circumstances. Except, 
 however, in extreme cases, the lithic acid appears in the form 
 of crystallized gravel only ; and hence the secondary symptoms 
 of irritation in the urinary organs, &c., are by no means severe, 
 and consequently attract but little of the patient's attention ; 
 
LITHIC ACID. RED GRAVEL, &;c. 
 
 203 
 
 more especially as his health, however paradoxical it may 
 appear, will be generally found to be in a better state than or- 
 dinary at those periods when lithic acid gravel is deposited in 
 the urine. Partly for the reasons stated, and partly from other 
 circumstances to be noticed hereafter, there is less risk, at this 
 period of life, of the formation of calculi than at any other ; 
 and consequently this occurrence seldom takes place, except by 
 accident ; or when there is more than ordinary disposition to 
 the disease. 
 
 About the age of forty an important change commonly takes 
 place in the constitution, which for the most part materially 
 influences the deposition of lithic acid from the urine. It will 
 now be generally found that the lithic acid is apt to be de- 
 posited at intervals in larger quantities than usual ; and that for 
 some time previously to this occurrence, there is more or less 
 of feverish indisposition and derangement of the general health. 
 About this period of life, also, there is a tendency in the con- 
 stitution, under the above (hsemotrophic) circumstances parti- 
 ticularly, to separate the lithic acid in a concrete state ; and 
 thus to give origin to the formation of renal calculus, and the 
 consequent train of secondary symptoms, to be detailed when 
 we come to speak particularly of that circumstance. Such oc- 
 currences are most liable to take place in those individuals who 
 have all their lives been subject to lithic acid deposits ; but 
 they not unfrequently occur also at the period of life we are 
 considering, in those who have never previously suffered from 
 these affections ; but who have lived luxuriously and indolently ; 
 or who inherit a tendency to gout, though they have never, 
 perhaps, had an open attack of that disease. 
 
 About this period of life, or later, we occasionally see, in cer- 
 tain modifications of gouty constitution, large quantities of the 
 lithate of soda, perfectly white, deposited in the urine. This 
 compound sometimes assumes the form of amorphous sediment, 
 .and renders the urine quite milky when passed ; but I have 
 seen it copiously secreted of the consistence of mortar, especially 
 during the night ; and in this case it is apt to collect into masses, 
 
204 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 and block up the urethra, so as to occasion considerable diffi- 
 culty in passing the urine. Such instances are very rare, and 
 appear to be associated with organic disease of the kidneys, and, 
 perhaps, of other organs. 
 
 The above state of things will continue, or at least occur, till 
 old age ; but frequently about the age of sixty or seventy, some- 
 times before, another change takes place in the mode in which 
 the lithic acid is separated from the system. At this period 
 of life, the urinary organs not only begin to participate in the 
 general decay of the constitution, but are apt to be deranged 
 from other causes ; and more particularly to suffer from the 
 delinquencies of early life. Frequently, also, they become 
 organically diseased ; and this, in conjunction perhaps with 
 other causes that will be hereafter noticed, produces a dis- 
 position in the system to secrete neutral urine, or even the 
 earthy phosphates. Under these circumstances, when the urine 
 had previously for years deposited the lithic acid, chiefly in the 
 state of crystals, the crystals will in a great measure disappear ; 
 and minute globules of lithic acid of various sizes will be 
 separated from the kidneys instead, in great abundance. 
 In most of these cases there is a good deal of pain in the back, 
 and irritation about the urinary organs ; even when the concre- 
 tions are only of small size. In other instances, there is much 
 less irritation than one would imagine. In all instances, 
 however, this may be considered as a dangerous state of 
 disease, not only on account of the constant liability of the 
 patient to the formation of renal or vesical calculi, which every 
 thing conspires to render probable ; but on the other hand, 
 on account of the danger there is of suddenly checking, by any 
 means, the secretion of lithic acid ; which is apt to be followed 
 by great derangement of the general health. Thus, I have 
 witnessed, under these circumstances, affections of the heart, 
 accompanied by symptoms of angina pectoris, take place. 
 The most frequent serious affection, however, which usually 
 follows suppression of the lithic acid, is apoplexy, or other affec- 
 tions of the brain. 
 
LITHIC ACID. 
 
 205 
 
 On taking a review of what has been stated, it will be 
 seen — that the earlier periods of life are marked by the de- 
 position of the amorphous sediments and crystallized gravel ; 
 that, about the middle period of life, the lithic acid begins 
 to assume the amorphous concrete form, and to give occa- 
 sion to the formation of renal and vesical calculi ; and lastly, 
 that in more advanced age, there is occasionally a tendency 
 to form numerous small calculi by the deposition of lithic 
 acid round minute nuclei ; which small calculi differ both in 
 their appearance and structure from those secreted about the 
 middle period of life. Now, though many exceptions occur to 
 these remarks, it may be stated that they very generally hold 
 good ; so that a person accustomed to observe on such sub- 
 jects, can in most instances readily determine the age as well 
 as the general symptoms of his patient from the characters 
 of the calculi passed by him. 
 
 We come now to make a few remarks on the pathology of 
 lithic acid deposits ; under which head will be included general 
 remarks on their causes, diagnosis, and prognosis. 
 
 The causes giving origin to lithic acid sediments, may, like 
 those producing most other derangements, be considered as of 
 two kinds, predisposing and exciting. With respect to predis- 
 posing causes, there cannot, I think, be any doubt that certain 
 individuals are much more liable to these sediments than others. 
 This tendency, like the tendency to urinary diseases in general, 
 is not unfrequently inherited. Thus, I have repeatedly seen 
 the children and grandchildren of individuals who had suffer- 
 ed from lithic acid concretions, liable to the same depositions. 
 As before observed, the children of gouty individuals, who 
 have never themselves had gout in an open form, are ex- 
 ceedingly liable to lithic acid sediments. In certain modifica- 
 tions of the strumous diathesis also, indicated by a general 
 haemotrophy of the system, in which the solids are of a loose and 
 flabby texture, the deposition of lithic acid is very common. 
 Indeed, this modification of the strumous diathesis, when asso- 
 ciated with gout, as is often the case, is, perhaps, more than 
 
206 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 any other condition of the system, liable to lithic acid deposits. 
 Such associated diatheses are not unfrequently displayed in the 
 form of cutaneous disease ; and it is an old remark, that cer- 
 tain forms of cutaneous disease are often accompanied by a de- 
 position of lithic acid. Thus, Sir Gilbert Blane observes, that 
 he has frequently noticed calculous disorders connected with 
 those impetiginous affections, incident to what is called a scor- 
 hutic habit ; and which usually depends on hereditary constitu- 
 tion."^ I had made this remark long: before I was aware that 
 it had been noticed by others ; and, indeed, I have no doubt of 
 the frequent connexion between the two forms of disease. A 
 late eminent writer, however, seems to call the opinion in ques- 
 tion.f After all, perhaps, the differences thus expressed, are 
 more apparent than real, and may be easily reconciled ; for I 
 have noticed in such cases, that when the cutaneous affections 
 are most troublesome, the kidneys generally perform their 
 functions most satisfactorily ; while on the contrary, when there 
 are copious deposits in the urine, the cutaneous affection dis- 
 appears. Hence a casual observer, who did not know or in- 
 quire into the history of the patient, would not be likely to 
 detect any connexion between the two forms of disease. 
 
 The causes more immediately exciting or producing a depo- 
 sition of the lithic acid sediments in the urine, especially in the 
 predisposed, may be classed under the three heads of diet, ex- 
 ercise, and atmospheric influences. 
 
 Errors of diet may consist either in a simple excess of the 
 usual wholesome articles of food ; or in the partaking of food 
 which is unwholeso7ne, or which uniformly disagrees with an in- 
 dividual. With respect to an excess of wholesome food, it may 
 be observed, that all other circumstances being the same, an 
 unusually heavy meal, especially of animal food, or of bread, 
 is almost invariably followed by a deposition of lithic acid from 
 
 * See " An Essay on the effect of pure alkalis in various complaints^" 
 in a work entitled, "Select Dissertations on Several Subjects of Medical 
 Science." By Sir Gilbert Blane, Bart. Page 203. 
 
 + Rayer, Traite des Maladies des Reins, &c. Vol. i. page 55. 
 
LTTHIC ACID. 
 
 207' 
 
 the urine in some form or other ; the same may be said of mix- 
 tures of animal and farinaceous matters ; or, from the quantity 
 of azote it contains, any articles made of wheaten flour alone ; 
 but those who live chiefly on matters purely farinaceous, or free 
 from azote, are little liable to lithic acid deposits. With re- 
 spect to the unwholesomeness of food, so much depends on cus- 
 tom and idiosyncrasy, that this point can be hardly determined, 
 in many instances, except by observation and experiment. 
 Whatever agrees with the stomach of an individual, when taken 
 in moderate quantity, may, perhaps, be presumed to be easily 
 digested, and therefore wholesome as far as regards that indi- 
 vidual ; and the stomachs of individuals are, by custom and 
 idiosyncrasy, rendered so various and capricious in this respect, 
 that there is scarcely any kind of food but some stomach may 
 be found capable of digesting it. Certain substances, however, 
 are universally acknowledged to be more difficult of digestion 
 than others ; and among these, perhaps, none surpass the 
 compounds above alluded to, made of wheaten flour ; such as 
 heavy unfermented bread, and compact, hard-boiled, fat dump- 
 lings or puddings, all of which, and many others of the same 
 kind, I have observed to be particularly liable to produce lithic 
 acid deposits in the urine. With respect to drinks, it may be 
 observed generally, that malt liquors, particularly when both 
 sweet and acescent, rank among the most powerful in produc- 
 ing lithic acid deposits ; such are most of the strong and pale 
 ales ; porter, and other malt liquors made of scorched malt, 
 have, probably, when acid, a similar effect ; though certainly in 
 a less degree. Similar remarks extend to wines. The strong 
 and sweet wines, which by keeping usually become more or 
 less acid, act very similarly to malt liquors ; while the drier 
 species, even when acescent, though they may act unfavourably 
 on some individuals, are certainly on the whole much less liable 
 to produce lithic acid deposits than might be expected. In 
 such cases, perhaps, a good deal depends on the nature of the 
 acid existing in the liquors ; I have reason to believe that the 
 lactic, acetic, and oxalic acids act much more unfavourably on 
 
208 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 the stomach than the malic, tartaric, or citric acids. Lastly, 
 with respect to waters, it may be observed, that hard and im- 
 pure waters possess great influence in urinary diseases and 
 deposits ; an old opinion, of the truth of which I am con- 
 stantly reminded by experience. They operate in various ways, 
 and produce very different effects in different diseases and con- 
 stitutions ; but their general influence in all forms of urinary 
 deposition is, according to my observation, very unfavourable. 
 
 Exercise, in every form and degree, so taken as to interfere 
 with the assimilating processes, as, for instance, immediately 
 after a meal, &;c., is, other things being the same, very apt to 
 promote the formation of lithic sediments. Various exercises, 
 affecting in particular the dorsal system, such as riding on 
 horseback, have been observed to produce urinary deposits in 
 those who have been unaccustomed to such exercise ; these 
 effects, however, are generally transient, and cease alike, 
 either by the repetition, or by the cessation of the exciting 
 cause. On the contrary, the want of exercise, after a certain 
 stage of the digestive process^ has been completed, is usually 
 followed by the same consequences. Indeed, bodily inactivity, 
 conjoined with a full or improper diet, ranks among the most 
 fertile and powerful causes of such deposits ; and however 
 healthy and strong the individual may be, if he persists in such 
 habits, he will be almost certain, sooner or later, to suffer from 
 their consequences ; either in the form of urinary deposits or of 
 gout. 
 
 Under the head of atmospheric influences, we include cold 
 and moisture, and all the external circumstances peculiar to 
 particular districts or localities. Cold and moisture alone, in- 
 dependently of other causes, appear to exert considerable 
 power in causing turbid conditions of the urine ; as any one 
 must have noticed who has paid the least attention to the 
 subject in our variable climate. The effects of cold and mois- 
 ture are, however, much more remarkably striking when they 
 concur with the other exciting causes mentioned, viz. errors of 
 diet, complete bodily inactivity, &:c. In a warm and dry state 
 
LITHIC ACID. 
 
 209 
 
 of the atmosphere, when cutaneous exhalation is active, such 
 slight causes often scarcely affect the urine ; but in cold and 
 damp weather they are sure to be followed, even in the most 
 healthy, by a deposition of the alkaline lithates. Malarious in- 
 fluence in warm climates does not seem to lead tolithic deposites ; 
 but in cold climates, where it operates more especially by in- 
 ducing rheumatism and ague, it may be considered, especially 
 when concurring with other causes, as a fertile source of such 
 depositions. 
 
 To these exciting or external causes a variety of others may 
 be added, having no principle in common, except, perhaps, that 
 of deranging the assimilating processes, and of diminishing the 
 vital energies. Such are depressing passions of the mind ; in- 
 ordinate bodily or mental fatigue ; long fasting, &c. ; all of 
 which, and many besides, especially when they concur with 
 the other causes mentioned, are apt to produce turbidity of 
 the urine. With respect to the operation of these causes in 
 general, it is only necessary to remind the reader, in conclusion, 
 that although the exciting causes enumerated exert certain in- 
 fluences under all circumstances, yet that their effects are con- 
 siderably modified by the operation of the predisposing causes. 
 Thus, in young children, the exciting causes most frequently 
 produce a tendency to lithic acid amorphous sediments, and 
 gravel ; in young adults, to amorphous sediments ; in middle 
 aged individuals, to amorphous sediments and concretions ; in 
 old age, to pisiform concretions, &:c. Hence, to enable us to 
 form a correct estimate of the operation of causes, we must 
 take into account the effects of those which predispose to, as 
 well as those which immediately excite, disease. 
 
 What may be considered in one point of view as the proxi- 
 mate cause of lithic acid deposites, and their intimate patholo- 
 gical relations, may be thus briefly stated : 
 
 The lithic acid and its compounds we suppose to be princi- 
 pally derived from the albuminous principles, not only of the 
 chyle and blood, but also of the albuminous textures of the 
 body ; in the same sense and modes in which we supposed urea, 
 
 p 
 
210 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 and lactic acid to be principally derived from the gelatinous 
 textures. When, on account of the imperfect assimilation of 
 alimentary matters by the stomach and primary assimilating 
 processes, the chylous principles are not raised to that standard 
 of perfection by which they are fitted to become component 
 parts of the blood ; we suppose that the healthy kidney posses- 
 ses the power of selecting and disorganizing such imperfectly de- 
 veloped chylous matters, and of converting them into the lithate 
 of ammonia. Such is the presumed origin of most of the com- 
 mon yellow amorphous sediments occurring to healthy indi- 
 viduals from slight errors in diet, &:c. 
 
 During feverish or other derangements, in which the func- 
 tions of the hepatic system are particularly involved, the lithate 
 of ammonia is not only supposed to be derived from the im- 
 perfectly assimilated chyle, and the deteriorated albuminous 
 principles of the blood ; but also from the deranged second- 
 ary assimilation of the albuminous textures of the body. The 
 lithate of ammonia thus developed, appears in the urine more 
 especially under the forms of the red and pink amorphous 
 sediments ; and is distinguished by the large quantities of 
 colouring matters developed in conjunction with it. Lastly, 
 the massive forms of lithic acid deposites are derived from 
 the same sources as the above ; but when thus deposited, the 
 lithic acid is secreted, either in connexion with acids, which, by 
 combining with the ammonia of the lithates, set the lithic 
 acid free ; or in connexion with other bases, as soda, &:c., the 
 compounds of lithic acid with which are less soluble than the 
 lithate of ammonia. 
 
 With regard to the general pathological relations of lithic 
 acid and its compounds, we may remark, that as the lactic acid 
 developed principally during the secondary mal-assimilation of 
 the gelatinous textures was considered as the characteristic 
 feature in rheumatism; so the lithic acid developed prin- 
 cipally during the mal-assimilation of the albuminous textures, 
 may be considered as the characteristic feature in gout. More- 
 over, when the lactic and lithic acids are developed together, 
 as they may be, and often are, the phenomenon may be sup- 
 
LITHIC ACID. 
 
 211 
 
 posed to show tliat the mal-assimilation involves both the gela- ' 
 tinous and albuminous textures ; and that the accompanying 
 disease partakes of a mixed character ; or in fact constitutes 
 what is not improperly termed rheumatic gout — a form of dis- 
 ease, which every one knows, is usually of a much more deep- 
 seated and obstinate character than either gout or rheumatism 
 alone. According, therefore, to these views, the lactic and 
 lithic acids, considered with reference to rheumatism and gout, 
 may be regarded somewhat in the light of materies morhorum ; 
 or, strictly speaking, the undue presence of these acids in the 
 urine or elsewhere, under certain circumstances, may be viewed 
 as indices of the existence of certain diseased actions going on in 
 the primary tissues of the body ; and which are known by the 
 names of rheumatism and gout. 
 
 I do not think it worth while to illustrate these views further, 
 much less to enter into a formal defence of them ; but shall 
 merely observe, that those who will take the pains to under- 
 stand them, and to study the phenomena presented by rheuma- 
 tism, gout, and other allied diseases, will find that these views 
 are neither altogether groundless nor useless ; but that they 
 will often furnish a clue to diseased operations, which would be 
 sought for in vain through any other channel. 
 
 As further illustrations of the general pathological relations 
 of lithic acid deposites in the urine, I shall briefly notice three 
 very important forms of disease in which this phenomenon occa- 
 sionally occurs. The two first of the instances to be mentioned 
 may be viewed in some respects as the extremes of their re- 
 spective classes ; and consequently as including a great variety 
 of similar affections in various states of combination, as well 
 as of inferior degree. The third instance, by establishing the 
 connexion between the deposition of lithic acid and diabetes, 
 throws considerable light on the pathology of both affections. 
 
 Whoever has much attended to urinary diseases, must have 
 remarked that many individuals subject to derangements of 
 the general health, seldom feel so well with respect to their 
 health, as when lithic acid deposites take place in the urine. 
 
 p 2 
 
212 PATHOLOGY OF ALBUMINOUS ASSIMILxlTION AND SECRETION. 
 
 This circumstance is, perhaps, most strikingly exemplified by 
 those attacks of gravel which are apt to commence about the 
 middle period of life in gouty individuals. Thus, we frequently 
 find that patients, who had previously for months, or even for 
 years, been subject to various anomalous affections and pains 
 in different parts of the body, accompanied by great derange- 
 ments of the assimilative functions, will suddenly obtain relief 
 from the whole by a discharge of lithic acid gravel, or 
 perhaps of a small lithic acid calculus from the kidney. Now, 
 although it would be absurd to consider the lithic acid in such 
 cases as the real materies morhi, yet in many instances we may 
 practically proceed on such a supposition ; as will be shown 
 hereafter. In this class of diseases, therefore, the appearance 
 of lithic acid in the urine may be considered in a favourable 
 point of Yiew. In the following classes of disease, the indica- 
 tions afforded by the deposition of lithic acid in the urine are 
 often far different. Individuals, whose general health has 
 been impaired from a long residence in hot climates, and who 
 in particular have suffered from hepatic disease, are often very 
 subject to lithic acid deposites, particularly during the winter 
 months; and in such instances the right kidney is much more 
 frequently the immediate seat of the inconvenience than the left. 
 Again, those who have suffered in early life from injury of the 
 back and kidneys, by falls, (fee, are often very liable to lithic 
 acid deposites about the middle period of life ; particularly if 
 they inherit a gouty constitution. Another class of sufferers 
 from the same depositions are middle-aged females, who have 
 laboured (or who are about to labour) under chronic uterine 
 disorders ; particularly of the malignant kind. I have said 
 ahout to labour ; for in most of the cases of this kind which 
 have fallen under my notice, there has appeared to be diseased 
 action going on in the uterus, and affecting the neighbouring 
 viscera, which had not yet showed itself openly ; at least not in 
 its most alarming forms. Now, when the deposition of lithic acid 
 thus appears about the middle period of life, for the first time, 
 in broken down constitutions and unhealthy subjects, so far 
 
LITHIC ACID. 
 
 213 
 
 from bringing relief or indicating a favourable result, as in the 
 first class of affections above stated, such deposition is not unfre- 
 quentlythe sure forerunner of a general break up of the system, 
 and of a speedy dissolution ; of which I have seen a great many 
 instances. Intimately connected with the two preceding in- 
 stances, yet differing in some degree from both, is the third 
 point we have to mention ; viz. the connexion of lithic acid 
 with diabetes. When speaking of diabetes, we stated 
 that in certain cases of this disease, lithic acid occasionally 
 appears in the urine ; and that the circumstance, as far as re- 
 gards the diabetes, is rather of a favourable character. When, 
 however, the deposition of lithic acid is the prominent disease, 
 and saccharine matter appears only occasionally in the urine, 
 the circumstance is anything but favourable ; for the combina- 
 tion not only indicates deep-seated derangement of the assimi- 
 lating organs, as regards the albuminous principle ; but also as 
 regards the still more important and fundamental saccharine 
 principle. Such a combination is by no means unusual in cor- 
 pulent middle-aged individuals of a gouty strumous habit ; and 
 is always to be viewed w^ith some degree of anxiety. I have 
 generally noticed that such individuals die of some sudden and 
 overwhelming attack of internal inflammation, rapidly assum- 
 ing the adynamic form ; or of apoplexy. They seem, also, to 
 be subject to the severer forms of erysipelas ; and to diffuse 
 inflammation in general of the cellular tissue. Indeed, the 
 greater number of instances of fatal diffuse inflammation, 
 arising either spontaneously, or from simple innocuous punc- 
 tured wounds, which have fallen under my notice, have happened 
 in individuals, whose urine occasionally contained sugar, as 
 well as deposited lithic acid gravel. Lastly, it may be well to 
 remind the reader that the tendency to lithic acid deposites is 
 almost invariably connected with an haemotrophied condition 
 of the kidneys.^ 
 
 The diagnosis in lithic acid deposites is sufficiently marked by 
 the chemical character of the sediments. The prognosis, also, 
 
 * See page 1 80. 
 
214 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 after what has been stated, scarcely needs to be formally dis- 
 cussed ; it will be sufficient, therefore, to remind the reader of 
 a few of the leading points. First, with regard to amorphous 
 sediments, it may be observed — that they are of a less favourable 
 character, in the proportion as they are whiter, or of a more 
 pure pink colour. When pale-coloured, they denote, in gene- 
 ral, a tendency to the phosphates ; when of a pink colour, 
 generally some organic or deeply-seated disease. In drawing 
 our conclusions, however, respecting these sediments, other 
 circumstances must at the same time be taken into account ; 
 and particularly the more or less constant deposition ; and the 
 greater or less quantity of these sediments. A constant de- 
 position of amorphous sediments in large quantity will almost 
 certainly, sooner or later, end in an attack of gravel or calcu- 
 lus, or some other mischief : the occasional deposition of the 
 sediments in small quantities is seldom attended with much 
 danger. 
 
 Nearly the same remarks may be made with respect to lithic 
 acid gravel. Generally speaking, except a calculus already 
 exists in the kidney or bladder, the appearance of lithic acid 
 gravel is not dangerous, as long as it is not deposited while the 
 urine is warm. When deposited in very large quantity ; or in 
 a state disposed to concrete together ; there is a great risk of 
 the formation of calculus. The deposition of lithic acid by 
 gouty and rheumatic individuals about the middle period of 
 life, is often accompanied by relief to the system ; while, on the 
 contrary, in broken down and diseased habits, it is as frequently 
 the forerunner of a general decay, and speedy dissolution. 
 Lastly, it may be mentioned, that of lithic acid concretions, the 
 pisiform, for the reasons stated, is the most dangerous va- 
 riety. 
 
 Treatment. — We come now to consider the means by which 
 the lithic acid diathesis is to be best counteracted, and its dis- 
 tressing consequences prevented. 
 
 Amorphous Sediments. — The first or yellow species of amor- 
 phous sediment is not, in general, accompanied by any pro- 
 
LITHIC ACID. 215 
 
 minent symptom ; and fever, in particular, is altogether absent, 
 or very slight. Hence this variety of sediment scarcely re- 
 quires a formal treatment with medicine ; but a careful at- 
 tention on the part of the patient to avoid all those cir- 
 cumstances which have a tendency to aggravate the disease. 
 Of these circumstances errors in diet, from their being mOst 
 liable to be constant, are of the chief importance ; and the 
 error of quantity in diet is of infinitely more importance than 
 the error of quality. Any stomach may digest a little of any- 
 thing ; but no stomach can digest a great deal of anything. 
 This is a maxim that ought to be universally borne in mind 
 when diet is concerned ; and, in particular, is of the very first 
 consequence in the present diseases. I do not mean that indi- 
 viduals subject to these affections should indulge themselves 
 with a little of whatever comes in their way ; such a license, 
 from the modes in which the term a little would be construed 
 by different individuals, would be exceedingly dangerous ; on 
 the contrary, they should abstain altogether from things which 
 manifestly disagree with them, and which must be unwhole- 
 some to all ; such as heavy unfermented bread ; hard-boiled 
 and fat puddings ; salted and dried meats ; acescent fruits ; 
 and (if the converting powers of the stomach be much debilitated) 
 from soups of every kind, (fee. In general, also, malt liquors 
 and wines, particularly when of an acescent quality, should be 
 avoided. Simple attention to these rules with respect to diet 
 and exercise ; the ensuring a due performance of the cutaneous 
 functions by wearing flannel, particularly about the loins ; the 
 preserving a regular state of the bowels ; and perhaps the occa- 
 sional use of alterative medicines, are all that are commonly 
 requisite in this form of the complaint ; and will scarcely ever 
 fail to prevent its terminating in serious consequences. 
 
 When these sediments are very pale-coloured, and liable to 
 be produced by the slightest causes, as trifling errors of diet a 
 chilly state of the atmosphere, &c., they commonly denote, as 
 before observed, a feverish irritability of the system bordering 
 upon that which accompanies the phosphates. In this state 
 
216 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 tliey are more dangerous, and require a kind of treatment to 
 be hereafter more particularly described when we come to 
 speak of the phosphatic diathesis. 
 
 The second variety of amorphous lithic sediment is common 
 to many diseases, accompanied by inflammatory action and 
 phlogistic fever ; but more especially to certain modifications of 
 gout and rheumatism. Of course, therefore, the general treat- 
 ment must correspond with this state of the system, while the 
 particular treatment will depend on the peculiar character of 
 the inflammatory disease ; or on the organ particularly affected. 
 The same is true of the third variety ; in which the fever, 
 though very different from phlogistic fever in its character, may 
 yet be produced by affections situated in various organs. These 
 circumstances, of course, render it difficult, as well as unneces- 
 sary, to be more particular in this place respecting the mode 
 of treatment. 
 
 The following are the principles to be kept in view in the 
 treatment of lithic acid deposites in general, whether of the 
 pulverulent or massive kinds. The details of course will 
 require to be varied in individual cases according to the cir- 
 cumstances of the patient ; but these may be fairly left to the 
 judgment of the practitioner. 
 
 The point first claiming our particular attention in the 
 treatment of lithic acid deposites, is diet and regimen — a sub- 
 ject of so much importance, that if it be neglected, all other 
 means are of little avail. In discussing this subject, we shall 
 commence with the questio vexata ; whether an animal or a 
 vegetable diet be most appropriate in lithic acid deposites 1 
 On this point we need not say there has been much difference 
 of opinion. The philosopher, arguing from the known resem- 
 blance and analogy between the composition of lithic acid and 
 albuminous matters, has contended that animal matters should 
 be avoided by those who are subject to lithic acid deposites. 
 On the other hand, the mere practical physician, judging from 
 his experience alone, of the effects of crude vegetable matters 
 in producing lithic acid deposites in certain individuals, has 
 
LITHIC ACID. 
 
 217 
 
 as strenuously contended for the adoption of an animal diet. 
 As is usual in most disputes, the truth lies between the two 
 opinions ; both of which have been formed on exclusive and 
 hasty grounds. That is to say, in neither case has the influence 
 of quantity and of custom as regards diet been taken into 
 account ; on which more frequently depends than upon any 
 other cause whatever. We have already stated, that with 
 reference to diet, quantity is often of infinitely greater im- 
 portance than quality. Thus n^full meal, whether of animal or 
 of vegetable matters, or of a mixture of the two, will usually 
 produce a deposition of gravel in predisposed individuals, in 
 whom a spare meal of the very same materials is not followed 
 by such deposites. There are, however, many individuals, with 
 weak stomachs and strong gouty predisposition, in whom 
 certain articles of food to which they have been unaccustomed, 
 in almost any quantity and without apparent reference to their 
 vegetable or animal origin, will prove of difficult reduction, and 
 produce a deposition of lithic acid. Thus, among animal 
 matters, salted and dried meats, or veal, will often act in this 
 way ; while among vegetable maitters, potatoes more especially, 
 or the least quantity of any of the subacid fruits, (fee, will 
 produce a similar effect. In both these classes of cases, the 
 distinction between animal and vegetable matters is probably 
 quite out of the question ; and the deposition of lithic acid in 
 the first class depends on the mere quantity of matters taken ; 
 which matters may, or may not, furnish the elements from which 
 the lithic acid is elaborated ; while in the other class of in- 
 stances, the deposition of lithic acid depends on the increased 
 acidity produced in the stomach, &;c., by the difficult solubility 
 of the matters taken ; and the elements of the lithic acid are 
 not derived immediately from the food, but from the proximate 
 principles of the blood. Similar remarks may be made with 
 respect to wines and other fermented liquors. Thus indivi- 
 duals who have been long accustomed to the strong brandied 
 wines generally employed in this country, are almost sure to 
 bring on attacks of pain in the back and gravel by the occa- 
 
218 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 sional use of weak acescent wines ; such as the inferior hocks, 
 champagnes, &;c., particularly in cold climates ; and if they are 
 gouty, and subject to urinary deposites. On the contrary, indi- 
 viduals who have all their lives been accustomed to the use of 
 such weak wines ; and to the free use of cider ; or of perry ; 
 rarely suffer from gravel. Malt liquors of every kind operate 
 unfavourably in lithic acid deposites ; and the sweet, and the 
 acescent in particular, are perhaps among the very worst 
 articles that can be chosen. Of the diluents in common use, 
 weak tea appears to be the least objectionable. Coffee, particu- 
 larly if strong, and the heavier fluids, chocolate, &:c., should be 
 shunned altogether. Milk in any quantity usually acts unfa- 
 vourably ; and the unfavourable operation of ^11 these and 
 similar articles is much increased by being combined with 
 sugar. To this head may be referred also the subject of waters. 
 Hard waters should in all instances be avoided, by those who 
 are subject to lithic acid deposites. Such, for instance, are 
 most of the pump waters in and about London, and in chalky 
 districts in general. The Thames^and the New River water 
 boiled and filtered are unobjectionable ; as are most of the 
 waters in this neighbourhood, which come from a great depth ; 
 and are obtained by the new process of boring. Indeed, I 
 have known the water fi'om Artesian wells, probably from its 
 containing a little carbonated alkali, agree remarkably well in 
 lithic acid deposites ; and sometimes give ease, even when 
 lithic calculi existed in the bladder, after other means had 
 failed. 
 
 The general inferences then from these remarks on diet and 
 drinks are, that in all instances the strictest attention to quan- 
 tity is requisite ; and that the patient should never take more of 
 anything than he can fairly assimilate. While, in reference to the 
 qualities of alimentary matters, the habits and peculiarities of 
 countries or of individuals must be carefully considered, and the 
 alimentary matters must be adjusted accordingly ; — there being in 
 fact no one plan of diet, &:c., that will prove to be universally 
 applicable to all places and persons. In this country, generally 
 
LITHIC ACID. 
 
 219 
 
 Speaking, a light diet, consisting chiefly of animal and farina- 
 ceous matters, will be found most appropriate ; while if fer- 
 mented liquors be employed at all, dilute spirits and water, or 
 the more generous wines, should be chosen in preference. 
 Crude and indigestible vegetable matters, and the use of sweet 
 or acescent wines or other fluids, should be carefully avoided ; 
 as should the use of hard waters. Indeed, in every climate 
 and case, the employment of the purest water is indispensably 
 requisite. 
 
 In connexion with this part of the subject, it remains to 
 make a few remarks on exercise. A due propojtion of exercise 
 is proper, and even necessary, in every form of lithic acid 
 deposite ; as nothing is so liable to induce and to foster these 
 complaints as inactivity and indolence. The degree of exercise 
 must in a great measure be determined by the circumstances 
 of the patient ; and in no instance ought it to be carried so far 
 as to induce fatigue ; or, when massive concretions are present, 
 to cause the risk of haemorrhage or inflammatory action in the 
 kidney or bladder. Of the kinds of exercise it may be stated, 
 that under almost all circumstances walking will be proper. 
 In particular cases, horse exercise has many advantages. Next 
 to horse exercise, is riding in carriages. Carriage exercise, 
 however, often excites the irritable organs, without imparting 
 that benefit to the system, which muscular motion alone can 
 give. On the whole, therefore, if the patient has the use of 
 his limbs, walking, perhaps, constitutes the best form of exer- 
 cise. 
 
 It is more especially in lithic acid deposites that alkalies 
 are resorted to, with so much benefit ; we shall, therefore, take 
 this opportunity of making a few remarks on their employ- 
 ment in general ; as well as on the best modes of exhibiting 
 them in the present forms of disease. The objects with which 
 alkalies are usually administered, may be stated to be three- 
 fold ; first, with reference to the prevention of lithic acid 
 deposites , secondly, with reference to their solvent effects on 
 lithic concretions already formed ; and thirdly, with reference 
 
220 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION, 
 
 to their peculiar alterative effects. On each of these points 
 we shall make a few remarks. 
 
 We have stated in another place, that alkalies appear to 
 exert no curative influence of a permanent kind on lithic 
 acid deposites ; but that their operation is limited to their im- 
 mediate effects on the acid and unnatural matters resulting 
 from deranged assimilation. It follows, therefore, that alka- 
 lies, to be beneficial, with the view" of preventing lithic acid 
 deposites, must be so administered, as to counteract acidity at 
 the moment of its developement ; and that their use must be 
 daily and constantly repeated for a long time. With respect 
 to the first of these points, the moment best suited to counter- 
 act the acidity of digestion, it may be remarked — that in different 
 instances it varies considerably, but that it usually lies between 
 two and six hours after eating. As an average, perhaps, three 
 or four hours after a meal will be found the most appropriate 
 period. If the proper period for taking alkaline remedies be 
 attended to, it will be found that a very small proportion of 
 the remedy will, in all instances, be sufficient to accomplish 
 the purj)ose ; that is to say, from ten to twenty grains of the 
 carbonate of potash will, in almost every case, be found amply 
 sufficient to counteract the acid residuum of the meal ; which 
 in fact is all the real good that can probably be expected from 
 the use of the remedy. I have generally preferred potash, on 
 account of the greater solubility of the potash lithates ; but 
 soda is more grateful to a few stomachs ; while others prefer 
 magnesia. The good effects of magnesia as an antacid in 
 stomach affections, have I think been much overrated; at 
 least, such is the result of my own experience. In acidity of 
 the csecum and colon, and the peculiar symptoms dependent on 
 such acidity, magnesia is the preferable antacid ; because the 
 soluble alkalies are usually absorbed long before they reach 
 the lower bowels ; except they be taken in large and otherwise 
 injurious quantity. I generally prefer the carbonate of potash 
 to the liquor potasses ; in those, however, who are incom- 
 moded by the carbonic acid extricated from the carbonate, the 
 
LITHIC ACID. 
 
 221 
 
 liquor potassce is preferable. In almost all instances, likewise, 
 I associate the potash with a few grains of nitre ; from the 
 sedative effects of which on the morbid irritability of the sto- 
 mach usually present, the utmost benefit is often derived. In 
 general, I make no other combination; and think that when 
 alkalies are given as mere antacids, they are best exhibited 
 alone. By giving alkalies in combination with tonics, the 
 good effects of both are often lost ; but their separate use is 
 often highly beneficial. Thus I often give tonics, (even the 
 mineral acids,) before and between meals, at, the same time 
 that alkalies are taken after meals ; and with the best effect. 
 When it is necessary to give alkalies with reference to their 
 diuretic as well as their antacid effects ; or when more 
 than usually powerful antacid effects are indicated, the 
 alkalies may be often advantageously combined with a vege- 
 table acid ; such as the citric, tartaric, or malic acids. In this 
 case, the alkalies may be either administered still, or in an 
 effervescing form, as the circumstances of the patient may re- 
 quire ; they may be also beneficially combined with some other 
 diuretic, such as the spiritus cetheris nitrici, the spiritus juni- 
 peri comp., &c. This mode of exhibiting alkalies, it need 
 scarcely be stated, is particularly indicated in cases of great 
 irritability of the stomach ; or of febrile action, accompanied 
 by scanty and high-coloured urine, of more than ordinary 
 acidity. 
 
 The second object with which alkalies are exhibited in lithic 
 acid deposites, viz. their diuretic and solvent powers, come now 
 to be briefly considered. Attempts have been made to dis- 
 solve lithic acid concretions of all kinds, situated in the kidneys 
 and bladder, by the exhibition of large doses of alkalies both 
 in the carbonated and free state ; and wonderful stories have 
 been related of the success of the remedies thus exhibited. 
 That in some constitutions large doses of alkalies can be taken 
 for a great length of time, with apparent impunity, and so as 
 not only to affect the urine, but even to act on lithic acid 
 calculi lodged in the kidney and bladder, I have no doubt. The 
 
222 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 practice, however, in general, cannot be said to be a safe one ; 
 and in many instances its application is impossible. The best 
 mode of accomplishing the object when practicable, is to dis- 
 solve the alkali in a large quantity of water ; and in this way 
 both the diuretic and solvent powers of the remedy will be 
 exerted at the same time. On this principle many of the 
 natural mineral waters may be supposed to act ; such, for in- 
 stance, as the waters of Vichy in France, which may be placed 
 at the head of a very numerous class of similar waters, each 
 differing in its degree of alkaline power, and in various 
 minor circumstances, but all operating on the same general 
 principles. Of the waters in England most celebrated for 
 these affections, those of Malvern may be mentioned as the 
 chief. The quantity of alkali which the waters of Malvern 
 contain, is exceedingly minute ; indeed their leading character 
 consists in their extreme purity ; yet from their continual use, 
 great benefit is often derived ; of which I have seen repeated 
 instances. They may be taken in any quantity, ad libitum, 
 and at the same time employed for all the purposes of common 
 domestic water. As already mentioned, many of the waters 
 obtained by boring in the London district, resemble the Mal- 
 vern waters for their general purity ; while they often contain 
 a little carbonated alkali. Hence such waters often agree 
 remarkably well with those who are subject to lithic acid de- 
 posites. I do not think it necessary to enter further at present 
 on the subject of mineral waters. An account of the numerous 
 mineral waters on the Continent which have been celebrated 
 for calculous affections will be found in writers on the subject ; 
 to whom I beg leave to refer. The few further remarks we 
 have to make on the solvent powers of alkaline remedies will 
 be given when we come to speak of diseases connected with 
 the presence of lithic calculi in the bladder. 
 
 With respect to the third object with which alkaline reme- 
 dies are administered, viz. their alterative effects, we have little 
 to do in this place. When thus exhibited, their caustic form 
 is usually preferred : that is to say, in various chronic affec- 
 
LITHIC ACID. 
 
 223 
 
 tions, the liquor potassce, either alone or in combination with 
 some alterative or bitter decoction or infusion, as the decoctum 
 sarsaparillce, the infusum gentiance, &c., is to be persisted in for a 
 considerable length of time in free doses. The chronic affec- 
 tions particularly alluded to, are, various scrofulous enlarge- 
 ments of glands or other organs ; the power exerted o\ier 
 which in some instances, by the free alkalies when judiciously 
 administered, is very considerable; particularly when con- 
 joined with the use of the hydriodate of potash. The use of 
 alkalies, however, with these views, as already stated, scarcely 
 falls within our present design. 
 
 Before we close the subject of alkalies, it may be remarked, 
 that there are some individuals who cannot take alkalies in 
 any form, however strongly their use appears to be indicated. 
 I have seen several instances of this inability ; and in most of 
 these cases have observed that the lithic acid was deposited in 
 the white plastic state we have formerly described. In these 
 cases, the peculiar effects produced by the alkalies were great 
 nervous disturbance ; particularly of the cerebral functions. 
 In one gentleman, between fifty and sixty, in particular, the 
 excitement produced by alkalies was so great as to border on 
 delirium or mania. In this case, immense quantities of nearly 
 white lithic acid, mixed with a little lithate of soda, was 
 voided in irregular masses, which caused the most acute suffer- 
 ing both in passing from the kidney, and afterwards in the 
 bladder. The urine was acid, and everything strongly indicated 
 the use of alkalies, which were most carefully tried in every 
 form, but without success ; they seemed to act like a poison ; 
 and there was reason to believe, from the effects produced, 
 that if their use were persisted in, they would even lead to a 
 fatal termination. I lost sight of this curious case after a short 
 time, and do not know what became of the patient. In some 
 instances, when alkalies cannot be tolerated in a free or car- 
 bonated state, they can be taken in conjunction with a vegetable 
 acid. In other instances, the addition of ammonia will cause 
 them to be borne. Again, potash disagrees with certain indi- 
 
224 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 victuals, who can take soda or magnesia with impunity, &:c. 
 The effects of alkalies at all times, in large doses, and adminis- 
 tered at improper times, is injurious to the system. They not 
 only derange the assimilating functions, but produce serious 
 disorder of the nervous system ; in short, they so operate, as to 
 perpetuate, rather than cure, the diseases for which they are 
 administered. In certain habits also, and under certain cir- 
 cumstances, the injudicious use of alkalies occasions a deposite 
 of the phosphates in the urine ; and thus produces a more for- 
 midable disease than that whi^h they are intended to cure. 
 On the contrary, when judiciously given in small doses, I have 
 never witnessed any injurious effects follow the employment of 
 alkalies ; though their use has been daily persistbdf in for years 
 together. I believe, also, that when thus administered, in 
 gouty and dyspeptic habits, they are capable of doing a great 
 deal of good ; by preventing those troublesome secondary ef- 
 fects, which frequently arise from acidity in the primce vice ; 
 among which lithic acid deposite is one of the most prominent. 
 Lastly, it remains to state that alkalies have been said to exert 
 their bad effects by attenuating the blood ; and by inducing 
 general weakness and emaciation. What is meant by attenua- 
 ting the blood, I do not understand, and therefore cannot 
 speak on the subject. That the free and injudicious use of 
 alkalies promotes absorption of the living solids, and thus 
 attenuates the body, there seems to be little doubt. This effect 
 of alkalies, however, is not invariable ; and is much more 
 striking in some instances than others. 
 
 Although the employment of alkalies in lithic acid deposites 
 is thus so generally useful ; yet it must be borne in mind that 
 their operation is not of a curative, but of a corrective nature 
 only ; hence in the treatment of these affections, the use of 
 alkalies must never be trusted to alone, but their good effects 
 must be secured and maintained, by conjoining with their use 
 certain other means, and particularly purgatives and alteratives. 
 Moreover, in the general administration of these remedies, the 
 age and condition of the patient must be taken into account. 
 
LITHIC ACID. 
 
 225 
 
 We shall, therefore, briefly consider the application of these 
 and other remedies at the four different periods of life formerly 
 mentioned ; viz. before puberty ; between puberty and the age 
 of forty ; between forty and sixty ; and in extreme old age. 
 
 From the great tendency to deposit lithic acid by the children 
 of gouty and dyspeptic parents ; and particularly by the chil- 
 dren of those who suffer from urinary diseases in general ; 
 from the great risk there is also at this early period of life of 
 the formation of calculus in the bladder ; it becomes a duty 
 highly incumbent on parents to watch the condition of 
 their children's urine. They should constantly bear in mind 
 that by a regulated diet, &c., the formation of a stone in the 
 bladder may very probably be prevented ; while this fear- 
 ful malady will almost as certainly be the result of inat- 
 tention. I have repeatedly seen instances in which children, 
 strongly disposed to these affections, have been sent to school 
 and otherwise neglected, and who have suffered in conse- 
 quence from stone in the bladder. Moreover, such children 
 should never be considered as secure, till after the age of pu- 
 berty ; when, as we have stated, the tendency to this affection 
 is much diminished, or at least becomes less dangerous ; and 
 when of course they become old enough to attend to them- 
 selves. In the management of children with these affections, 
 attention to diet is, in the first place, of chief importance. Left 
 to themselves, children partake, in preference, of all sorts of 
 sour and sweet things, the whole of which ought to be strictly 
 prohibited. They should be also carefully prevented from 
 eating too much, even of bread or of milk. A plain and sim- 
 ple diet, consisting of a due admixture of animal and farina- 
 ceous matters in moderate quantity ; the use of the purest 
 water ; and free exercise in the open air, are requisites so 
 essential in the treatment of these affections in children, that, 
 without attention to them, all other means will be found of 
 little avail. The use of alkaline remedies in early life requires 
 some care. The urine of children, even when considered 
 healthy, is liable to great and sudden changes from a variety 
 
 Q 
 
226 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 of causes, so that one day we find it acid, and the next perhaps 
 neutral or alkaline. Alkaline remedies, therefore, should be 
 given in small doses, and their effects should be watched. 
 Five or six grains of the carbonate of potash or of magnesia, 
 given twice a day, two or three hours after breakfast and 
 after dinner, will in most instances be found quite sufficient for 
 children under ten years of age ; and even this quantity will 
 occasional]y require to be suspended for a time. By the aid 
 of these means, and the occasional' employment of mild purga- 
 tives or alteratives, as the hydrarg. cum creta, I have, in a great 
 many instances, seen the deposition of lithic acid kept in 
 abeyance during the whole period of childhood, and after the 
 age of puberty cease altogether. 
 
 The period of manhood is, as we have stated, very little 
 subject to lithic acid deposites. In those instances in which 
 such depositions take place at this period of life, the practice 
 will differ but little from that which we have to state as appli- 
 cable to the middle period of life, when, next to childhood, the 
 tendency to these depositions is perhaps the most strongly 
 marked. 
 
 Besides the steady use of alkaline remedies on the principles 
 formerly stated ; at the middle period of life, other remedies are 
 usually required to ensure and maintain their good effects. 
 Alkalis, therefore, can now be seldom trusted to alone, but 
 their use must be conjoined with appropriate purgatives and 
 alteratives. In the decided cases of gravel and concre- 
 tions which occur in middle life, there is usually a congested 
 state of the whole abdominal viscera, and particularly of the 
 hepatic system, requiring active purgatives and alteratives. 
 These must be selected and adapted to the particular case, ac- 
 cording to the judgment of the practitioner ; but if the patient 
 has been accustomed to the stimulus of calomel, nothing but 
 calomel will be found to answer the purpose. In other cases, 
 a few grains of the blue pill, or of the Plummer's pill, may be 
 taken at night, and followed the next morning by an active 
 dose of the subsulphate of magnesia ; or of a mixture of Rochelle 
 
LITHIC ACID. 
 
 227 
 
 salts and magnesia, with senna, &:c. The use of these means 
 must be repeated according to circumstances ; and if there be 
 a tendency to gout, colchicum may be often advantageously 
 combined with the remedies stated. These means will usually 
 subdue the acescent state of the urine ; and when this is ac- 
 complished, remedies, more especially of a diuretic nature, as 
 nitre, the spiritus cetheris nitride &c., may be associated with 
 them according to circumstances. Ordinary attacks of gravel 
 rarely fail to yield to these means, if properly directed. When 
 the symptoms run still higher, and there is indication of the 
 formation of a calculus in the kidney, other means, to be de- 
 tailed hereafter, adapted for this particular emergency, must 
 be resorted to. 
 
 We have said that about the age of forty, the lithic acid may 
 occasionally be considered as a sort of materies morbi ; that is, 
 the cause of irritation in the constitution, whatever it may 
 be, seems to be transferred to the kidneys ; which are induced 
 to secrete an extraordinary quantity of lithic acid, and thus 
 to meliorate the system in general. On a similar princi- 
 ple, the good effects long ascribed to certain remedies of the 
 active diuretic kind, may be probably explained : such reme- 
 dies appearing to possess the power, when given in favourable 
 conditions of the system, of exciting the kidneys to separate 
 large quantities of lithic acid ; and in this way, by bringing 
 about an artificial crisis, to produce great and immediate benefit. 
 Thus Dr. Henry has mentioned cases in which several ounces 
 of lithic acid were brought away in the course of a day or two, 
 by a remedy apparently composed of turpentine and laudanum 
 chiefly.* 
 
 In remedies of this class, opium, not only on account of its 
 sedative properties, but from the property it likewise possesses 
 
 * Med. Chirurg. Trans, x. 136. Dr. Henry thinks that in these cases 
 the lithic acid brought away was previously lodged in the kidneys This 
 might have been the case in part ; though I cannot help thinking that by 
 far the greater portion of it was actually secreted under the influence of 
 the medicine. 
 
 q2 
 
228 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 of increasing the secretion of lithic acid, should probably in 
 most instances form a constituent principle ; but the diuretic 
 ingredients may vary. Thus, instead of turpentine, a combina- 
 tion of muriatic acid and opium will sometimes answer very 
 well ; particularly when the lithic acid is not disposed to con- 
 crete, but to come away in the form of gravel : or the tere- 
 binthine remedy may be conjoined with the acid and opium. 
 When, on the contrary, the lithic acid is more disposed to 
 concrete, the muriatic acid may be omitted, and the liquor 
 potasscB may be substituted, by which means the lithic acid 
 will be held in solution ; and this, perhaps, in most instances is 
 the safer combination. To this class of remedies may be likewise 
 referred many of the ancient and still popular remedies in 
 gravelly affections, such as the seeds of the wild carrot ; the 
 parsley breakstone, {cdchemilla arvensis,)kc. ; many of which pro- 
 duce a large secretion of lithic acid in particular states of the 
 system. Even hard waters, however x paradoxical it may ap- 
 pear, sometimes do good on the same principle, and, by acting 
 as diuretics, bring away large quantities of gravel ; of which I 
 have seen many instances. Occasionally, however, a mere 
 change of water, not only from soft to hard, but the reverse, 
 will have the same effect. That such remedies are calculated 
 to do good when judiciously applied, there can be no doubt ; 
 but on the other hand, when indiscriminately exhibited, they 
 are liable to do much harm. Thus, when there is a tendency 
 to active inflammation in the kidney, or when the presence 
 of a renal calculus is suspected, too large to pass the ureter, 
 their exhibition will be likely to increase the affection : nor 
 does their employment seem to be adapted to any other species 
 of deposite, except crystallized lithic acid ; nor even perhaps in 
 this form of the disease, when occurring in very young, or in 
 very old subjects. Moreover, as remedies of this class do 
 not appear to exert any beneficial action, in any case, in re- 
 moving the peculiar tendency to gravel, and are calculated to 
 answer a particular and temporary purpose only ; the moment 
 this purpose has been effected, they should be no longer em- 
 
LITHIC ACID. 
 
 229 
 
 ployed ; but the means above recommended, adapted to pre- 
 vent a tendency to the affection, should be recurred to. 
 
 It cannot be too strongly impressed upon those who suffer 
 from gravelly affections in middle life, that the cause of these 
 affections lies deep in the constitution ; and that to counteract 
 their distressing effects, perseverance in the appropriate diet, 
 regimen, and medicines, is absolutely necessary. It is absurd 
 to look for permanent relief in these complaints, by attention 
 to regimen and medicines for a few days or weeks. In obsti- 
 nate cases, an adherence, more or less strict, according to cir- 
 cumstances, to the principles above stated, should be adopted 
 for months, or even for years, to ensure success. This will be 
 scarcely thought irksome by those who affix a just value on 
 health. By a few sensualists it may be considered a species of 
 slavery and sacrifice of enjoyment, too great to be endured for 
 ^ny future good whatever. 
 
 Perhaps the most dangerous form, in every point of view, 
 which the lithic acid assumes, as well as the most difficult of 
 treatment, is that above described as occasionally occurring in 
 old people. For, on the one hand, if a sudden stop be put to 
 the secretion, whether by the appropriate remedies or other- 
 wise, great constitutional derangement is likely to follow, with 
 sudden and fatal determination to the head or other parts ; as I 
 have more than once known to happen. On the other hand, 
 if permitted to proceed unchecked, from the combined effects 
 of so many concurring circumstances at this time of life, the 
 formation of a calculus in the bladder will almost certainly take 
 place. In such cases it is impossible to lay down any specific 
 plan of cure, which must depend on circumstances ; but in 
 general the principles of treatment must be of the constitu- 
 tional and preventive kind formerly laid down : and in con- 
 junction with these, the frequent application of leeches to the 
 region of the kidney, or an issue or seton in the back, may be 
 lad recourse to ; particularly if the presence of organic disease 
 oe suspected. 
 
 It may be observed, generally and in conclusion, that from 
 
230 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 the little pain usually occasioned by the descent of pisiform con- 
 cretions from the kidney, and the ease with which they either 
 escape, or are subsequently removed from the bladder, when 
 this organ is in a healthy state ; it will, in most instances, 
 under such circumstances, be the safer plan to interfere as 
 little as possible with the formation of these calculi by active 
 treatment ; and to trust chiefly to a careful diet, and the regu- 
 larity of the common functions only. On the other hand, if 
 the prostate be much enlarged, and the bladder irritable, as it 
 is too apt to be at this time of life, more active treatment of 
 the preventive kind will be often proper. For it may be re- 
 marked, that under such circumstances, active treatment of 
 the preventive kind may be often employed with much less 
 risk to the constitution, than when the bladder is sound — the 
 disease and irritation of the bladder seeming to act, as it were, 
 as a sort of safety-valve, and thus to divert the mischief from 
 falling on more important organs. Hence patients labouring 
 under chronic affections of the bladder seldom die of sudden 
 attacks of the brain, &c., except perhaps in the last stages. 
 Lastly, it may be proper to remind the reader that from the 
 proneness to an alkalescent state of the urine in advanced life, 
 particularly w^hen the prostate and bladder are affected, alka- 
 lis are not so well borne as in the earlier stages of the affec- 
 tion; hence they must be applied with caution, and their 
 effects must be carefully watched. 
 
 Such are the leading principles of treatment to be attended 
 to in the management of lithic acid diseases at different periods 
 of life. Those who have carefully studied these affections will, 
 I think, at once acknowledge the general truth of these prin- 
 ciples, and readily understand how they are to be varied 
 so as to meet particular exigencies ; while those who have 
 not studied these diseases as they deserve, will be furnished 
 with a clue to their general nature and treatment. 
 
CYSTIC OXIDE. 
 
 231 
 
 Section d. — Of Cystic Oxide. 
 
 Since the last edition of this volume was published, several 
 opportunities have occurred, both to others and to myself, of 
 investigating this rare species of disease. A most important 
 discovery also has been made in the composition of the cystic 
 oxide, which not only throws considerable light on its proper- 
 ties, but also on the pathology of the diseases with which it is 
 connected. The disease, however, must still be considered as 
 very rare, at least in its decided form ; we retain, therefore, 
 the following brief history of the discovery of this form of cal- 
 culus, given in the last edition, in order that we may complete 
 it up to the present period ; and thus throw all the light we are 
 able on a form of disease which we must acknowledge, from 
 its rarity, to be imperfectly understood, even at the present 
 time. 
 
 The first specimen of cystic oxide calculus, described by Dr. 
 Wollaston, its discoverer, was taken from a boy five years old, 
 and was covered with a loose coating of the phosphate of lime. 
 This boy afterwards died from the formation of another stone, 
 which consisted principally of the lithic acid ; but was peculiar 
 in having its centre hollow, by the removal, apparently, of 
 some more soluble substance of which the nucleus had con- 
 sisted.^ 
 
 The second specimen was likewise described by Dr. Wollas- 
 
 * Philos. Trans., 1810, p. 223. 
 
232 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 ton, and is preserved in the collection of Guy's Hospital. It 
 was taken from a man thirty-six years of age, of whose case no 
 particulars are recorded. 
 
 Soon after Dr. Wollaston's paper was published. Dr. Henry 
 recognised two specimens of this variety of calculus in 
 his collection ; but with the histories of both he was unac- 
 quainted."^ 
 
 The next case on record is described by Dr. Marcet.f It 
 was removed from the bladder of a gentleman about twenty years 
 of age. This gentleman, both before and after the operation, 
 passed several small calculi, composed of the same substance, 
 all of which had been distinctly traced from the kidney down 
 the ureter by the usual symptoms. After the operation he had 
 no symptoms of stone in the bladder, those descending into 
 that organ having been discharged immediately. His general 
 health was good, except when the calculus was passing down 
 the ureter ; though he was rather subject to be bilious or dys- 
 peptic ; but he was never troubled with acidity. Subsequently, 
 the fit of pain, previous to the evacuation of calculi, which 
 used to occur about once in three months, became much 
 milder, and the haemorrhage ceased ; though the evacua- 
 tion of calculous matter in small quantities recurred even 
 more frequently than before; that is to say, about once a 
 month. With the future history of this gentleman I am unac- 
 quainted. 
 
 For the next two instances we are likewise indebted to Dr. 
 Marcet. The first of these occurred in a gentleman thirty 
 years of age, who had died with symptoms of renal calculi. 
 On examination after death, a number of calculi were found in 
 the kidneys, which proved to be of this variety. The second case 
 was that of an elder brother of the same gentleman, who had 
 died of a similar affection, and in whose kidneys calculi of a simi- 
 lar kind were found, accompanied by extensive disorganization 
 of the kidneys and prostate gland. It may be worth while, 
 
 * Marcet^ p. 82, first edition. Henry, Med. Chirurg. Trans., vol. x. p. 140. 
 t Op, et loc. cit. 
 
CYSTIC OXIDE. 
 
 233 
 
 also, to remark, that a third brother of the same family 
 died with symptoms of calculi ; but their nature was not 
 ascertained. 
 
 Two cases of this form of disease have occurred to Mr. 
 Brande, who has heard of no others. In one, the calculus was 
 voided by a labourer, but no particulars were known of his 
 case. In the other, several of these calculi, varying in size 
 from a pin's head to that of a pea, had been voided, at different 
 times during a period of thirty years, by a gentleman forty 
 years of age. He had been subject, from the age of six or seven 
 years, to pain in the region of the loins, not confined to any 
 particular spot, and seldom of any acuteness, or such as to 
 prevent his ordinary occupation, which obliged him to lead 
 rather a sedentary life. His usual state of health was 
 good ; his habits were regular ; his diet ordinary and plain. 
 He had used soda water, magnesia, and the alkalis, with- 
 out any advantage. The further history of this case is un- 
 known.* 
 
 A short time before the last edition of this work was pub- 
 lished, I had an opportunity of seeing a case of this rare form 
 of disease for the first time, through the kindness of Sir Astley 
 Cooper, who sent the gentleman to me to have the nature of 
 the stone he had lately passed from the kidney, ascertained. 
 This gentleman appeared to be about thirty years of age. He 
 had been subject to urinary diseases since 1818 ; when, in con- 
 sequence of exposure to cold, he was seized with severe pain, 
 accompanied by inflammation of the kidneys. Six months 
 afterwards, he, for the first time, observed retention of urine, 
 from what appeared to be calculus in the bladder ; and, in 
 1820, a stone was extracted from the bladder which weighed 
 upwards of two ounces. The nature of this stone does not ap- 
 pear to have been ascertained, but it was supposed to be oxalate 
 of lime. The present small calculus, which consisted of pure 
 cystic oxide, passed down from the left kidney, about a fort- 
 
 * Royal Institution Journal, vol. viii. p. 71. 
 
234 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETIOI 
 
 night before I saw him, with considerable pain. Since that 
 time he had been taking alkaline remedies ; which appeared to 
 give him more relief from the severe harassing pain in the 
 back, that he was almost al^^^ays subject to, than anything else. 
 The urine voided in my presence about five p.m. was copious; 
 of a yellowish green colour, and strong peculiar smell. Its 
 specific gravity was 1*020; and, almost immediately on being 
 passed, a greasy- looking film was formed on the surface ; and 
 at the same time rather a copious pale-coloured precipitate ap- 
 peared ; and the urine became alkaline. This film and sedi- 
 ment consisted chiefly of the triple phosphate of magnesia and 
 ammonia, mixed with a little cystic oxide. There was very 
 little urea ; and hardly a trace of lithic acid was perceptible 
 on the addition of an acid. 
 
 The urine passed early the next morning (all medicine having 
 in the mean time been omitted) was more remarkable, and cha- 
 racteristic, I presume,^ of this affection. Its colour and appear- 
 ance were much the same as before, except that the tint was a 
 little deeper, and the peculiar smell stronger. It very faintly 
 reddened litmus paper; -and its specific gravity was r022. 
 There was a slight deposition on standing for some time, con- 
 sisting of a mixture of the cystic oxide, with a little of the triple 
 phosphate. A considerable proportion, however, of the cystic 
 oxide was precipitated from the urine on the addition of acetic 
 acid, which of course held at the same time the phosphates 
 in solution. 
 
 This gentleman seemed strong and robust ; but was liable to 
 affections of the stomach, which appeared to arise, in part at 
 least, from sympathy with the derangement of the kidney. 
 What is remarkable, he stated that he had a twin-brother who 
 was likewise subject to urinary affections; but of what kind he 
 could give no information. 
 
 About the same time. Professor Stromeyer found the cystic 
 oxide in the form of gravel, and also in considerable quantity 
 in the urine of a patient afflicted with stone. " In this urine 
 the lithic acid was almost entirely wanting ; nor was the urea 
 
CYSTIC OXIDE. 
 
 235 
 
 found in it in the natural quantity."^ M. Lassaigne also met 
 with this substance in the form of calculus in the bladder of a 
 dog.-f- 
 
 In 1828 a case occurred to Dr. Venables, who has described 
 it in the Royal Institution Journal.J The patient was a stout 
 corpulent woman, forty-seven years of age, who passed a small 
 calculus of this substance, weighing eighteen grains. The 
 urine presented properties and phenomena very similar to 
 those above described ; and, like that specimen, appeared to be 
 remarkably deficient in urea and lithic acid. Dr. Willis, in his 
 work on urinary diseases, states that he has recently detected cys- 
 tic oxide in a case in which no renal calculus had been passed, or 
 was supposed to exist. The urine had the greenish yellow colour, 
 the peculiar smell, and the oily-like appearance above described , 
 and these properties drew his attention to the circumstance. 
 It had a specific gravity of 1*030, and was slightly acid ; but no 
 lithic acid could be detected in it ; though Dr. W. could not 
 discover that it was deficient in urea. No particulars of the 
 patient are given. § 
 
 The next case I shall refer to, is one more accurately de- 
 scribed and investigated than any, I believe, which preceded it. 
 The early particulars of this case are given by Mr. Golding 
 Bird. The patient was a young gentleman, at that time 
 about twelve years of age, from whose urethra (where it had 
 lodged) a small cystic oxide calculus was removed by Mr. C. 
 Aston Key, and which is now in the museum of Guy's Hospital. || 
 This stone was removed in May 1836; soon after which time 
 Mr. Bird had opportunities of examining the urine. The 
 specimen voided four days after the operation was neutral, 
 had a specific gravity of 1*01148, contained much mucus, and 
 
 * Annals of Philosophy^ (new series,) vol. viii. p. 146. 
 t Ann. de Chimie et de Physique, vol xxiii. p. 328. Also Annals of 
 Philosophy, (new series,) vol. vi. p. 316. 
 
 J Journal of Science and Arts, vol. xxix., January 1830. 
 
 § Willis on Urinary Diseases, p. 109. 
 
 II Guy's Hospital Reports, No. iii. p 486. 
 
236 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 deposited tlie triple phospliates intermixed with the cystic 
 oxide.* Mr. B. examined different specimens of this urine, 
 voided at various intervals after the operation. The last he 
 examined was passed about a month after the operation ; 
 and in this the albuminous matter and cystic oxide had dis- 
 appeared. 
 
 In October of the same year this young* gentleman came 
 under my care ; and I have occasionally seen him since then to 
 the present time. When I first examined the urine it was 
 rather turbid, of a greenish yellow colour, specific gravity 
 1*026, and slightly acescent. It had a strong disagreeable 
 odour, somewhat resembling putrid cabbage ; and it deposited, 
 particularly after meals, large quantities of the cystic oxide. 
 The nitro-muriatic acid was ordered, which seemed to check the 
 formation of cystic oxide ; so that the quantity in the urine at 
 length was almos^ imperceptible. He became better, and was 
 sent to school ; but in the following summer symptoms of cal- 
 culus in the bladder became evident; and in October of 1827, 
 a calculus was removed by lithotomy, by Mr. Key, about the 
 size of an almond, consisting of the cystic oxide nearly pure. 
 He recovered from the operation better than could have been 
 expected, and at present is quite well ; except that occasionally 
 the urine flows from him involuntarily. He has employed the 
 nitro-muriatic acid more or less since the operation to the present 
 time ; and the urine is now much more healthy than it 
 has been at any time ; though it occasionally deposits a 
 little of the cystic oxide, and still retains, in a greater or 
 
 One thousand parts of this urine were found to consist of — 
 
 
 974-444 
 
 Urea, with alkaline chorides, phosphates, and lactates 
 
 0-7 
 
 Aqueous extract, with alkaline sulphates 
 
 14-7 
 
 Albuminous matter and earthy phosphates 
 
 4-8 
 
 
 •016 
 
 Cystic oxide ... . . . . 
 
 •340 
 
 1000-000 
 
CYSTIC OXIDE. 
 
 237 
 
 less degree, the peculiar odour of urine containing that sub- 
 stance. 
 
 Mr. Bird has expressed an opinion that the cystic oxide 
 occurs in the urine in small quantity more frequently than has 
 been suspected. My own observations lead me to the same 
 conclusion ; and I have reason to believe that the peculiar 
 smell emitted by the urine in certain forms of organic disease, 
 depends on the presence of cystic oxide, or some analogous sub- 
 stance. A late writer has expressed an opinion that the cystic 
 oxide disease is of an hereditary character, and runs in mem- 
 bers of the same family ; and of this he adduces several remark- 
 able instances. The facts I had formerly mentioned led me to 
 the same conclusion ; and I have now very strong grounds for 
 believing that this diathesis is connected with certain forms of 
 hereditary disease.* 
 
 Dr. Marcet has observed that all the specimens of cystic 
 oxide calculi which he had noticed were remarkable for their 
 purity ; and hence he concludes that this diathesis has a more 
 exclusive tendency in regard to the formation of other kinds 
 of calculi than any other species of urinary concretion. Like 
 the oxalic and lithic acid diatheses, however, the cystic oxide dia- 
 thesis may be evidently followed by the phosphates ; as appears 
 from one of the specimens of calculus above described ; and 
 also from the examination of the urine ; in which the tendency 
 to the deposition of the phosphates had been evidently pro- 
 duced by the use of alkaline remedies. This diathesis, like the 
 mulberry, may be also followed by the lithic acid diathesis ; as 
 happened in one of the instances given by Dr. Wollaston above 
 quoted. Dr. Henry also mentions an instance of lithic acid 
 calculus having a nucleus of cystic oxide. Mr. Bird has, 
 moreover, given an instance in which the cystic oxide must 
 have coexisted with the oxalate of lime, and the lithate of 
 ammonia diathesis, as well as with the phosphates ; but the in- 
 ference he draws from this solitary fact is illogical ; and I have 
 not the least doubt, from my own observation, that Dr. 
 
 * See below. 
 
238 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 Marcet's general conclusion respecting the exclusiveness of 
 the cystic oxide diathesis, when fairly established, is quite 
 correct.* 
 
 With respect to the causes of the cystic oxide disease, it may 
 he observed, that in most of the cases mentioned, an inherited 
 predisposition to the affection, as to most other well-defined 
 urinary diseases, has seemed to exist. Of this fact, the circum- 
 stance that in several instances more than one member of the 
 same family suffered from the disease, offers a striking illustra- 
 tion. As a further illustration of the same observation, I may 
 remark, that the maternal grandmother of the young gentle- 
 man whose case I have briefly given, died of extensive and 
 peculiar disease, both\of the kidneys and liver. The exact na- 
 ture of the disease was not ascertained ; but the symptoms and 
 phenomena of the affection appeared to partake of a malignant 
 character. Among other remarkable circumstances, fatty matter 
 was often voided in the urine ; and the waxy character of the 
 countenance, and other symptoms, appeared to denote the pre- 
 sence of that peculiar form of hepatic disease, termed greasy 
 liver. With a strong predisposition to the disease, a variety of 
 causes may excite it into activity. Thus, in one of our instances, 
 exposure to cold appears to have operated as the exciting cause. 
 Of the proximate cause or intimate nature of the affection we 
 can say little. The peculiar composition of the cystic oxide, and 
 particularly the sulphur present, appear to denote its albumi- 
 nous origin ; and to show that its formation results either from 
 an imperfect assimilation of the albuminous principle ; or most 
 
 * Exceptions are requisite to constitute a general law. The law to 
 which no exceptions have been observed, is so far a universal law ; a law 
 to which no exceptions can happen, is a necessary law, and therefore uni- 
 versal. We have already pointed out the confusion arising from want of 
 attention to these logical differences ; and in the present instance we have 
 a striking example. Dr. Marcet suggested the generality of the law, that 
 the cystic oxide excludes other diatheses ; but neither he nor any one else 
 asserted that this law was a universal, much less a necessary, law ; that is 
 to say, that it was a law that neither did nor could admit of exceptions. 
 
CYSTIC OXIDE. 
 
 239 
 
 probably from the future action of the kidney on such imper- 
 fectly developed albuminous principle. 
 
 The diagnosis in this affection is sufficiently marked by the 
 peculiar properties of the cystic oxide itself ; and by the pro- 
 perties of the urine. With respect to the prognosis, from all I 
 have since seen, I am more and more confirmed in the belief I 
 formerly expressed, that it is generally unfavourable. I then 
 stated that in most cases the affection seemed to be connected 
 with diseased kidney, of which it appeared to be the con- 
 sequence or cause ; and that in all instances an invete- 
 rate disposition to urinary diseases, apparently inherited, was 
 evident ; observations fully borne out by my subsequent 
 exjDerience. 
 
 Lastly, with respect to the treatment of the affection, little, 
 perhaps, can be satisfactorily stated. A carefully regulated 
 diet, consisting chiefly of animal and farinaceous matters, seems 
 to be indicated ; while all indigestible matters, all severe ex- 
 ercise, and other circumstances calculated to derange the sto- 
 mach, or excite inflammatory action and fever, to which there 
 seems to be a strong tendency, should be avoided. Among 
 remedies, alkalis may be sometimes proper ; but much more 
 frequently the use of acids seems to be indicated. Of acids, 
 I have generally preferred the nitro-muriatic ; which I was 
 first induced to employ, from observing its remarkable power 
 of correcting a strong and peculiar odour occasionally con- 
 nected with the urine ; and which seems to be closely allied 
 to the smell produced by the cystic oxide. Under the use 
 of this acid, I have seen the peculiar smell of the urine in 
 the cystic oxide diathesis very much abated ; and all the 
 properties of the secretion so much improved, that the pe- 
 culiar principle itself has for a time disappeared. On leav- 
 ing off the remedy, the complaint, however, in general, has 
 shown a disposition to return ; but, by recurring to the 
 medicine, the deposition has been again suspended ; and this 
 alternation has repeatedly occurred in the same individual. 
 
 It need scarcely be noticed, that attention to the general 
 
240 PATHOLOGY OF ALBUMINOUS ASSIMILATION AND SECRETION. 
 
 health, and especially to the state of the bowels, will be 
 proper. Mercurial alteratives and purgatives, also, may be 
 occasionally required ; but I have reason to believe, that mer- 
 cury, if pushed too far. is capable of doing much mis- 
 chief. Finally, if obvious disease of the kidney be present, 
 local counter-stimuli, as setons or issues, may be serviceable in 
 some instances. 
 
 / 
 
241 
 
 CHAPTER III. 
 
 GENERAL OBSERVATIONS ON THE PATHOLOGY OF OLEAGINOUS 
 ASSIMILATION AND SECRETION. 
 
 Although the oleaginous aliments and tissues, whether viewed 
 with reference to health or to disease, do not occupy the pro- 
 minent place of the saccharine and albuminous aliments and 
 tissues ; yet as all the more perfect animals involve the oleagi- 
 nous principle, we may conclude that its presence confributes 
 in some way to the welfare, if not to the very existence, of the 
 animal economy. Moreover, if this inference be taken for 
 granted, we may also infer, that like the other great sta- 
 minal principles, the assimilation of the oleaginous principle, 
 both primary and secondary, is not only liable to be deranged ; 
 but give occasion to various secondary diseases. Now that 
 such derangements of these secondary diseases (of the nature of 
 which, we must confess at the outset, we know much less than 
 we ought to know,) constitute the principal subject of the 
 present inquiry. 
 
 The peculiar affections which we shall select as resulting 
 from deranged assimilation of the oleaginous principle are ; 
 First, certain affections connected with an excessive and de- 
 ficient quantity of oleaginous matters in the system ; obesity 
 and leanness : and secondly, certain affections connected with 
 the mal-assimilation of the oleaginous principle, and produc- 
 ing derangements in the qualities of the principle ; of which, 
 as a particular illustration, will be given the history of Biliary 
 concretions, or gall stones. 
 
 R 
 
242 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 Section a. — Of Obesity and Leanness. 
 
 We have stated in the Introduction that the natural law of 
 the deposition of fat varies considerably at different ages, and 
 in the different sexes. In children and in females, especially 
 in early age, the chief seat of the fatty deposit is in the cellu- 
 lar texture infmediately under the skin. During adolescence, 
 the fat has a tendency to disappear from this situation ; but, 
 about the middle age, it frequently becomes again deposited 
 not only in the subcutaneous tissues ; but also in the neigh- 
 bourhood of certain internal viscera. In a perfectly healthy 
 individual, however, no abnormal deposition of fat can be sup- 
 posed to take place, at any age or in any locality ; provided the 
 natural appetites and muscular powers be regulated as they 
 ought. Whenever, therefore, we see an individual unnaturally 
 fat or lean, we may safely conclude that an error exists some- 
 where ; and that such an individual either inherits a propen- 
 sity to disease, or is producing for himself such a propensity. 
 The chief circumstances which seem to concur in producing 
 derangements of the oleaginous assimilation, are the following : 
 
 First, an inherited tendency. No one can doubt that 
 certain families have a natural tendency to obesity, which can 
 be often traced through many successive generations. It is 
 curious also to observe how this tendency is varied in different 
 families, and even in different individuals of the same family. 
 Thus in one family we see the children or females possess a 
 striking tendency to embonpoint; while the male adults, 
 particularly in advanced age, are as remarkable for their lean- 
 
OBESITY AND LEANNJISS. 
 
 243 
 
 ness. In another family, directly the reverse may be ob- 
 served, and the children or females are lean, diseased, and 
 squalid ; while the middle-aged adults are conspicuous for 
 their obesity. These, and other variations which might be 
 named, doubtless indicate deviations from the normal state of 
 health, which, if carefully studied, might throw no small light 
 on the nature of many hereditary affections, at present but 
 little understood. 
 
 Other circumstances which seem to exert considerable in- 
 fluence on the deposition of fat, are climate and locality. The 
 inhabitants of low swampy situations in temperate climates 
 are usually remarkable for their bulky flabbiness and propen- 
 sity to corpulence ; while the inhabitants of very hot, and of 
 very cold climates, as well as the inhabitants of mountainous 
 regions, have perhaps less tendency to obesity.^' There is this 
 remarkable difference, however, between the inhabitants of hot 
 and of cold climates; the inhabitants of hot climates can 
 scarcely become fat without becoming otherwise diseased ; 
 while the inhabitants of cold climates seem not only to derive 
 protection from the influence of the external cold, by the 
 layer of fat with which their bodies may become enveloped ; 
 
 * The reader is desired to observe that the natural tendency is to be 
 here understood, such as it exists (or ought to exist) in civilised society. 
 Bodily and mental indolence and overfeeding will induce obesity every- 
 where, and in hot climates perhaps, even sooner than in cold ; of which 
 innumerable disgusting instances are given by travellers among the 
 savages of Africa. As stated, however, in the text, there is reason to 
 believe, that corpulence degenerates into disease, sooner in warm, than 
 in cold climates ; particularly in Europeans. On the other hand, although 
 there appears to be naturally little tendency to corpulence in cold cli- 
 mates ; but even to leanness, on account of the scantiness, and the labour 
 of procuring food; yet mankind in a savage state, like mere animals, as 
 the Esquimaux, for example, sometimes become fat in cold climates. 
 In these instances the fat appears to serve the useful purpose, by its 
 feeble conducting powers, of causing the retention of the animal heat ; 
 and thus of mitigating the effects of the external cold. Perhaps also, as 
 stated in the text, by combining with oxygen, the carbon of the fat may, 
 in some way, even contribute to the development of heat. 
 
 ii2 
 
244 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 but the superfluous carbon of the fat by combining with oxygen, 
 during the secondary assimilating processes, has, with some 
 reason, been supposed to contribute to the production of 
 animal heat. Many beautiful provisions illustrative of these 
 observations might be pointed out, did our time and subject 
 permit ; we pass on, however, to the consideration of diet and 
 exercise^ two other very important circumstances influencing 
 the deposition of fat in animals. 
 
 Healthy individuals who spend their time in sleep, and in 
 bodily and mental indolence, and who partake largely of fat 
 and luxuriant food, and of ale or other strong malt liquors, 
 have at all ages a, tendency to become corpulent. This ten- 
 dency to become corpulent, however, is usually most remark- 
 able about the middle period of life, when it is apt to termi- 
 nate in gout, or some still more formidable disease ; particu- 
 larly if the individual persists in his indolent and luxurious 
 habits. It is by the practical application of these well-known 
 facts, that animals are fattened for domestic use, and the ra- 
 tionale of the process is sufficiently obvious; as is also the 
 rationale of certain refinements of cruelty, said to be prac- 
 tised in the fattening of particular animals ; as, for instance, 
 in the fattening of geese, in which the poor animals 
 are immovably fixed in a high temperature, and crammed till 
 their livers become diseased.*' We have alluded abo\e to 
 the influence of temperature with reference to corpulence ; 
 and we may now further observe, that as regards diet, 
 temperature, even in the same climate, is a point of con- 
 siderable importance ; and on a hot day in summer, most in- 
 dividuals would turn with disgust from the fat roast beef, and 
 the greasy mince pies, which they would relish at Christmas. 
 Nature has furnished ample supplies of food appropriate for 
 
 * It is probable that in this and many similar instances the poor ani- 
 mals sometimes have their revenge. Indolent and dyspeptic individuals 
 who partake of these diseased and poisonous productions can scarcely be 
 supposed in all instances to assimilate them ; and consequently run con- 
 siderable risk in inoculating and converting their own livers or other 
 organs into a similar mass of disease. 
 
OBESITY AND LEANNESS. 
 
 245 
 
 all climes and seasons ; and when the dietary thus beneficently 
 provided is violated, as, for instance, when large quantities of 
 fatty matter are taken in warm climates or seasons, they inva- 
 riably produce derangements more especially of the liver ; and 
 the transgressor is sure to be punished for his temerity. 
 
 Such are the most prominent circumstances which favour a 
 tendency to obesity in healthy individuals ; there are, however, 
 many instances of obesity which cannot be referred to any of 
 these causes, and in which the tendency must in part be con- 
 sidered as a disease. Thus I have seen individuals (chiefly 
 middle aged females) oppressed with fat, whose habits with 
 regard to eating and drinking were very moderate ; and who 
 took as much exercise as most people of their age. Such 
 individuals, to use their common expression, would grow fat 
 on bread and water — an expression apparently not exaggerated. 
 In cases of this kind it is impossible to suppose that all is right ; 
 and the primary organs of assimilation must either convert 
 the greater part of the aliments taken into fatty matter ; or 
 the secondary organs of assimilation, from imperfect or sus- 
 pended action, must fail to do their duty, and thus allow the 
 fat to accumulate. It is probable that both these circumstances 
 coexist ; and that in such cases the secondary assimilating pro- 
 cesses are very imperfectly performed. In corroboration of 
 which remark, it may be mentioned, that I have generally 
 observed such unnaturally fat individuals to die prematurely 
 of organic disease, in which the liver appeared to be particu- 
 larly involved. 
 
 The term leanness, as here understood, implies a simple ab- 
 sence of fat ; and is not to be confounded with thinness and 
 emaciation — terms expressing in different degrees the absence, 
 not only of fat, but also of the gelatinous and albuminous 
 tissues. Leanness, like obesity, when extreme, and when it 
 cannot be referred to a satisfactory cause, must be accounted a 
 disease. In such cases, leanness is usually accompanied 
 by more or less of thinness or emaciation — states of the 
 system which, if not explicable on obvious principles, must 
 almost always be considered as morbid. 
 
246 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 Leanness, like obesity, depends either on predisposing or on 
 exciting causes. That some individuals have a natural tendency 
 to leanness as others have to obesity, there cannot be a doubt. 
 Moreover, such tendency to leanness often runs in families, 
 and even descends through several generations. The exciting 
 causes of leanness, like those of obesity, may be considered 
 under the heads of climate and locality ; and diet and exercise. 
 I know of no climate or locality, the inhabitants of which are 
 naturally lean ; except the inhabitants of mountainous regions, 
 may be said to be so. Leanness, more than from any other 
 causes, results from deficient or innutritions diet ; from the 
 free use of acid liquors, as cider, &c. ; from excessive bodily 
 and mental activity ; and from a variety of affections capable 
 of deranging- or suspending the primary assimilating processes, 
 and thus of cutting off the supplies ; the modus operandi of 
 all which, and particularly of deficient and innutritions diet, 
 and of excessive bodily exercise, is sufficiently obvious. 
 
 Another cause of leanness may consist in a natural imper- 
 fection of the faculty of assimilating the oleaginous principle ; 
 or, as just stated, such imperfection may be induced by a variety 
 of circumstances. This incapacity of assimilating oleaginous 
 matters shows itself in a variety of ways. Thus there are 
 some individuals whose stomachs will not tolerate the least 
 portion of fatty matters ; there are others, who, though the 
 stomach may tolerate fat, never fail to subsequently suffer 
 from its use, by what is called bilious derangement. Such 
 individuals are usually lean. On the other hand, there are 
 individuals whose stomach will bear any quantity of fat with 
 impunity, and who yet remain lean ; or certainly, at least, do 
 not become fat ; however freely they may partake of oleaginous 
 matters. These three conditions of the system undoubtedly 
 depend on very different causes. The two first conditions, in 
 particular, most usually occur in individuals of an anxious and 
 nervous character ; of great mental susceptibility and ac- 
 tivity ; and who, moreover, have suffered much mental afilic- 
 tion, real or imaginary. The first form, in particular, viz. the 
 total incapacity of taking oleaginous matter in any state, I 
 
OBESITY AND LEANNESS. 
 
 247 
 
 have once or twice seen connected with cerebral disease, which 
 has subsequently proved fatal. In spare individuals, who take 
 fat with impunity, the fat is either not assimilated at all, and 
 passes through the bowels unchanged, as in many strumous 
 individuals ; or if the fat be primarily assimilated, the second- 
 ary functions dispose of it as fast as it is deposited, so as to 
 prevent its accumulation. This latter more particularly occurs 
 in healthy individuals who take much exercise, or are mentally 
 worried ; and who under no system of diet whatever would 
 become fat. As a general rule, perhaps, it may be finally 
 stated that obesity is connected with hsemotrophy, and lean- 
 ness with ansemotrophy ; but the preceding remarks will show 
 that though this rule is almost necessarily true in extreme 
 instances, yet that, under the common circumstances in which 
 mankind is placed in a state of civilisation, there are nume- 
 rous apparent exceptions to it.* 
 
 Although the oleaginous principle, from what has been 
 elsewhere, as well as above, stated, seems to be less subjected 
 to change in the primary assimilating organs than either of 
 the other great alimentary principles, so that it is doubtful 
 whether it be converted by the mere action of the stomach, 
 &:c., into albuminous matters ; yet the case is very different 
 with respect to the operations of the secondary assimilating 
 processes on this principle. In those important secondary 
 assimilating processes, for instance, which are constantly going 
 on in all organized beings, and which cannot cease for a moment 
 without the destruction of the being, the oleaginous principle 
 obviously plays a very important part. Thus in febrile and 
 other diseases, in which the primary assimilating processes are 
 often entirely suspended, the rapid disappearance of fatty and 
 other matters from the system, and the consequent general 
 emaciation produced, not only show that the secondary assimi- 
 
 * It is a popular notion that frequent bleedings favour obesity ; and 
 perhaps, by conducing to bodily and mental inactivity, it nuiy do so within 
 certain limits. 
 
248 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 lating processes are even more active than in health ; but that 
 the fatty matter, in common with the other matters, is some- 
 how appropriated to the purposes of the economy. The same 
 appears from the phenomena of hibernating animals, which 
 may be almost said to live on their fat during their dormant 
 state. The exact changes which the fat undergoes during 
 these secondary assimilating processes are unknown ; but in 
 whatever these changes consist, they are probably essential to 
 the existence of organic life ; and therefore of first-rate im- 
 portance. 
 
 That the oleaginous principle, as laid up in the great reser- 
 voirs in which It is deposited in animals, partakes less of the 
 characters of a living organized substance than either of the 
 other constiiuents of which their bodies are composed, cannot 
 be doubted ; yet that fat, or some nearly allied principle, ad- 
 mits of the highest degree of organization of which matter is 
 perhaps capable, is evident from the large proportion into 
 which it enters in the nervous and cerebral tissues ; one fourth, 
 at least, of the solid matters composing which tissues is said to 
 consist of oleaginous principles. With the oleaginous principles 
 are associated an unusually large proportion of phosphorus and 
 other incidental mineral matters ; the use of which, as well as 
 their states of combination, are absolutely unknown to us. The 
 proportion of the nervous and cerebral masses to the other 
 soft parts of animals is comparatively small, but of course is 
 different in different animals ; as a general rule, the proportion 
 is the greatest in the more perfect animals, in whom the brain 
 and nervous system are the largest. Moreover, as the quan- 
 tity of fatty matter in animals seems to bear an inverse rela- 
 tion to the quantity of bodily and mental, i. e. of nervous 
 activity ;^ can the leanness proverbially produced by nervous 
 
 * The reader will observe that the term nervous is to be here taken in 
 its most comprehensive sense ; that is, as including all vital acts, from the 
 lowest automatic, to the highest mental and abstract; every one of which 
 acts is equally accomplished through the medium of different forms of 
 organized nervous matter. 
 
OBESITY ASB LEANNESS. 
 
 249 
 
 activity be referred to the more rapid consumption, and conse- 
 quent renovation from the oleaginous principle, of the general 
 mass of nervous matter ? Further, is not this extra consump- 
 tion of the nervous matter attended by the presence of a 
 larger proportion of phosphorus in the urine ? And cannot 
 the occasional appearance of a large proportion of the earthy 
 phosphates in the urine be referred to the same operations ? 
 
 We have made these remarks for the sake of bringing 
 together under one point of view the little we know of the 
 general physiology, and particularly of the assimilation, of the 
 oleaginous principle. They are acknowledged to be very 
 imperfect ; but the remarks, incomplete as they are, may have 
 the effect of drawing the attention of others to the subject ; 
 we shall, moreover, have occasion to refer to some of them in 
 subsequent parts of this volume. 
 
 Although obesity and leanness may, as we have seen, be- 
 come of themselves diseases ; yet in all their common modes 
 of existence they are rather to be considered as symptoms 
 only. A formal account of the treatment of obesity and 
 leanness, therefore, is not necessary ; and they much more 
 naturally fall to be considered in connexion with those pecu- 
 liar conditions of the system to which they usually belong as 
 symptoms. 
 
250 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 Section h. — Of Cholesterine and its deposites. 
 
 As an illustration of tlie Pathology of the oleaginous principle, 
 we shall briefly consider the phenomena and symptoras of that 
 condition of the hepatic system terminating in the formation 
 of biliary concretions ; as well as the secondary symptoms 
 arising from the presence of such concretions. 
 
 The existence of biliary concretions, and consequently the 
 part they perform in the production of disease, seem to have 
 been unknown to the ancients ; and it was not till anatomy 
 began to be practically studied in the seventeenth century, 
 that their existence and connexion with disease appear to have 
 been distinctly recognised.* After their discovery, their 
 pathology attracted considerable attention ; but their chemical 
 composition and relations remained unknown till towards the 
 middle of the last century ; when the celebrated Haller, I 
 believe, first pointed out the nature and some of the proper- 
 ties of the peculiar substance of which gall stones usually con- 
 sist. This substance was subsequently examined by others, 
 and particularly by Fourcroy, who confounded it with the 
 principle he named Adipocere. At a later period, Chevreul 
 took up the inquiry, and, after determining it to be a princi- 
 ple sui generis, gave it the name it now generally bears, viz. 
 Cholesterine. 
 
 Although cholesterine forms the most usual and abundant 
 
 * Previously to this period, if recognised at aii^ gall stoDes appear 
 to have been confounded with the intestinal concretions called by the 
 general term Bezoars. 
 
GALL STONES. 
 
 251 
 
 ingredient of biliary concretions, yet, as we stated in the in- 
 troduction, these concretions sometimes consist of other ingre- 
 dients. The subject, however, has not been studied as it 
 deserves ; so that we can neither point out the pathological 
 relations of the different species of concretion, nor even of 
 cholesterine itself, so clearly as could be wished. Indeed, 
 beyond the mere mechanical symptoms and effects produced 
 by these concretions, we know but little ; and as the little we 
 do know will appear to the greatest advantage by way of in- 
 ference from the phenomena, we shall in the first place briefly 
 state the pathological history and symptoms of biliary concre- 
 tions. 
 
 Biliary concretions are most usually found in the gall 
 bladder, or in the common duct communicating with the intes- 
 tine. They are not, however, confined to these localities, but 
 have been also met with in almost every situation to which 
 the bile has access ; as for instance, in the cystic duct ; in the 
 hepatic and biliary ducts, and their ramifications ; in various 
 parts of the intestines ; Sec. Their more frequent appearance 
 in the gall bladder has been accounted for from the longer 
 sojourn and stagnated state in which the bile exists in that 
 receptacle ; but when we consider that the existence of con- 
 cretions in the gall bladder constitutes the exception rather 
 than the rule ; and that their occasional occurrence in the 
 minute ramifications of the bile ducts, can only be explained 
 on the supposition that the biliary principles of which they 
 are formed are in an unnatural and isolated state ; we may 
 probably infer, with tolerable certainty, that wherever gall 
 stones exist, the properties of the bile, and consequently 
 the functions of the liver, deviate from the state of health. 
 Moreover, we may generally infer, that when gall stones 
 are found in the intestines, their nuclei at least have been 
 formed in the gall bladder. More frequently, however, on 
 such occasions, the gall stones have had the appearance of 
 being entirely formed in the gall bladder; from whence 
 they have passed to the intestines, either through the ex- 
 
252 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 panded common duct, or through an ulcerated opening, in a 
 manner to be presently explained. 
 
 The symptoms produced by biliary concretions, may be 
 divided into primary and secondary. By primary symptoms 
 are meant those derangements of the health, and more espe- 
 cially of the liver, vrhich give occasion to the formation of gall 
 stones ; under the head of secondary symptoms are included 
 all those derangements connected with, or arising from, the 
 mechanical irritation they produce. 
 
 The primary symptoms accompanying the formation of gall 
 stones, and dependent on their general pathology, are, as we 
 have said, very imperfectly understood ; and if any symptoms 
 peculiarly characteristic of such a state of the system exist, they 
 have beeii hitherto overlooked ; or confounded with the symp- 
 toms of other derangements. On this part of our subject, 
 therefore, we have little to offer ; and the few remarks to be 
 made will be advantageously deferred till we have entered 
 more fully into their history. 
 
 The secondary symptoms produced by gall stones actually 
 formed differ exceedingly according to their locality, magni- 
 tude, and a variety of other circumstances ; as the following 
 observations will show. 
 
 Unless of unusual magnitude, gall stones give very little 
 uneasiness when quiescent in the gall bladder ; and when they 
 do not obstruct the passage of the bile from that receptacle. 
 Hence gall stones are often found in the gall bladder after 
 death, the presence of which had never been suspected during 
 the lifetime of the patient. When of unusual size, or when a 
 great number of them exist in the gall bladder, patients some- 
 times complain of a sense of uneasiness in the region of the 
 organ ; the functions of the stomach and bowels are more or 
 less deranged ; the motions become deficient in bile ; and the 
 eyes and general countenance slightly jaundiced ; sometimes 
 there is a sense of fulness and tenderness in the epigastrium ; 
 accompanied by an uneasiness in the region of the liver, which 
 extends through to the right shoulder blade, and occasionally 
 
GALL STONES. 
 
 253 
 
 affects more or less the whole of the right side of the 
 abdomen, and even the right arm. This uneasiness is apt to 
 be increased by certain movements of the body ; or by a deep 
 inspiration. When the concretions are very large, or obstruct 
 the passage of the bile so as to cause distension of the gall 
 bladder, the distended organ can in thin persons be some- 
 times distinctly felt. The constitutional symptoms attendant 
 on the presence of gall stones, and resulting either from their 
 mechanical irritation or from the peculiar diathesis producing 
 them, or most likely from both causes, are, in different indivi- 
 duals, and under different circumstances, very various and 
 anomalous. Sometimes the brain and nervous system in gene- 
 ral are particularly affected, and there is headache, vertigo, 
 convulsive starting, cramp, &;c. ; the spirits also are unusually 
 depressed ; and there is complete hypochondriasis. At other 
 times the assimilating organs more especially suffer ; and in 
 connexion with a greater or less degree of the nervous symp- 
 toms, there is obstinate dyspepsia, particularly marked by great 
 acidity of the stomach ; and a colicky, irregular condition of 
 the bowels. There is frequently congestion of the abdominal 
 viscera, with a tendency to hsemorrhois ; and in females the 
 catamenia are apt to become disordered, being either in excess, 
 or in the opposite extreme, or even altogether suppressed. 
 The urinary organs often become particularly involved ; the 
 urine is not only loaded with bile, but is occasionally serous ; 
 or deposits large quantities of lithic acid gravel, &;c. The 
 bladder often participates in the derangement, becomes highly 
 irritable, and its inner membrane throws off much mucus. 
 At other times the mucous membrane is but little affected, 
 and the urine is limpid and colourless, and voided in inordi- 
 nate quantity. I have seen several instances of biliary con- 
 cretion, in which the urinary derangements have become so 
 prominent as to exclude the other symptoms ; so that the true 
 nature of the disease has been overlooked. Thus many years 
 ago I attended a patient for a supposed urinary affection 
 which disappeared after an attack of gall stones, the existence 
 
254 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 of which had not been suspected. In this case the urine was 
 copious, almost limpid, and constantly serous ; there was con- 
 siderable irritation of the bladder, particularly towards the 
 morning ; a dull uneasy sensation was also felt about the region 
 of the kidneys, and the functions of the stomach and bowels 
 were much disturbed. All these and other symptoms, how- 
 ever apparently indicating renal affection, to my surprise, 
 either left or ceased to trouble my patient after a severe 
 attack of jaundice, accompanied by the passage of gall stones. 
 In this case, a great tendency to disease, if not actual incipient 
 disease of the kidneys, was excited, or perhaps produced, by a 
 remote mechanical irritant. Nor can there be any reason to 
 doubt, that if this exciting cause had not been removed, the 
 disease of the kidneys would have become confirmed and taken 
 its usual course. I am unable to state whether the urine en- 
 tirely recovered its healthy condition, or having recovered its 
 healthy condition, whether it still retains such condition ; 
 but the patient is alive, and apparently well. Such are the 
 symptoms most commonly accompanying the presence of con- 
 cretions in the gall bladder. During the passage of these 
 concretions from the gall bladder to the intestines, another 
 and much more formidable train of symptoms is usually pro- 
 duced, which we have in the next place to consider. 
 
 The symptoms produced by the passage of gall stones from 
 the gall bladder are generally sudden in their invasion ; severe 
 both in kind and degree ; and for the most part assume the 
 paroxysmal form. The attacks usually commence two or three 
 hours after eating, with uneasiness and pain in the region of 
 the gall bladder, which rapidly increases, and at length be- 
 comes so excruciating that the patient is almost bent double ; 
 or rolls about the room in agony ; or sometimes falls into a 
 state of syncope. The pain is usually somewhat mitigated by 
 pressure ; hence the hands are instinctively and forcibly ap- 
 plied to the epigastrium. To this severe state of suffering, 
 there is superadded the most distressing nausea and tendency 
 to vomiting; and the matters ejected are intensely acid or 
 
GALL STONES. 
 
 255 
 
 bitter. The stomach and bowels are distended with flatulence, 
 which sometimes produces painful cholic ; there is usually a 
 tendency to constipation ; and the motions, whether naturally 
 or artificially produced, on account of the obstruction of the 
 biliary secretion, are always clay-coloured, and deficient in 
 bile. The paroxysms are of uncertain duration; sometimes 
 lasting for a few hours only, at other times extending over 
 several days, with intervals of comparative remission from suf- 
 fering ; but in almost all instances, especially when the attacks 
 last for a considerable time, or are unusually severe, or re- 
 peatedly occur at short intervals, the system becomes sur- 
 charged with bile ; and there is either complete jaundice, or the 
 eyes at least assume a yellowish tinge. The urine also becomes 
 scanty, and loaded with bile ; and occasionally there is consider- 
 able irritation about the bladder. During the whole of this 
 time the pulse is scarcely affected, and there is no fever ; except 
 in violent and protracted cases, when the tongue becomes 
 loaded ; there is less of flesh and strength ; and the epigastric 
 region becomes tender to the touch, showing incipient inflam» 
 matory action. In favourable cases the attacks usually termi- 
 nate as suddenly as they began, the moment the gall stone 
 has escaped into the intestines ; and if there be no repetition 
 of the paroxysm, the patient speedily recovers his former 
 health and spirits. 
 
 Biliary concretions, from the mechanical irritation they 
 produce, often give occasion to various forms of organic de- 
 rangement or disease. Of such effects, innumerable instances 
 are related by different authors ; but the following are among 
 the most usual and remarkable : 
 
 Perhaps one of the most frequent, as well as favourable 
 effects produced by biliary calculi, is dilatation of the biliary, 
 and particularly of the common duct; by which not only the 
 exit of concretions already formed, but of those that may be 
 formed hereafter, is promoted, and thus much of the suffering 
 which would have been induced by them, is consequently pre- 
 vented. When we consider the small size of the common 
 
256 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 duct in its healthy state, the extent to which its dilatation is 
 sometimes carried seems almost incredible, were the facts not 
 well authenticated. Thus the celebrated Morgagni relates a 
 case in which he found the diameter of the common duct 
 dilated to nearly two fingers' breadth ; and many instances are 
 recorded, in which the duct has been found large enough to 
 admit the finger. Another effect of biliary concretions, which 
 proves speedily fatal, is rupture of the gall bladder. In such 
 instances, the passage of the bile has been observed to be 
 completely obstructed by the gall stone ; and the bile, by ac- 
 cumulating in the gall bladder, has caused this organ to 
 become so distended, that its coats have suddenly given way ; 
 generally during a severe fit of vomiting. Other effects pro- 
 duced by gall stones, particularly when of large size, or very 
 numerous, are inflammation and ulceration, not only of the 
 gall bladder and its appendages, but of contiguous viscera. 
 On such occasions, adhesions occasionally take place between 
 the gall bladder or its ducts, and different internal cavities ; 
 or sometimes even between the gall bladder and the external 
 parietes of the abdomen. These adhesions favour the exit of 
 the concretions ; which gradually make their way by an ulce- 
 rative process through the adhering parts, and thus finally 
 escape into the stomach, colon, cavity of the abdomen, &c. ; or 
 even occasionally at the external surface of the body, through 
 openings in the epigastrium, the umbilicus, &c. ; instances of all 
 which, as well as of other remarkable escapes of biliary con- 
 cretions, are mentioned by different authors. 
 
 Nor are these the only secondary effects produced by biliary 
 concretions ; for in some instances, when they have left the 
 gall bladder and passed into the intestines, by subsequently 
 obstructing and otherwise interfering with the functions of 
 this canal, they give occasion to many distressing symptoms. 
 When of small, or of moderate size, they produce little incon- 
 venience during their passage down the canal, besides tempo- 
 rary constipation, colic, tenesmus, &c. ; but when of large 
 size, they sometimes lodge in various parts ; particularly in 
 
GALL STONES. 
 
 257 
 
 the caecum, or in the sigmoid flexure of the colon, or in the rec- 
 tum, when they cause obstruction, terminating in inflammation, 
 &c., and thus not only endanger, but even destroy the life of 
 the patient. Instances are also recorded in which biliary 
 concretions impacted in the caecum, &;c., have produced ulce- 
 ration, and been discharged externally. 
 
 Causes. — The general pathology and peculiar conditions of 
 the system predisposing to, or inducing the formation of biliary 
 concretions, have, as already stated, been imperfectly studied, 
 and consequently are not well understood. The little that is 
 known, chiefly applies to the variety of concretion consisting 
 of cholesterine, to vfhich, therefore, our observations v/ill be 
 principally directed. 
 
 That cholesterine is connected with the oleaginous principle 
 is evident from its chemical properties and composition ; 
 indeed it contains a larger proportion of carbon than any 
 known crystallisable solid in which likewise both oxygen and 
 hydrogen exist. Cholesterine, as formerly noticed, is said to 
 be an ingredient of healthy bile, as the lithic acid is of the 
 urine ; and like the lithic acid, in the healthy condition of that 
 secretion, seems to be retained in a state of solution. The 
 nature of this state of solution, however, is not known ; but 
 in certain diseases it appears to be imperfect or deranged, 
 and the cholesterine, set free from its solvent, becomes deve- 
 loped in its pure and crystallised form, and thus gives occasion 
 to biliary concretions ; precisely as in certain conditions of the 
 system, the lithic acid is set free and gives occasion to urinary 
 concretions. Cholesterine also, like lithic acid, is found in 
 places remote from the organ where it is supposed to be prin- 
 cipally developed ; as, for instance, in cavities and cysts in 
 various parts of the body, the contents of which have been 
 long pent up and retained in a passive state, ^n such cases, 
 the cholesterine has been probably developed on the spot from 
 the oleaginous principle ; and not formed in, or by, the agency 
 of the hepatic system — a circumstance which, if well founded, 
 
 s 
 
258 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 seems to throw liglit on the development of this prmciple in 
 the liver itself. 
 
 Biliary concretions are of very rare occurrence before the 
 age of puberty ; and indeed are seldom met with before the 
 middle or decline of life. They are so much more common 
 in females than in males, that we sometimes see four or five 
 cases in women, for one in men. They occur most frequently 
 in corpulent individuals who live fully, take but little exercise, 
 and spend much of their time in sleep. Such habits, together, 
 perhaps, with a peculiar predisposition to derangements of the 
 assimilatin'^ processes, favour dyspepsia in all its forms ; and 
 particularly a torpid and congested condition of the hepatic 
 system. It has been supposed that those who more particu- 
 larly suffer from lithic acid deposites, are less liable to biliary 
 concretions ; but were I to judge from my own experience, I 
 should say that this opinion is not well founded ; and that the 
 two states of disease often go together. Indeed, I have seen 
 few cases of biliary concretions, in which the urinary organs 
 have not in some way been seriously deranged. The popular 
 notion, that urinary calculi are more frequent in men, and 
 biliary concretions in women, on which the above opinion 
 seems to be founded, probably arises more from accidental 
 circumstances than reality. The reasons why women are less 
 subject to urinary calculi than men, are obviously mechanical ; 
 and have no reference to the frequency or infrequency of the 
 calculous diathesis. For even supposing the tendency to cal- 
 culous deposits in the two sexes to be the same, the reasonable 
 inference must be, that men will be much more likely to sufier 
 from stone in the bladder, than women. While, therefore, it 
 must be admitted that women are more subject to gall stones 
 than men ; this admission proves nothing with regard to the 
 equally admitted fact, that men are more liable to urinary 
 concretions than women ; because this latter fact can be other- 
 wise satisfactorily explained ; even supposing the tendencies to 
 urinary derangements in the two sexes to be equal. The 
 
GALL STONES. 
 
 259 
 
 real question is, whether women, were they not thus favoured 
 by natural conformation, would not be more subject than men 
 to urinary concretions, as they are admitted to be to biliary con- 
 cretions? This question in the present state of our knowledge 
 cannot, and probably never will, be satisfactorily answered ; 
 but my belief is, that, cceteris paribus, women would be at least 
 as much, if not more, liable to urinary concretions than men. 
 
 Biliary concretions, though occasionally, are not necessarily, 
 connected with diseased liver. Many instances occur of biliary 
 concretions, in which the structure of the liver is not visibly 
 deranged ; while, on the other hand, innumerable cases of 
 diseased liver occur, in which biliary concretions do not exist. 
 In this resjiect we have another analogy between cholesterine 
 and lithic acid ; lithic acid, as we formerly stated, not being 
 necessarily connected with a diseased kidney. Further, the 
 very condition (hsemotrophy) of the system favouring the 
 development of lithic acid, seems also to favour the develop- 
 ment of cholesterine ; for, as lithic acid is seldom found in the 
 anaemotrophied kidney, of which the granulated kidney of Dr. 
 Bright may be considered as an extreme instance ; so deposites 
 of cholesterine, I believe, are seldom found in the correspond- 
 ing states of the hepatic system produced by the abuse of 
 ardent spirits. 
 
 On the whole, then, we may conclude that cholesterine con- 
 cretions arise from, or are connected with the imperfect assimi- 
 lation, primary and secondary, of the oleaginous principle ; 
 and a retarded and sluggish action of the liver — circumstances 
 most frequently associated with a peculiar haemotrophied con- 
 dition of the body, produced or aggravated by a full diet ; by 
 the use of generous wines and malt liquors ; by muscular inac- 
 tivity, and too much sleep ; and perhaps, in some instances, by 
 certain modifications or degrees of malarious influence ; the 
 effects of which on the hepatic, in common with the system in 
 general, are well known. Finally, it is not improbable that 
 the greater tendency of females to biliary concretions, arises 
 in part from their being exposed in a greater degree than 
 
 s 2 
 
260 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 males to some of the predisposing, as well as of tlie exciting 
 causes above mentioned. 
 
 Dtaynosis. — The mere existence of biliary concretions in the 
 gall bladder or elsewhere, when quiescent, can scarcely be 
 satisfactorily inferred from any characteristic symptoms. 
 Even when they produce those peculiar symptoms usually 
 attendant on their passage through the ducts, &c., these symp- 
 toms are often so mixed up with, or masked by other symp- 
 toms, that it is not easy in all instances to pronounce a 
 decided opinion. I have several times known attacks of gall 
 stones confounded with nephritic attacks, and vice versa ; so 
 nearly, in many instances, do the two affections correspond with 
 each other. When jaundice appears, the liver must be in- 
 volved in some way, and if the other symptoms favour the 
 supposition, we may conceive the jaundice to depend on gall 
 stones ; but the absence of jaundice does not prove the absence 
 of biliary concretions, which may exist without producing 
 jaundice. Much may be learnt from the preceding history 
 and general circumstances of the patient ; and indeed, without 
 a knowledge of these facts, we are unable in the great majority 
 of cases to arrive at satisfactory conclusions. 
 
 The Prognosis in biliary concretions is as uncertain and 
 difficult as the diagnosis. Innumerable instances occur, in 
 which gallstones are found after death, the existence of which had 
 given occasion to no uneasiness, or been even suspected during 
 the life of the individual. The mere presence of gall stones, 
 therefore, abstractedly considered, cannot be considered dan- 
 gerous. The danger from gall stones arises from their 
 number or magnitude ; from the degree of irritation or disor- 
 ganization they produce ; in short, from the interruption or 
 impediments they may occasion to the functions of life ; which 
 interruptions are sometimes so serious as to render gall stones 
 one of the most formidable diseases to which humanity is 
 liable. 
 
 Treatment. — The treatment of gall stones is naturally di- 
 viedd into two distinct branches, viz. the treatment having 
 
GALL STONES. 
 
 261 
 
 reference to the peculiar diathesis or constitutional symptoms 
 causing their formation ; and the treatment having reference 
 to the mechanical or secondary effects produced by them. 
 
 When a tendency to biliary concretions, or their actual 
 existence in the gall bladder is suspected, the following are 
 among the principal means usually recommended. The con- 
 tinental writers in general reprobate the use of mercurial reme- 
 dies in these affections, principally, I believe, on the grounds, 
 that the evil is likely to be increased by exciting a flow of bile, 
 when an impediment to its escape exists ; or that by pro- 
 pelling the concretions into the ducts, they may cause such 
 impediment. If actual obstruction of the gall ducts exist, or 
 if there be symptoms denoting organic disease of the liver, 
 mercurial remedies must certainly be given with great caution, 
 or be altogether avoided ; as under such circumstances there 
 can be little doubt that they are calculated to do great and 
 irreparable mischief. But when neither of these circumstances 
 are present, and the affection appears to be purely functional, as 
 indicated by a deranged condition of the bile, rather than by a 
 deficiency of the secretion ; there can be no objection to a 
 cautious use of the remedy ; and indeed, under such circum- 
 stances, Ihave seen more benefit derived from mercury, than from 
 all other remedies put together. To be effective, the remedy 
 should be given in very small doses, for a considerable time, in 
 conjunction with taraxacum or some analogous deobstruent. 
 The effects must be carefully watched; and if jaundice super- 
 venes, the remedy may be intermitted, or conjoined with some 
 sedative, as henbane or opium; provided the cause of the jaun- 
 dice, as it often does, depends chiefly on spasm of the ducts. 
 If, however, there be reason, from the obstinacy of the symptoms, 
 or other circumstances, to suspect permanent mechanical ob- 
 struction of the ducts, the mercury must be suspended alto- 
 gether, and the other means commonly resorted to, applied ; 
 such are the taraxacum before mentioned ; also the alkaline 
 carbonates, the muriate of ammonia, the borate or acetate of* 
 
262 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 potasfl, Castile soap,'^ &;c. To these may be added sulphuric 
 sether, or combinations of this with turpentine, &:c. ; a class of 
 remedies strongly recommended by some continental physicians, 
 but not much employed, I believe, in this country ; at least, 
 I can speak very little of their effects from my own experience. 
 With these means, gentle laxatives calculated to ensure regu- 
 larity both of the secreting and mechanical functions of the 
 bowels, should be employed ; such as the Decoct, aloes comp., 
 or, in some instances, small doses of castor or olive oil, manna, 
 &c. In other instances, and at particular periods of the affec- 
 tion, a gentle course of the Cheltenham or Leamington saline 
 waters may be recommended with advantage ; while there are 
 a few obstinate cases, which, after resisting every means we 
 can devise in this country, will be much relieved by some of 
 the continental waters ; particularly those of Carlsbad. With 
 respect, however, to the purgative class of remedies in general, 
 it may be observed, that the same rule is applicable to them as 
 to mercury, and for the same reasons ; viz. that while gentle 
 laxatives are necessary and beneficial, strong purgatives, by 
 too much exciting the action of the hepatic system, and thus 
 by forcing the concretions into the ducts, have often a ten- 
 dency to increase the biliary obstruction, rather than to re- 
 move it. 
 
 Whether there be any remedies possessing the power of dis- 
 solving biliary concretions, I am unable to state. The aetherial 
 and turpentine class of remedies above mentioned, were first, 
 I believe, chiefly recommended on this supposition ; but their 
 effects in this way seem to be more than doubtful. Cholesterine, 
 
 * Castile soap has been particularly recommended in this affection ; but 
 the good effects of the remedy can depend only on the alkali present, 
 which will probably be more efficient given alone. When we consider^, 
 also, that the oily principle of the soap is reduced by the process of sapo- 
 nification into a substance analogous to cholesterine, or at least capa- 
 ble of assuming the crystallized form ; the propriety of administering 
 soap in large quantities becomes still more doubtful. 
 
GALL STONES. 
 
 263 
 
 as we have stated, appears to be held in solution in healthy 
 bile, by some unknown principle. The most probable mode, 
 therefore, of dissolving concretions of this substance in the gall 
 bladder, is to promote a permanently healthy condition of the 
 bile ; and thus, by constantly keeping the solvent principle 
 in contact with the concretion, we may hope in time to 
 gradually dissolve it; or at least to cause its disintegration. 
 I mention this circumstance with the view of statitig, that 
 within the last few years I cannot help thinking that I have 
 seen two or three instances of such a dissolution of gall stones 
 under the plan of treatment mentioned. In these instances, 
 the symptoms of gall stones, which were strong, unequivocal, 
 and of years' duration, gradually and entirely subsided after a 
 steady perseverance, for many months, in a gentle course of 
 alteratives and deobstruents ; and my belief, from various cir- 
 cumstances, was, (particularly in one of the instances,) that the 
 gall stones became either softened or disintegrated, so as to 
 pass away with little inconvenience to the patient. 
 
 We have now to make a few remarks on the means to be 
 adopted during a paroxysm produced by the passage of gall 
 stones into the intestines. 
 
 The great and almost the only means of relief during severe 
 paroxysms of pain from gall stones, is opium. The urgent and 
 distressing vomiting usually present, prevents fluid medicines 
 from staying on the stomach ; hence opium is generally 
 best exhibited in a full dose, in the form of pill ; either alone, or 
 combined with calomel, as circumstances may appear to indi- 
 cate. In other instances, medicines of the effervescing kind, 
 combined with opium, will be beneficial. The sulphuric aether 
 variously associated, particularly with opium, is a favourite 
 remedy with some practitioners, and occasionally the remedy 
 apparently affords relief. I have seen more immediate allevi- 
 ation afforded by large draughts of hot water, containing the 
 carbonate of soda in solution, (in the proportion of from one to 
 two drams of the carbonate to a pint of water,) than by any 
 other means. The alkali counteracts the distressing symptoms 
 
264 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 produced by the acidity of the stomach ; while the hot water 
 acts like a fomentation to the seat of the pain. The first portions 
 of Avater are commonly rejected almost immediately ; but others 
 may be repeatedly taken ; and after some time, it will be 
 usually found that the pain will become less, and the water 
 be retained. Another advantage of this plan of treatment 
 is, that the water abates the severity of the retching ; which is 
 usually most severe and dangerous, where there is nothing 
 present on which the stomach can react. This plan does not 
 supersede the use of opium, which may be given in any way 
 deemed most desirable; and in some instances, a few drops of 
 laudanum may be advantageously conjoined with the alkaline 
 solution, after it has been once or twice rejected. 
 
 In connexion with the preceding internal expedients, warm 
 or sedative applications in the shape of poultice, fomentation, 
 kc, may be applied externally to the seat of the pain ; of such 
 applications, a large and warm linseed poultice, sprinkled over 
 with laudanum or camphor liniment, or a mixture of the two, 
 may be adduced as an instance. On the other hand, instead of 
 warm, some have strongly advocated the use of cold, expe- 
 dients, e. g. the constant application of a bladder of pounded 
 ice to the seat of pain ; and a great many instances are men- 
 tioned, in which this mode of practice has proved successful. 
 Bloodletting either general or local is seldom indicated ; yet if 
 there be great tenderness in the region of the gall bladder, 
 and the pulse, &c., denote a tendency to inflammatory action, 
 leeching, or sometimes blistering, may be occasionally resorted 
 to with great advantage. 
 
 When the symptoms indicate that the concretions have 
 passed into the intestines, laxatives, injections, &:c., should be 
 perseveringly applied till they be evacuated ; and as ocular evi- 
 dence of this fact is always desirable, directions should be given 
 to mix the fiaeces with water, on the surface of which, if present, 
 the concretions will be found floating. When the concretions are 
 of large size, and lodge, as they sometimes do, in the intestines, 
 particidarly in the ceecum, the same expedients, varied accord- 
 
GALL STONES. 
 
 265 
 
 ing to circumstances, will be proper ; but if the concretions 
 get impacted into the rectum, or anywhere within the reach 
 of instruments, mechanical aid, in addition to the other means, 
 must be resorted to for their speedy removal. 
 
 After everything that medicines can do for the patient 
 has been accomplished, he should be put on a rigid plan of 
 diet, exercise, kc, with the view of preventing future attacks. 
 With respect to diet, this should consist principally of those 
 animal and farinaceous matters, which are light and easy of 
 digestion ; but the oleaginous principle, in every form, should 
 as much as possible be excluded ; hence butter, chocolate, fat 
 meats, kc, should be altogether shunned. The necessity of 
 avoiding too much sleep, and indolent habits in general, 
 should be particularly insisted upon ; hence early rising and 
 plenty of exercise, both on foot and horseback, should be recom- 
 mended ; and to ensure these, if the circumstances of the 
 patient permit, he should be advised to travel ; and to take 
 the opportunity this would afford him^ of trying the effects of 
 one or more of the numerous continental mineral waters 
 adapted to his case. 
 
 The preceding observations apply chiefly, as we stated, to 
 the most common variety of gall stones, those namely composed 
 of cholesterine. With respect to the pathology of gall stones, 
 composed of what has been called inspissated bile, &c., little is 
 known. Nor am I aware that their existence can be distin- 
 guished by any peculiar symptoms. I mention the subject 
 with the view of observing, that while I have noticed choles- 
 terine concretions to be most usually associated with the ap- 
 pearance of lithic acid in the urine ; I have fancied that I have 
 found the other kinds of concretion (and particularly that 
 composed of dark coloured inspissated biliary matter) to be 
 associated with the tendency to the formation of oxalic acid 
 and to malignant disease, more especially of the liver. On 
 these matters, however, I wish it to be at present understood 
 that I make no assertions ; but simply throw out the hint for 
 future inquirers. 
 
266 PATHOLOGY OF OLEAGINOUS ASSIMILATION AND SECRETION. 
 
 For the reasons stated at the commencement of this chap- 
 ter, as well as for the additional reason that most of the 
 diseases fall without my design, I shall not attempt to enter 
 further, in this place, on the pathology of the oleaginous prin- 
 ciple. The subject, however, in many points of view, is one of 
 great importance ; as I am satisfied, from long attention to the 
 matter, that the oleaginous principle is much more deeply im- 
 plicated, not only in the operations of organic life, but in those 
 higher operations connected with the animal functions, than is 
 commonly supposed. If such be the case, its pathology must 
 be commensurate ; and I venture to foretell that this will 
 hereafter prove to be the case ; and that some of the most for- 
 midable diseases to which animal existence is liable, will be 
 found to be connected with, or to result from, the mal-assimila- 
 tion of the oleaginous principle. Should no one else pursue 
 the investigation, I may at some future time publish a few 
 remarks on the subject ; but to follow it out in all its details, 
 is the business of a lifetime ; and as our profession is at present 
 circumstanced, such an attempt can be only satisfactorily made 
 during the ardour and comparative leisure of youth. ^ 
 
 * An ingenious and highly probable explanation of the retention of 
 the oleaginous principle in its peculiar tissue, has been just suggested by 
 Mr. Paget, (See Medical Gazette, vol. xxv. p. 674.) Mr. Paget sup- 
 poses that the oleaginous matter is retained in the cells in which it is 
 deposited, by the moist condition of their membranous parietes; in 
 other words, by the natural repulsion existing between watery and olea- 
 ginous fluids. 
 
267 
 
 CHAPTER IV. 
 
 GENERAL OBSERVATIONS ON THE PATHOLOGY OF THE INCIDENTAL 
 MATTERS OF ORGANISED PRODUCTS. 
 
 We come now to consider a formidable class of diseases, whe- 
 ther we view them with relation to the peculiar constitutional 
 disorders with which they are associated ; or with reference to 
 the secondary diseases to which they give occasion in the 
 urinary and other organs, viz. the diseases connected with, or 
 arising from, the incidental matters existing in organised 
 products. 
 
 These diseases we shall consider under two heads or Sub- 
 species, namely, — Subspecies a. Diseases connected with inso- 
 luble incidental matters, including the triple phosphate of 
 magnesia and ammonia, and the phosphate of lime ; and Sub- 
 species h. Diseases connected with the soluble incidental mat- 
 ters, including soda and potash ; to which may be added, 
 ammonia. As on a former occasion, however, and for similar 
 reasons, the 'phenomena^ symptoms^ and causes^ only, of these two 
 Subspecies, will be considered under separate heads ; the diag- 
 nosis, prognosis, and treatment of the two Subspecies, will be 
 spoken of in conjunction. 
 
 Subspecies a. Of the diseases connected with the insoluble 
 incidental matters, the triple phosphate of magnesia and ammo- 
 nia, and the phosphate of lime. In a perfectly healthy condi- 
 tion of the system, the earthy phosphates incidentally neces- 
 sary to the existence of all organised bodies, and resulting from 
 their decay or mal-assimilation, are every where eliminated 
 
268 
 
 PATHOLOGY OF INCIDENTAL PRINCIPLES. 
 
 from tlie economy in a state of solution. In certain constitu- 
 tional diseases, however, the balance of the healthy and natural 
 affinities is broken, and the phosphates are deposited in the 
 urine, and in other parts of the body in the solid state ; and 
 thus give occasion to various distressing secondary diseases, 
 to be now considered. The phosphatic salts more especially 
 claiming our attention at present, are the triple phosphate 
 of magnesia and ammonia, and the phosphate of lime ; and 
 as the constitutional symptoms as well as the immediate origin 
 of these two compounds appear to be somewhat different, 
 they require a separate consideration. 
 
 The triple phosphate of magnesia and ammonia is usually de- 
 posited from the urine in the form of perfectly white shining 
 crystals, and constitutes what is denominated white gravel; in 
 contradistinction to the lithic acid crystals, which, from their 
 colour, is termed red gravel. The white form of gravel some- 
 times occurs alone, but very frequently it alternates with, or is 
 accompanied by, the pale coloured lithic amorphous sediments ; 
 or the amorphous variety of phosphatic sediment, to be pre- 
 sently described. 
 
 The urine depositing the triple phosphate of magnesia and 
 ammonia, is generally pale coloured, and very slightly acescent 
 when passed. For the most part also it is abundant in quan- 
 tity, and of moderate or low specific gravity. On being ex- 
 posed to the air for a short time, it gradually becomes alka- 
 lescent at the surface, even in some instances before it is cold ; 
 and on such occasions an irridescent pellicle is usually formed 
 on the surface, which, on examination, proves to be crystallized, 
 and to consist of the triple phosphatic salt in question. About 
 the same time, alsOj minute crystals of the salt begin to attach 
 themselves to the sides of the vessel in which the urine has 
 stood for a short time ; and the urine speedily becomes alka- 
 line and putrescent. In some instances the urine abounding 
 in this salt is deep coloured, and of considerable specific ' gra- 
 vity. When this salt is present in large quantities, the urine 
 is occasionally alkalescent when voided. In such cases, the 
 
PHOSPHATE OF MAGNESIA AND AMMONIA. 269 
 
 salt is sometimes deposited, before the urine is discharged from 
 the bladder, and immediately subsides to the bottom of the 
 vessel in which the urine is passed. The period of time 
 elapsing before the urine becomes alkaline, enables us to form 
 a rude estimate of the severity of the disease ; that is to say, 
 other things being equal, the sooner the urine becomes alka- 
 lescent after being passed from the bladder, the more decided 
 the disease. The properties of the urine will be further consi- 
 dered, when we come to speak of the deposition of the mixed 
 phosphates. 
 
 The constitutional symptoms, in well-marked instances of 
 the triple phosphate deposite are characterised by what, for 
 want of a better term, we must denominate nervous irritability. 
 This nervous irritability is displayed in various ways, accord- 
 ing to the idiosyncrasy of the patient. In some individuals it 
 assumes the form of spasm of the respiratory organs, more or 
 less resembling asthma. In others, it shows itself in the form 
 of a spasmodic or excessive peristaltic action of the bowels, 
 accompanied by borborygmi and flatulence ; and sometimes by 
 copious exhausting semifluid motions. Sec. In all instances, 
 especially where the diathesis assumes a permanent character, 
 there is more or less of a sense of debility ; and of sinking or 
 exhaustion ; with fatigue and pain in the back, on the 
 slightest exertion. These and analogous symptoms exist in 
 every possible form and degree in different instances. The 
 severer forms of these affections, however, generally occur 
 only when the mixed phosphates are deposited ; they will, 
 therefore, be considered hereafter. 
 
 Causes. — A predisposition to this affection depending on 
 natural conformation, is often innate or inherited. But whether 
 the tendency be innate or acquired, the delicate and feeble are 
 the most susceptible of the affection. Thus a disposition to 
 deposite the triple phosphate is often present, or is easily in- 
 duced, in the urine of those who have been long in bad health ; 
 and in whom the constitution may be considered as giving 
 way, or, to use a common expression, breaking up. The con- 
 
270 
 
 PATHOLOGY OF INCIDENTAL PRINCIPLES. 
 
 dition of childhood also seems to predispose to this affection; 
 for children in general, either from their natural irritahility, or 
 from the derangement of the digestive organs to which they 
 are subject, are liable from the slightest causes to have this 
 deposite in the urine. With respect to the exciting causes, 
 these are various ; but they all partake more or less of the 
 reducing character. Thus causes unfavourably affecting the 
 system in general, and producing what is termed nervous de- 
 rangement ; as the depressing passions, and particularly 
 mental anxiety or fear, will, in many predisposed individuals, 
 cause a deposition of the triple phosphate in the urine. The 
 same is also true of many articles of food and of medicine, 
 which produce a hurried secretion of the urine, and act as 
 diuretics ; such as the neutral salts in some instances, and 
 particularly the Rocheile and other saline compounds, in which 
 the acid is of vegetable origin, or destructible. So also the 
 long continued use or abuse of alkaline remedies, and of mer- 
 cury, will, in irritable habits, likewise produce a tendency to 
 an excess of this salt, as well as of the phosphates in general ; 
 and even lead to their deposition in the urine. Other exciting 
 causes will be mentioned, when we come to speak of the mixed 
 phosphates. In the mean time, with respect to the proximate 
 cause of this form of deposite, we may be said to know little. 
 That the deposition of this salt is connected with the inordinate 
 consumption or mal-assimilation of some tissue intimately con- 
 nected (I do not say identical) with the organic system of 
 nerves, is evident from all its pathological relations ; and more 
 especially from its extraordinary development during excessive 
 activity, not of growing and increasing, but of common and 
 necessary organic operations. When the triple phosphate is 
 deposited in large quantity, the material of this tissue (pro- 
 bably in a modified form) is often likewise present in the urine 
 in large quantity. It is usually confounded with mucus ; but 
 it is quite distinct from the ordinary or diseased mucus of the 
 bladder, or of any of the urinary passages, that I am acquainted 
 with. I have for many years been quite familiar with this 
 
PHOSPHATE OF LIME. 
 
 271 
 
 form of animal matter; and of late I believe it has been 
 noticed and described by a continental writer, who has given 
 it some arbitrary appellation, which I neither remember, 
 nor am at present able to refer to ; but which, as far as my 
 memory serves me, has no reference to its true pathological 
 relations. 
 
 The phosphate of lifne is deposited from the urine in the form 
 of an impalpable amorphous powder, which is generally white ; 
 though occasionally it is slightly tinged with the colouring 
 matters of the urine. The properties of the secretion deposit- 
 ing the phosphate of lime are various. In a few instances, I 
 have seen deep coloured, acescent urine, of a specific gravity 
 above 1*030, and possessing all the sensible qualities of urine 
 in an exalted degree, deposite phosphate of lime in large 
 quantity ; indeed urine depositing this salt is not unfrequently 
 acescent, at least when passed. In the greater number of in- 
 stances, the urine is rather pale coloured, and of moderate or 
 low specific gravity ; and the phosphate of lime is often so 
 abundant as to be deposited on exposing it to heat, notwith- 
 standing its apparent acid reaction ; which even remains after 
 the urine has been boiled.* Urine, however, abounding in the 
 phosphate of lime generally becomes alkalescent sooner than 
 healthy urine. 
 
 The constitutional symptoms accompanying the deposition 
 of the phosphate of lime partake of the irritable character of 
 those accompanying the deposition of the triple phosphate ; 
 but they are I believe much less strongly marked, and exhibit 
 some characteristic differences. In the instances above alluded 
 to, in which the urine was high coloured, and of considerable 
 specific gravity, the patients were decidedly gouty ; and the 
 deposition took place either during, or immediately after, an 
 attack of gout. In many other instances, also, in which the 
 
 * The same phenomena in a somewhat modified form take place when 
 urine containing the triple phosphate in excess is submitted to heat. As 
 elsewhere stated, I was long acquainted with these phenomena;, before 
 they were publicly pointed out by Mr. Bird. 
 
272 
 
 PATHOLOGY OF INCIDENTAL PRINCIPLES. 
 
 urine depositing the phosphates has been of low specific gra- 
 vity, the patients have been subject to gout or rheumatism ; or 
 have inherited a tendency to these affections. In these latter 
 cases, however, there has been usually likewise present a 
 peculiar cachectic state of the system, manifested by cutaneous 
 eruptions of a scaly or leprous character. These eruptions 
 have appeared in various parts of the body ; but they have 
 most frequently occupied the inner parts of the thighs and 
 scrotum ; and when the eruptions have been in these parts, there 
 has usually been more or less of irritation about the urinary 
 organs, with which the external appearance of the eruptive dis- 
 ease appeared to alternate ; that is to say, the urinary affection 
 has become better, as the cutaneous affection has become worse, 
 and vice versa. In all these cases the urine has abounded in 
 the phosphate of lime ; and in many of them the patient has 
 occasionally suffered from nephritic attacks produced by 
 concretions formed either of the phosphate, carbonate, or 
 oxalate of lime ; and sometimes by a mixture of all the three 
 salts.^ 
 
 The causes predisposing to a deposition of the phosphate of 
 lime seem to be generally inherited, and to consist in a pe- 
 culiar cachectic state of the system, into which gout and 
 struma often enter as elements. I have sometimes thought 
 also, that an inherited syphilitic taint frequently constitutes 
 another element of this peculiar cachexia ; at any rate, I have 
 very often seen the deposition of the phosphate of lime asso- 
 ciated with a remote, but obvious syphilitic taint. Long con- 
 tinued bad health, arising from bodily infirmity or mental 
 anxiety, especially when conjoined with the other predisposing 
 causes, seems occasionally to add to their intensity ; and under 
 such strong predisposition, a variety of circumstances having 
 no apparent connexion will often act as exciting causes. In 
 some instances, the affection seems to pervade, more or less, 
 
 * The oxalate, carbonate, and phosphate of lime are often intermixed, or 
 appear to merge into each other ; probably on account of the relations 
 alluded to in a subsequent note. 
 
PHOSPHATE OF LIME. 
 
 273 
 
 the whole system, and deposites of phosphate of lime take 
 place simultaneously in many parts of the body. In the 
 greater number of instances, however, the deposition is deter- 
 mined by local causes, acting as irritants ; or exciting that pe- 
 culiar chronic degenerating process in certain tissues, which 
 seems immediately essential to the deposition of the earthy 
 matter. This is, perhaps, the reason why the deposition more 
 commonly takes place in the urinary and sexual organs, than 
 in other parts of the system — these organs being more liable 
 to be abused, and to be more frequently inoculated with morbid 
 poisons than all the rest of the body put together. A deposi- 
 tion of the phosphate of lime may perhaps take place in various 
 tissues ; but that form of deposition we are now more especially 
 considering, seems to be generally associated with a tissue 
 common both to the skin and to the mucous membranes. 
 Thus the mucous membrane lining the bladder, the cavities of 
 the kidney, prostate, &:c., often throw off immense quantities 
 of the phosphate and carbonate of lime ; and from the mucous 
 membrane of the bladder in particular, much of the phosphate 
 of lime usually found in urinary deposites is derived. The 
 remainder is separated by the mucous membrane lining the 
 cavities of the kidneys, or perhaps by the kidneys themselves ; 
 the quantity naturally secreted by these organs being appa- 
 rently liable to be much augmented during the peculiar con- 
 ditions of the system above mentioned. I do not pretend to 
 define at present the exact nature or relations of the tissue, 
 during the mal-assimilation or destruction of which the phosphate 
 of lime is eliminated ; but have no hesitation in saying that it 
 is totally different from the tissue above alluded to, from which 
 the triple phosphate is eliminated. The tissue from which 
 the triple phosphate is eliminated appears to belong to the 
 albuminous class ; while the tissue from which the phosphate 
 of lime is eliminated seems to have more relation to the 
 dermoid variety of the gelatinous tissues.^' 
 
 * I have elsewhere given my opinion, that the phosphorus in orga- 
 nised beings is in some manner immediately connected with the nervous 
 
 T 
 
274 
 
 PATHOLOGY OF INCIDENTAL PRI^^ t>LES. 
 
 We have given the above sketch of the prominent pheno- 
 mena and symptoms distinguishing the deposites of the triple 
 phosphate of magnesia and ammonia, from that of the phos- 
 phate of lime ; but the reader is to observe that the depo- 
 sition of these two salts in their separate states is compara- 
 tively a rare occurrence ; and that in by far the greater num- 
 ber of cases, the earthy deposites consist of a mixture of the 
 triple phosphate of magnesia and ammonia, and the phosphate 
 of lime; the proportions of the two salts in dilferent instances 
 being varied in every possible grade. The further considera- 
 tion of the subject falls now, therefore, to be spoken of under 
 the head of the mixed phosphates. 
 
 The phenomena presented by the urinary deposite consist- 
 ing of the mixed phosphates, vary considerably, according as 
 the one or the other salt abounds, and according, more espe- 
 cially, to the source of the phosphate of lime. When the triple 
 phosphate predominates, the deposite assumes more of the 
 crystallised form ; when the phosphate of lime predominates, 
 and is derived from the kindey, the deposite is usually in the 
 form of a white (or yellowish) impalpable powder ; or if the 
 phosphate of lime be derived from the coats of the bladder, 
 the deposite usually appears partly in the form of a white 
 powder, and partly in the form of large crystalline granules, 
 enveloped in much tenaceous mucus. As in the other form of 
 
 tissue and nervous action ; and if this view be correct, the magnesia of 
 the triple phosphate will alone be characteristic of the albuminous tissue 
 formerly described ; while the lime of the phosphate of lime will, on the 
 other hand, be characteristic of the gelatinous tissue above noticed. As 
 corroborative of this view, I may state that I have seen several instances 
 in which phosphorus or phosphoric acid has abounded, without an ex- 
 cess of earthy matters; and have no doubt, therefore, of the existence of 
 such a condition of the system ; though I am not prepared to enter 
 on the subject so completely as I could wish. Lastly, whether the 
 above views be admitted, or whether with some we suppose the phos- 
 phorus and earthy matters to be generated de novo ; still the existence 
 of excessive, or otherwise deranged, nervous action, must be admitted — 
 and hence the nervous exhaustion, irritability, and debility so commonly 
 present, and characteristic of the present class of diseases. 
 
MIXED PHOSPHATES. 
 
 275 
 
 the deposite, the phenomena presented by the urine abounding 
 in the phosphates is liable to great variations. When the 
 disease is constitutional, and not connected with local causes, 
 as disease of the bladder, &c., the urine is almost always pale 
 coloured, and, on the whole, voided in greater quantity than 
 natural. The quantity (and of course the quality) is subject to 
 very great and capricious changes, and sometimes, especially 
 by day, the urine is voided in enormous quantity, amounting 
 to actual diuresis. On such occasions the urine is pale coloured 
 and of low specific gravity ; indeed, I have occasionally seen it 
 perfectly limpid, and scarcely differing in weight from common 
 spring water. At other times, the urine is voided in very 
 small quantity, in which case it is deep coloured, and of a 
 specific gravity of 1'025 or higher. When the urine is abun- 
 dant and of low specific gravity, it is usually free from deposite ; 
 on being submitted to heat, however, it generally becomes turbid 
 from a deposition of the phosphates. When voided in small 
 quantity, on the contrary, the urine is often turbid when passed ; 
 and in almost all instances, on standing for a time, it deposits 
 the mixed phosphates in abundance. When the bladder is dis- 
 eased, the urine is generally alkalescent from the beginning ; 
 and the earthy deposites are enveloped in large quantities of 
 mucus, which is sometimes tinged with blood. In all 
 instances, however, even if it be slightly acescent at first, it be- 
 comes alkalescent on cooling ; hence, from its proneness to 
 decomposition, urine depositing the phosphates is apt to become 
 exceedingly offensive in a short time after it is passed. 
 
 A deposition of the mixed phosphates in the urine has been 
 long observed to be accompanied by very distressing constitu- 
 tional symptoms, independently of the local diseases of the blad- 
 der, (fee, by which such deposition is most frequently accom- 
 panied. These symptoms vary considerably ; but in general 
 they consist of a combination of those previously described 
 as marking the separate deposition of the two forms of the 
 phosphatic salt. Thus there is great derangement of the 
 chylopoietic viscera, accompanied by unusual irritability of 
 
 T 2 
 
276 PATHOLOGY OF INCIDENTAL PRINCIPLES. 
 
 the system in general. The derangement of the stomach 
 is usually marked by distressing flatulence and nausea, at- 
 tended, in some instances, by great acidity ; the derangement 
 of the bowels, by obstinate constipation or peculiarly debili- 
 tating diarrhoea, which frequently alternate. The dejections 
 are usually very unnatural, being either nearly black, or, what 
 is more frequent, clay coloured, and resembling yeast. This 
 condition of the assimilating organs is always accompanied by 
 more or less of a sensation of uneasiness, weakness, or pain in 
 the back and loins. There is a sallow, haggard expression of 
 countenance ; and as the disease proceeds, symptoms somewhat 
 analogous to those of diabetes begin to appear ; such as great 
 languor and depression of spirits, coldness of the legs, ana- 
 phrodisia, and other symptoms of extreme debility ; and the 
 disease, if not speedily checked, seems capable of terminating 
 fatally. 
 
 An excess of the mixed phosphates in the urine, considered 
 as an idiopathic disease, is not of common occurrence ; and 
 the deposition of these salts is much more frequently accom- 
 panied by local diseases of the urinary organs. Hence a de- 
 position of the phosphates usually accompanies protracted 
 bladder and prostate affections ; and thus superadds too fre- 
 quently the miseries of stone to the other sufferings of the 
 patient. Even the presence of a stone in the bladder, of 
 whatever it may be originally composed, if permitted to remain, 
 sooner or later produces a deposition of the phosphates, 
 which, by incrusting the stone, adds rapidly to its bulk, and 
 thus increases tenfold the patient's misery ; as we shall more 
 particularly point out hereafter. 
 
 The causes predisposing to a deposition of the mixed phos- 
 phates are the same, in various states of combination, as those 
 predisposing to the separate deposition of these salts. That a 
 tendency to a deposition of these earthy salts is often in- 
 herited, there can be no doubt. Moreover, this tendency often 
 assumes different forms in different members of the same 
 family ; and even in the same individual at different periods of 
 
MIXED PHOSPHATES. 
 
 277 
 
 his life. Thus when one individual of a family has suffered 
 from a deposition of the phosphates, another has suffered from 
 gout, a second from asthma, a third from cutaneous disease, 
 (fee. ; and several times I have seen, in the same individual, a 
 severe asthmatic affection suddenly cease, on the appearance 
 (generally from local exciting causes) of the phosphates in the 
 urine. In most of these instances, a low chronic inflammatory 
 action pervades the organs particularly affected ; which often 
 seems to partake in its character of gout and struma com- 
 bined. Among acquired predispositions may be mentioned, 
 enfeebled conditions of the nervous system, and more espe- 
 cially of the spinal nerves, from a variety of causes. Thus 
 injuries of the back, by concussions, blows, or other accidents, 
 are exceedingly liable to bring on depositions of the phosphates 
 in the urine ; particularly if other causes of a predisposing or 
 exciting nature favour the operation of such accidents. Causes 
 of this kind may vary indefinitely ; but perhaps one of the most 
 frequent is a fall from a horse, by which the individual has 
 ]*eceived, in connexion with a general violent concussion of the 
 spine, some local injury of the back.'^' In a great many in- 
 stances, the immediate effects of such accidents have not 
 appeared to be severe ; and sometimes have been even for- 
 gotten, till the patient's attention has been drawn to the sub- 
 ject. Among the general exciting causes may be also mentioned 
 severe and protracted debilitating passions, excessive fatigue, &;c. 
 
 * It is, I believe, an old observation that certain injuries of the back 
 are often accompanied by alkaline urine ; and Sir B. Brodie informs us 
 that he noticed the circumstance as early as 1807. I w^as not aware of 
 Sir B. Brodie's observation when the last edition of this work was pub- 
 lished ; but adduced the fact in explanation of the presence of the phos- 
 phates in the urine — an explanation now, I believe, generally admitted in 
 this country. The phenomenon seems to occur in other animals as 
 well as in man. Thus I have frequently observed jaded and worn-out 
 horses pass great quantities of lime in their urine ; the same also takes 
 place occasionally in dogs, particularly of the sporting kinds ; and in both 
 these instances, I have thought it probable that the circumstance was 
 connected with some strain or injury of the back, produced by over-exer.. 
 tion, or other causes. 
 
278 
 
 PATHOLOGY OF INCIDENTAL PRINCIPLES. 
 
 Thus I have seen many instances, in which individuals have 
 been alarmed by a deposition of the phosphates in the urine, 
 after several days of excessive exercise and fatigue, in shoot- 
 ing, Sec. The most frequent exciting causes, however, of 
 such deposites, are local irritations, affecting for a considerable 
 time the bladder or urethra ; as, for instance, any foreign sub- 
 stance introduced into the bladder, and producing excitement 
 of that organ, including, as we have before mentioned, all sorts 
 of calculi in certain circumstances ; the retention of a bougie 
 or catheter in the urethra ; strictures of the urethra in parti- 
 cular constitutions ; all which, and many similar causes, are 
 capable of producing, in all individuals, a condition of the urine 
 readily depositing the phosphates.* 
 
 Subspecies b. — Of the diseases connected ivith the soluble 
 
 * I cannot admit the explanation of the deposition of the phosphates 
 under such circumstances to be generally true ; namely, that the urine in 
 contact with the foreign substance always undergoes an incipient process of 
 decomposition. If this were really the case, all sorts of calculi might be 
 supposed to act as foreign substances, and ought to be immediately co- 
 vered with the phosphates— a circumstance in direct opposition to ex- 
 perience. The fact is, that the foreign substance, before it is, or can be, 
 covered with the phosphates, sympathetically aiFects the system, and 
 causes the urine to abound in these salts. Mr. Forbes has some excellent 
 observations on this point, which, as they exactly coincide with my views, 
 by substituting "phosphates" for " concreting acid," I shall quote. In 
 proper or healthy urine, there is not in clean vessels a particle of the 
 phosphates deposited, the whole of these being in perfect solution ;" and 
 
 to the end of time there would not be calculus from renewed applications 
 of urine in which the phosphates do not predominate." " When a foreign 
 body gets into the bladder, if it meets with the phosphates already re- 
 dundant, it would operate by irritation so as to occasion redundancy." 
 Hence, if a piece of bougie were to get into the bladder of a person 
 the state of whose urine is perfectly natural, it must operate to the pro- 
 duction of different qualities in that fluid before it can be incrusted. 
 When the misfortune has occurred, the urine has been before in a state 
 too much adapted to incrustation. The diseases which require catheters 
 and bougies are almost uniformly accompanied by prevalence of the 
 phosphates, from the general and particular sympathies by which they 
 are attended." Treatise upon Gravel and upon Gout, in which their 
 sources and connexions are ascertained, &c., page 74. By Murray Forbes, 
 Esq. 
 
SODA, POTASH. AMMONIA. 
 
 279 
 
 incidental matters^ including soda, potash, and ammonia. 
 I am not aware that diseases characterised by derangements 
 of the soluble incidental alkaline matters have been separately 
 noticed by authors — a circumstance probably referable to their 
 close connexion and usual co-existence with a deposition of 
 the earthy phosphates. That there are, however, several 
 distinct forms of disease connected with derangements of the 
 soluble alkalies in the urine, independently of the phosphates, 
 I have long observed ; I shall therefore briefly notice them ; 
 though, in a practical point of view, their treatment, perhaps, 
 differs but little from the treatment appropriate to a deposition 
 of the phosphates. 
 
 The urine in most of these diseases is alkalescent when 
 passed. Its smell is ammoniacal, modified by an odour 
 strongly urinous and offensive ; sometimes peculiar. It is 
 usually pale coloured, but occasionally assumes a reddish tint, 
 like that of the washings of flesh ; and from the mucus or pus 
 always present, it is more or less opake. The earthy phos- 
 phates are rarely entirely absent, but their quantity seems to 
 be below the standard quantity of health ; while the quantity 
 of soda (potash ?) and ammonia appears to be in excess ; or 
 strictly speaking, the carbonates of these alkalies appear to be 
 in excess ; hence such urine generally effervesces strongly on 
 the addition of an acid. The quantity of urea present is usually 
 deficient ; but what is remarkable, in some of the varieties of 
 this form of alkaline urine, the secretion contains a large pro- 
 portion of the lithate of ammonia and soda, which, being depo- 
 sited as the urine cools, adds to its opalescence. The specific 
 gravity of these specimens of alkaline urine is subject to 
 considerable variety. In some instances the specific gravity is 
 below the standard of health ; while in those instances, more 
 especially, in which the alkaline lithates abound, the specific 
 gravity is usually higher than natural. The quantity voided 
 also is subject to much variety. Occasionally the quantity 
 exceeds that of health ; but in those instances in which the 
 specific gravity is higher than natural, the quantity is usually 
 
280 
 
 PATHOLOGY OF INCIDENTAL PRINCIPLES. 
 
 limited ; notwithstanding the very frequent calls upon the 
 patient to void it from the bladder. 
 
 The constitutional symptoms accompanying the various 
 forms of urinary disorder now under consideration, partake of 
 the characters of those accompanying the deposition of the 
 phosphates. They are subject, however, to considerable modi- 
 fications, though in general they are marked by their severity. 
 Indeed, some of the varieties may be viewed as constituting 
 the last stages of the phosphatic diathesis, when accompanied 
 by the aggravated misery arising from organic disease, and 
 stone in the bladder ; under which heads, therefore, they fall 
 more properly to be considered. 
 
 The causes, both predisposing and exciting, are analogous 
 to, if not identical v»^ith, those producing a deposition of the 
 phosphates. Indeed the most frequent forms of the affection 
 usually take place, when the general health has become se- 
 riously affected by the long continuation of the phosphatic 
 disease ; particularly if aggravated, as is usually the case, by 
 injury of the spine, or by a stone in the bladder. Under these 
 circumstances, the mucous coat of the bladder becomes disor- 
 ganised, and its natural functions impaired or destroyed ; 
 hence, instead of mucus charged with the phosphate of lime, 
 the diseased surface of the bladder throws out large quantities 
 of the serum of the blood, more or less altered ; and the alka- 
 line matters naturally incidental to this serum give occasion 
 to the phenomena in question. Cases of this description con- 
 stitute the varieties of the disease usually distinguished by 
 urine of low specific gravity ; and in such cases it is probable 
 that the disorganising processes are not confined to the coats of 
 the bladder, but extend to those of the kidneys. On the 
 other hand, in those instances in which the urine is of high 
 specific gravity, and is loaded with the lithate of ammonia, the 
 disease appears to be chiefly confined to the bladder. I say 
 appears^ for I have had no opportunity of verifying the re- 
 mark ; and confess myself unable to explain the causes of the 
 differences assumed by the urine in these two modifications of 
 
PHOSPHATES. 
 
 281 
 
 the disease, which often appear to merge into each other ; and 
 to be most frequently connected with the same cause, viz. 
 spinal derangement. It may be further remarked, that in 
 several of the instances in which the urine was of high specific 
 gravity, and loaded with the lithates, the patients were, or 
 had been, subject to gout. 
 
 Having detailed the usual phenomena, constitutional symp- 
 toms, and causes of the two varieties of disease connected 
 with the insoluble and the soluble incidental matters of or- 
 ganised products ; we come now to speak of the diagnosis, 
 prognosis, and treatment of the whole in conjunction. 
 
 On the diagnosis of these affections we need not dwell ; as 
 the chemical properties of the sedimentary matters at once 
 afford the means of distinguishing them one from the other. 
 Those, therefore, who are acquainted with these chemical pro- 
 perties, will find no difficulty in recognising the different 
 states of disease with which they are associated. 
 
 The prognosis m these affections varies considerably in the 
 different forms of the disease, as well as in the same disease, 
 according to the nature of their cause, and the degree of their 
 severity. Taken as a whole, however, the prognosis in these 
 diseases may be said to be of an unfavourable character, on 
 account of their deep-seated and constitutional nature. The 
 prognosis in the deposition of the triple phosphate, provided 
 it be of a temporary nature and dependent on a cause that 
 can be mitigated or removed, is not very unfavourable : but if 
 the deposition be constant, and the cause be of such a na- 
 ture as not to admit of mitigation or removal, the progno- 
 sis is very unfavourable. So in the occasional deposition 
 of the phosphate of lime from gout, the prognosis is much 
 less unfavourable, than when the deposition is constant and 
 depends on disorganisation of the mucous membrane of the 
 bladder, &c. Nearly the same observations apply to the de- 
 position of the mixed phosphates. If the nervous system be 
 deeply involved from injury of the spine or from other cause ; if 
 the prostate has become enlarged and irritable, and the mucous 
 
282 
 
 PATHOLOGY OF INCIDENTAL PRINCIPLES. 
 
 surface of the bladder, &:c., diseased, the deposition of the 
 phosphates can hardly be prevented by any known means ; 
 and the chance, moreover, will be, that the patient will suffer 
 from the formation of a stone in the bladder, in addition to his 
 other complaints ; and finally sink under this complication of 
 miseries. The prognosis in those cases in which the soluble 
 incidental matters are chiefly concerned, is, on the whole, perhaps, 
 even more unfavourable than those in which the phosphates are 
 deposited. The danger is least in those forms of the disease of 
 occasional occurrence, or which are connected with gout ; but 
 in those severe forms which occasionally follow injuries of the 
 spine ; or as the sequelae of the phosphatic deposition, and 
 which, for the most part, denote irremediable organic disease, 
 there is scarcely a chance of recovery. 
 
 In speaking of the treatment of these affections, we shall first 
 consider the subject of diet and regimen. 
 
 From the alkalescent, and more especially from the ammo" 
 niacal condition of the urine in these affections, a diet as free 
 as possible from azote, and of a vegetable and acescent nature, 
 has been insisted on, by some writers, in these diseases. The 
 reasoning, however, on which this plan of diet has been re- 
 commended, is, perhaps, too exclusively chemical ; and has been 
 made without reference to those important constitutional 
 symptoms which we have stated to accompany the affection. 
 We have seen, that generally speaking the vital powers are in 
 an asthenic condition during the deposition of the phosphates. 
 So far, therefore, from an innutritions vegetable diet being 
 appropriate, a diet precisely the reverse appears to be indi- 
 cated ; that is to say, a diet consisting of a due proportion of 
 easily assimilated and nutritious animal matters. Experience 
 accords with this view of the case ; and I have always found 
 that when the constitution is deeply involved, as is usually the 
 case, in an habitual deposition of the phosphates, a generous 
 animal diet agrees by far the best with the patient ; and is 
 indeed necessary to his well-being. The diet also should con- 
 sist principally of solids ; and fluid aliments, such as soups, &;c,. 
 
PHOSPHATES. 
 
 283 
 
 should be sparingly employed. If the patient has been accus- 
 tomed to wine, some of the more generous of the Rhine, 
 Moselle, or Bucellas wines will be generally found preferable ; 
 at least in this climate. In warm weather, and in warm cli- 
 mates, the lighter French wines, as the Chablis, &c., have 
 been particularly recommended, and in many instances they 
 appear to exert a beneficial action ; as do sound cider and 
 perry ; indeed fluids containing the malic acid seem to possess 
 peculiar powers in arresting the deposition of the phosphates 
 in some individuals. 
 
 The same principles should be kept in view with regard to 
 exercise and general regimen. Whatever fatigues or exhausts, 
 either bodily or mentally, will do mischief. Hence absence 
 from care, the exhilarating air of the country, and such occu- 
 pations as are consistent with the patient's peculiar condition, 
 will perhaps, more than anything else, contribute to the cure ; 
 particularly in those slighter and induced cases, in which the 
 affection is not complicated with local injury. The observa- 
 tions on diet and regimen here given are to be understood in a 
 general sense as applicable to the whole class of the affections 
 under consideration ; and it scarcely need be added, that the 
 details must be varied so as to suit particular cases, according 
 to the judgment of the practitioner. 
 
 From the peculiarly nervous state of the system which 
 commonly attends a marked deposition of the triple phosphate, 
 the use of some sedative is generally indicated as a constitu- 
 ent element of the means of treatment. The same state of 
 nervous irritation is usually accompanied by, or is the result 
 of, debility ; hence another class of remedies usually indicated 
 is tonics of various kinds ; lastly, the alkaline or alkalescent 
 condition of the urine requires to be corrected, as far as we 
 are able, by acids. Sedatives, tonics, and antalkaline remedies, 
 therefore, of various kinds, and variously associated, according 
 to the particular symptoms and circumstances of the case, 
 constitute the most efficient means we possess of combating 
 that peculiar condition of the system, accompanied by a de- 
 
284 
 
 PATHOLOGY OF I^TCIDENTAL PRINCIPLES. 
 
 position of the triple phosphate in the urine ; and in general 
 the slighter cases will readily yield to the due administration 
 of these remedies ; while the severer and more deep-seated 
 cases will commonly become ameliorated under such a plan of 
 treatment. Of particular sedatives, those which seem best 
 adapted to the milder forms of the disease, are henbane and 
 camphor, either separate or combined, according to circum- 
 stances : while in the severer forms of the affection the various 
 preparations of opium are necessary, of which, perhaps, the best 
 suited to this particular form of disease is the liquor opii sedativus 
 of Battley. These or other sedatives may be associated with 
 different tonic infusions ; or with the decoction of the Pareira 
 h'CLva, or of the Lythrum salicaria, the infusion of the alchemilla 
 arvensis, the acidulated infusion of roses with quinine, iron, 
 &c., according to the judgment of the practitioner. If there 
 be a sense of uneasiness or pain in the back, as is usually the 
 case, various plasters or liniments may be resorted to ; such as 
 the opium or belladonna plasters ; the Linimentum camphorce 
 comp. &LC, Lastly, with a view of corroborating the system 
 generally, the shower-bath, tepid or cold, and particularly the 
 tepid sea shower-bath, will be often found serviceable. 
 
 Of the remedies best suited to a deposition of the phosphate 
 of lime, considered as a separate disease, I can say but little. 
 The affection is so rare, that in the last twenty years I have 
 not seen half a dozen well-marked instances. Of these, as I 
 have stated, the greater portion has been distinctly associated 
 with the gouty diathesis ; and have not only occurred either 
 during, or subsequently to, an attack of that disorder ; but the 
 deposition of the phosphates has subsided as the gout has dis- 
 appeared. With the history of the remaining cases I am 
 unacquainted. What little, therefore, is to be said on this 
 subject, will be more appropriately given under the head of 
 the mixed phosphates. 
 
 A decided deposition of the mixed phosphates, whether 
 viewed as an idiopathic affection, or as associated with disor- 
 ganisation of the bladder, &:c., is a very formidable state of dis- 
 
PHOSPHATES. 
 
 285 
 
 ease. As, however, the two conditions of the affection just stated 
 differ somewhat both in their pathology and treatment, we 
 shall consider their treatment separately. 
 
 The general indications of treatment in an idiopathic depo- 
 sition of the mixed phosphates, resemble in all respects the 
 indications of treatment of the triple phosphate, before men- 
 tioned ; but differ considerably in degree. That is to say, the 
 use of sedatives, tonics, and acids, is more or less indicated. 
 In severe idiopathic cases of the mixed phosphates, the only 
 remedy of the class of sedatives that can be relied on, is opium 
 in some one or other of its forms. This remedy it will be 
 often necessary to administer freely, at short intervals ; as, for 
 instance, in doses of from one grain to five grains, twice or 
 thrice a day. Under the use of this remedy, the more 
 distressing symptoms will be commonly relieved ; and when 
 such relief has been obtained, the dose of opium may be gra- 
 dually diminished, and the use of tonic and antalkaline reme- 
 dies introduced ; such as the different preparations of iron, or of 
 bark, with the mineral acids, &c. Sedative plasters also, as 
 formerly mentioned, may be applied to the loins ; or if the 
 symptoms be unusually severe, or connected with permanent 
 local injury, setons or issues may be applied to the neighbour- 
 hood of the parts immediately affected. The state of the 
 bowels, as we have noticed, is very irregular and difficult of 
 management, during a deposition of the mixed phosphates. 
 Most frequently they are constipated, but purgatives, especially 
 of the more active class, must be administered with caution. I 
 have seen, for instance, the most serious consequences brought 
 on by a small dose of calomel, which, by inducing diarrhoea 
 and consequent debility, has much aggravated all the symp- 
 toms, and even endangered the life of the patient. Saline 
 purgatives also, more especially those containing a vegetable 
 acid, as the Rochelle salts, the Seidlitz powders, and even 
 the common effervescing saline draught, are to be carefully 
 avoided ; and recourse must be had to small doses of castor 
 oil, or to laxative injections. Mercury in all its forms, parti- 
 
286 PATHOLOGY OF INCIDENTAL PRINCIPLES. 
 
 ciilarly when pushed so far as to produce its specific action on 
 the constitution, seems capable of doing a great deal of mis- 
 chief ; more especially in the severer forms of the affection : 
 and if from other causes it be judged necessary or proper to 
 administer this remedy, it must be managed with great care, 
 and its effects closely watched. Perhaps the best mode of ex- 
 hibiting mercury in such cases is to combine it with opium, or, 
 in some instances, with a purgative. In the severe forms of 
 the disease, however, now under consideration, the use of 
 mercury, if possible, had better be omitted altogether till the 
 more distressing symptoms have somewhat yielded, and the 
 patient has recovered a little strength. Nearly the same re- 
 marks apply to alkaline remedies in general, and indeed to 
 all remedies calculated to increase that tendency to periodical 
 diuresis which frequently constitutes a striking feature in the 
 disease. Among such diuretic articles may be mentioned 
 hard waters, the influence of which, in every point of view, is 
 generally most unfavourable. 
 
 In less severe cases, when the source of irritation, or cause 
 of the disease, is temporary or local, that is to say, when it 
 depends on the abuse of mercury or any other reducing cause, 
 or on local affections of the urinary organs ; in short, in all 
 cases in which the disease has been induced rather than 
 original, and in which, consequently, the general health and 
 strength have been but little impaired, means similar to the 
 above are to be resorted to, though they seldom require to be 
 carried to the same extent ; thus if opiates are necessary, the 
 milder preparations of this drug, as the aqueous extract ; or the 
 compound tincture of camphor, either alone or associated with 
 henbane, conium, &c., will be commonly found to be more 
 appropriate than the powerful preparations, morphia^ &c. ; or 
 even than crude opium. Moreover, when the cause depends 
 on local irritation about the bladder, of a temporary character, 
 and the constitution has not yet become involved, leeches or 
 purgatives, or both, may often advantageously precede or ac- 
 company the use of sedatives ; and the sedatives, instead of 
 
PHOSPHATES. 
 
 287 
 
 being associated with tonics, &c., as in severe cases, may be 
 much more beneficially combined with the citrate or acetate 
 of ammonia. This arises from the inflammatory character of 
 many local affections in their early stages ; which inflammatory 
 action, if it be injudiciously treated with tonics and astringents, 
 and not promptly met at the outset, often gives occasion to 
 aggravated forms of disease, too frequently incurable by any 
 means whatever. In temporary depositions of the phosphates 
 connected with a gouty diathesis, acidity of the stomach is 
 often a troublesome symptom ; and in such cases much relief 
 is obtained by the use of small doses of the carbonate of soda, 
 combined with bitter infusions. So, again, the temporary de- 
 position of the phosphates in the urine of children generally 
 depends on derangement of the bowels, &:c., and readily yields 
 to the judicious use of purgatives, (of which calomel, in many 
 instances, may form an ingredient,) without the aid of sedatives. 
 
 In the severer forms of local disease of the urinary organs, 
 accompanied by a deposition of the mixed phosphates, and 
 associated, as they too frequently are, with stone in the blad- 
 der, the principles of treatment will, in general, be the same as 
 those above mentioned. In such instances, however, the local 
 symptoms are of so prominent a character as to constitute 
 specific diseases, requiring, in addition to the general means 
 above alluded to, specific or peculiar treatment. The conside- 
 ration, therefore, of the deposition of the phosphates, under 
 these forms, will be deferred till a future chapter, expressly 
 devoted to the subject. 
 
 The deposition of the triple phosphate in excess, is so com- 
 mon, that every one who has paid attention to urinary diseases 
 must have noticed it ; I do not think it necessary, therefore, 
 to illustrate the affection by reciting cases. The deposition of 
 the phosphate of lime in excess, is much more rare ; and though 
 I have seen several well-marked instances of this affection, I 
 am unable to give a detailed history of any one case. The 
 deposition of the mixed phosphates is common enough in con- 
 nexion with disease of the bladder and calculus ; but is much 
 
288 PATHOLOGY OF INCIDENTAL PRINCIPLES. 
 
 more unusual as an idiopathic affection. I shall, therefore, 
 reprint the following cases, illustrative of such idiopathic de- 
 position of the phosphates, as I have nothing more striking 
 to offer on the subject. 
 
 Case I. — August 14th, 1820. — J. E. Joiner, aged 42, has 
 been a sailor ; and nineteen years ago, when on board a ship, 
 got a fall upon his back, which particularly affected the left 
 side, about the region of the loins. This fall confined him 
 three months on crutches ; but he afterwards, as he supposed, 
 got completely well ; though every spring or summer since 
 that period, he has always suffered more or less, and for a 
 greater or less time, with pain in his loins. The present at- 
 tack commenced eighteen months ago, in the usual manner, 
 but with greater severity, and has continued more or less ever 
 since. Till within these four months, however, he had not 
 been led to observe anything peculiar in his urine ; but had 
 been only annoyed with the usual painful symptoms and weak- 
 ness in the back. At this time, the quantity of water began 
 to increase very much, and he observed it to deposit occa- 
 sionally a very large sediment of earthy matter. Under 
 these circumstances, he went to a dispensary, where his disease 
 appears to have been considered as diabetes, and treated ac- 
 cordingly ; but without any advantage. His symptoms at 
 present are severe enervating pains in the region of the loins, 
 extending round to the groin and lower part of the abdomen, 
 and occasionally down the thighs and legs, accompanied by 
 retraction and soreness of the testes. Occasionally, also, he 
 suffers excruciating pains in the head, affecting his sight. All 
 these symptoms, however, are much worse on certain days 
 than others, and the worse symptoms are usually accompanied 
 by diarrhcEa. Latterly he has become much thinner than 
 usual ; his appetite has fallen off ; he sweats on the least 
 exertion ; and among other symptoms of debility has complete 
 anaphrodisia. He is thirsty ; his tongue is clean, and rather 
 redder than usual ; he is troubled with flatulence, and his 
 bowels are very irregular. The state of his urine, also, is very 
 
MIXED PHOSPHATES. 
 
 289 
 
 variable. What he passes first in the morning, and perhaps 
 once more in some other part of the day, is at first commonly 
 transparent, and of a light yellow colour, but soon deposits a 
 sort of mucous cloud, which in a few hours becomes converted 
 into a perfectly white earthy matter. The specimen of the 
 urine of this description which he brought with him, was con- 
 tained in a two-ounce phial. Its specific gravity was 1*0234 ; 
 and the earthy matter, after it had been allowed to stand some 
 time, occupied nearly one-third of the height of the bottle. 
 The earthy matter was in the form of a fine white powder, and 
 was found to consist of the mixed phosphates. This urine, 
 when first voided, reddened litmus paper ; and contained a 
 large proportion of urea, and fully the usual quantity of pale- 
 coloured lithic acid. At other periods of the day, and particu- 
 larly during the morning, he is conscious of a sense of tight- 
 ness or fulness of the abdomen ; from which he is relieved by 
 a fit of diuresis, during which he voids large quantities of a 
 limpid colourless urine, nearly free from all sediment. I had 
 likewise an opportunity of examining a specimen of this urine, 
 and found its properties exactly resembling the other ; except 
 that it was much more watery, and its specific gravity was only 
 1-0064. The urine had a disagreeable smell, and was very 
 prone to putrefaction ; in which state the smell emitted was 
 peculiarly offensive. It may be also observed, that the urine 
 was passed without difficulty or urgent desire, except what 
 arose from its quantity ; which he supposed amounted, in twenty- 
 four hours, to four or five quarts. Ordered pil. saponis c. opto 
 gr. V. his die. 
 
 August 22. — Pound instant relief after taking the pills ; 
 urine reduced to three quarts in twenty-four hours. States 
 that the white sediment has nearly disappeared ; complains of 
 being very costive. On examining the urine voided yesterday 
 morning, its specific gravity was found to be 1-0137 ; and there 
 was a slight deposite of the earthy phosphates ; but its pro- 
 perties in other respects were nearly as before. The urine 
 voided this day, at six in the evening, was almost perfectly 
 
 u 
 
290 
 
 PATHOLOGY OF INCIDENTAL PRINCIPLES. 
 
 colourless and transparent, and had a specific gravity of only 
 1-0027. Contr. pil. saponis c. opto gr. v. ter die. Simat eras 
 mane olei ricini ^i. 
 
 23rd. — The castor oil affected the bowels moderately, and 
 afforded him some relief. Continues tolerably free from pain. 
 The urine voided in my presence at six o'clock in the evening 
 did not differ in appearance and specific gravity from common 
 spring water ; though it still emitted in a less degree the same 
 offensive smell as formerly. 
 
 29th. — Felt better for three days after I last saw him ; the 
 urine diminished in quantity, and the white deposite entirely 
 disappeared, For the three last days the pain has returned, 
 and the urine has increased in quantity. What was passed 
 this morning had a specific gravity of 1 .0242, and deposited a 
 very copious mucous cloud, but no earthy sediment. The 
 quantity of urea was excessive. Pil. saponis c. opio gr, x. 
 ter die. 
 
 September 2nd. — Feels a great deal better. Little or no 
 pain for the last three days. The urine deposits no white 
 sediment ; and he passes only a little of the clear urine in the 
 afternoon, the whole amounting in twenty -four hours to two 
 quarts. The specific gravity of what was passed this morning 
 was 1*0201, and it contained an excess of urea. He has been 
 costive for the last two days. Pil. saponis cum opio gr. x. ter 
 die. 01. Ricini |i. eras mane, 
 
 12th. — Almost quite free from pain, and tried in consequence 
 to resume his work ; but was obliged to desist, on account of 
 a distressing sense of weakness in the back. His appetite is 
 much improved, he sweats less than usual, and is not sleepy. 
 Rather costive. Urine reduced to two quarts in twenty-four 
 hours; specific gravity of that voided in the morning 1*0174. 
 Pil. saponis c. opio gr. x. mane meridieque, et gr. xv. hora somni. 
 Olei ricini "$1. eras mane. Emplast. pieis eomp. lumhis. 
 
 19th. — Took the castor oil, which induced a diarrhoea that 
 lasted for two or three days, during which time his pain re- 
 turned. It was less severe, however, than usual ; and was 
 
MIXED PHOSPHATES. 
 
 291 
 
 accompanied by a peculiar sense of coldness and weakness in 
 the calves of his legs. Has now recovered from the diarrhoea, 
 and all the other symptoms, and has not felt so well for many 
 months. Urine in twenty-four hours about two quarts, and 
 quite free from earthy sediment. Specific gravity of that 
 voided this morning, 1-0207. Pil. saponis c. opio gr. x. ter 
 die. 
 
 November 30th. — I saw this poor man again, and was happy 
 to hear that he had continued quite well from the last date, 
 and had followed his work as usual ; having taken the pills 
 occasionally. He had recovered his ordinary strength, &:c., 
 and his urine now abounded in the lithate of ammonia. 
 
 In September 1822, nearly two years after the last date, I 
 learned that this patient had remained quite free from his 
 complaint ; and was then so well in all respects as to be able 
 to follow his work as usual. Since that period I have not 
 heard of him. 
 
 The only case on record that I am at present acquainted 
 with, equal to the above in severity, is one summarily described 
 by the late Dr. Henry, as follows 
 
 Case 2. — Several years ago, the Rev. Mr. R , of 
 
 Cheadle in Stafibrdshire, consulted me respecting a train of 
 very distressing symptoms, some of which evidently denoted 
 considerable disease in the kidneys. His urine, which 
 sometimes was perfectly limpid, was at others loaded with a 
 white substance, which gave it, when first voided, the opacity 
 of milk. On standing, a copious deposite took place, a portion 
 of which was sent me for examination. It was perfectly 
 
 * Med. Chirurg. Trans, x. p. 139. There are also two cases somewhat 
 similar in Dr. Rollo's Treatise on Diabetes, p. 424, second edition- Both 
 these cases were produced by injuries of the back, and were considered 
 to be of a diabetic nature. The deposition of the phosphates is not indeed 
 mentioned ; but as this is a symptom not constantly present in these 
 affections, the circumstance might have been overlooked ; particularly as 
 the attention was otherwise directed. In these cases. Diuresis was the 
 remarkable symptom. See page 105, where similar instances are alluded 
 to. 
 
 U 2 
 
292 
 
 PATHOLOGY OF INCIDENTAL PRINCIPLES. 
 
 white, and so impalpable as to resemble a chemical precipitate. 
 On analysis it proved to be composed of nearly equal parts of 
 the triple phosphate and phosphate of lime. The discharge of 
 this powder was always preceded by violent attacks of sickness 
 and vomiting ; and its quantity was invariably increased when- 
 ever he took soda water, or any other alkaline medicines. Be- 
 sides the affection of the kidneys, there appeared to me to 
 exist important disease of the chylopoietic viscera ; and to this 
 I ascribe his death, which took place a few months afterwards. 
 In this case it was remarkable that the weight of the body 
 was reduced from one hundred and eighty three pounds to one 
 hundred pounds, at rather an early state of the disease ; with- 
 out a corresponding degree of muscular emaciation." 
 
 Ko one can doubt, I think, that this case differs from the 
 preceding, except in degree ; and it is to be regretted that we 
 know so little about it — particularly its cause. 
 
 Case 3. — The following case I relate principally with the 
 view of illustrating an opinion I have advanced, that the de- 
 position of the phosphates is, in some instances, rather to be 
 considered as indicating an increased secretion of earthy mat- 
 ter, than of the phosphoric acid. The patient was a gentleman 
 between thirty and forty years of age, who had for several 
 years laboured under stricture of the urethra, (acquired, I 
 believe, in the usual manner,) for which he had consulted an 
 eminent surgeon, and obtained much relief. He never consi- 
 dered it, however, as entirely removed ; and was in the habit 
 of occasionally introducing a bougie himself. Latterly, the 
 irritation had become greater than usual, especially at the 
 moment of voiding the last portions of urine, and for some 
 time afterwards ; and he now observed, that he passed at this 
 time a very considerable portion of white earthy matter mixed 
 with mucus. At length he voided one or two small calculi 
 composed of the same earthy matter, which gave him the 
 alarm, and induced him to apply for medical advice. His 
 countenance was sallow and unhealthy, and the functions of 
 the digestive organs evidently deranged. The earthy matter, 
 
MIXED PHOSPHATES 
 
 293 
 
 and particularly the small calculi, consisted almost entirely of 
 the carbonate of lime, mixed with a small proportion of the 
 earthy phosphates. He was ordered an alterative pill com- 
 posed of the piL. hydrarg. and extract of gentian, and to take 
 the muriatic acid thrice a day. The acid disagreed so much 
 with him, that he was obliged to leave it off immediately. 
 Nothing else was ordered ; but he took a little respite 
 from the fatigues of business, and went into the country ; 
 from whence he returned in the course of a few weeks, per- 
 fectly well ; and has had no return of the affection since. It 
 may be also remarked, that the symptoms of irritation in the 
 urethra, ascribed to the stricture, subsided with the disap- 
 pearance of the earthy matter. 
 
 In this case the secretion of lime without phosphoric aciS 
 is remarkable. That the origin of this carbonate of lime was 
 from the irritated surface of the bladder or urethra, there can 
 be no doubt ; but why the lime should in this instance be se- 
 creted without the phosphoric acid, as is usual, hardly admits 
 of explanation, except on the supposition previously advanced 
 — that the two ingredients are connected with different tissues 
 and different diseases. It may be remarked, that the phos- 
 phate of lime secreted from diseased mucous membranes is 
 almost always mixed with a little carbonate of lime.*' 
 
 Lastly, I wish the reader to distinctly bear in mind that the 
 urinary organs are not the only parts of the body through 
 which the incidental matters of organisation are separated from 
 the system. Immense quantities of the phosphates, and par- 
 ticularly of the triple phosphate of magnesia and ammonia, 
 are sometimes discharged from the intestines ; from the salivary 
 glands ; and from other outlets of the body ; as well as from the 
 
 * See note, page 273. Of the remarks stated in the note referred to, 
 viz. that lime and phosphoric acid (phosphorus) are derived from dif- 
 ferent sources, or rather are the results of different diseased actions, the 
 present case constitutes a striking example. The carbonate of lime could 
 scarcely have been derived in this instance from any other source than 
 the mal assimilation or destruction of the peculiar tissue of which lime 
 forms the characteristic incidental element. 
 
294 
 
 TRANSITION TO THE PHOSPHATES. 
 
 kidneys. The same is true also of the phosphate and car- 
 bonate of lime, which are deposited in, and discharged from, a 
 variety of localities. In such, and indeed in all cases, the cir- 
 cumstances that determine the separation of these earthy 
 matters are probably of a local nature, and partake of the 
 characters of what, for want of a better term, we must deno- 
 minate chronic inflammation, or rather chronic degeneration. 
 The observations and principles of treatment mentioned in the 
 preceding pages as applicable to the discharge of these earthy 
 matters from the urine, are probably equally applicable to the 
 deposition of them in other organs : though it must be confessed 
 that this part of the subject has not been so carefully studied 
 as it deserves to be. When the earthy matters are discharged 
 from the bowels, as they most usually are, they are rarely seen • 
 and hence the reason, probably, why this mode of their exit 
 has been so long overlooked. Sometimes the quantity of the 
 earthy phosphates is so large, particularly in children, as to 
 attract notice ; while in adults they occasionally form intestinal 
 concretions ; of which numerous instances are recorded. 
 
 We shall close this part of our treatise with a few general 
 remarks, partly recapitulatory and partly supplementary. In 
 the first place, however, we shall briefly notice some of the 
 most remarkable phenomena presented by the urine during 
 the conditions, intermediate between the other diatheses and 
 the phosphatic diathesis. 
 
 We have stated that a deposition of the phosphates in the 
 urine is much more frequently an induced than an original dis- 
 ease : that is, the phosphatic deposition is generally the conse- 
 quence of some local disease or irritation in the urinary organs. 
 Hence the phosphatic diathesis becomes, as it were, the point 
 towards which all the other diatheses converge. Now, as the 
 change from the other diatheses to the phosphatic does not take 
 place suddenly, but is usually a slow and gradual process ; it may 
 not be deemed uninteresting nor uninstructive to make a few 
 remarks on the phenomena presented by the urine during its 
 transition stages. 
 
TRANSITION TO THE PHOSPHATES. 
 
 295 
 
 Transition from the oxalate of lime to tJie phosphatic diathesis. 
 — From the dissection of calculi, as well as from observing the 
 phenomena presented by the urine, I have noticed that one of 
 the first changes which usually presents itself during the tran- 
 sition from the oxalate of lime to the phosphatic diathesis, is the 
 secretion of an excess of (carbonate of) lime ; and that as the 
 quantity of lime becomes greater, the proportion of the oxalic 
 acid is decreased, while that of the phosphoric acid is increased, 
 until at length phosphate of lime in nearly a pure state is de- 
 posited. The urine during these changes also frequently de- 
 posits the triple phosphate ; but, according to my remarks, the 
 deposition of this salt is much less abundant than during the 
 transition from the lithic to the phosphatic diathesis, to be 
 presently noticed. As the changes proceed, the urine assumes 
 all the properties of phosphatic urine ; though even to the last, 
 in adults, the phosphate of lime occasionally predominates 
 over the triple phosphate. In children, the oxalate of lime, 
 during its transition to the phosphates, is often accompanied by 
 a portion of pale clay-coloured, or nearly white, lithate of am- 
 monia ; as well as by the triple phosphate of magnesia and 
 ammonia. The constitutional symptoms resemble those pre- 
 sent when the oxalic acid diathesis prevails ; but are almost 
 invariably marked by local as well as by general irritation ; 
 that is, there is usually more or less of pain and uneasiness 
 about the loins, and very frequently in the bladder ; even 
 when there is no calculus in that organ. 
 
 Transition from the lithic to the phosphatic diathesis. — The 
 first circumstances in the condition of the urine which gene- 
 rally denote a change from the lithic acid to the phosphatic 
 diathesis, are the general paleness of its colour, and sometimes 
 its increased quantity. There is also, for the most part, a 
 great tendency in the urine, from the slightest causes, to de- 
 posit the lithic amorphous sediments ; which on such occa- 
 sions are always of a pale colour, and generally contain more 
 or less of the phosphates intermixed with them. As the ten- 
 dency to change proceeds, the urine, though acescent when 
 
296 
 
 TRANSITION TO THE PHOSPHATES. 
 
 passed, may frequently be observed, after standing some 
 hours, to be covered with an irrideseent pellicleon its surface ; 
 which on examination will be found to consist of the triple 
 phosphate of magnesia and ammonia ; and if at this time it be 
 suffered to remain at rest for a while, especially in warm 
 weather, it becomes putrescent ; and will be frequently found 
 to contain large spicular crystals of the variety^ of the triple 
 phosphate of magnesia and ammonia, termed by Berzelius 
 the bibasic. 
 
 This intermediate or transition state of the urine often occurs 
 in sickly children, in whom the functions of the digestive 
 organs are much deranged. It is liable also to be produced 
 in irritable habits ; and in those, who from any cause deranging 
 the general health, or exciting local irritation in the urinary 
 organs, habitually deposit the lithates. As to the constitu- 
 tional symptoms, they are usually of the irritable character • and 
 are generally accompanied by derangements of the digestive 
 organs. In adults also, there is not unfrequently some un- 
 easiness felt in the region of the kidneys. This tendency to 
 change can be generally mitigated or arrested by the judicious 
 application of the means formerly recommended ; provided the 
 exciting causes can be removed. But if these exciting causes 
 be permitted to operate ; or are of such a nature that their 
 action cannot be prevented ; the phosphatic diathesis will 
 sooner or later become confirmed ; particularly if there be 
 already a calculus in the bladder. In such unfortunate cases, 
 the urine gradually assumes a more decidedly whey-like 
 colour ; and is either alkaline vvhen passed, or very soon be- 
 comes so. The lithate of ammonia also diminishes in quantity, 
 or entirely disappears ; while the quantity of triple phosphate 
 of magnesia and ammonia is increased. In short, this last 
 stage runs into the confirmed phosphatic diathesis by such 
 imperceptible grades, that, in a practical point of view, it is 
 difficult or unnecessary to draw the line of distinction. 
 
 Transition fr^om the cystic oxide to the phosphatic diathesis. — 
 On account of the rarity of this form of disease, I have had 
 
RECAPITULATION. 
 
 297 
 
 but few opportunities of noticing the changes which take place 
 in the urine during the transition from the cystic oxide dia- 
 thesis to the phosphates. In all the instances I have seen, 
 however, the triple phosphate has not only occasionally co- 
 existed with the cystic oxide ; but sometimes surpassed it in 
 quantity ; though in no instance have I seen the phosphates 
 entirely supersede the cystic oxide ; which has always existed 
 in the urine in greater or less proportion ; even after the urine 
 had become alkalescent, and the deposition of the phosphates 
 had apparently become established. Specimens of calculi, 
 however, are said to exist, in which a nucleus of the cystic 
 oxide is surrounded by the phosphates ; though I do not re- 
 member to have seen such a specimen. I may remark also, 
 that in all those instances in which the phosphates have co- 
 existed with, or followed the deposition of the cystic oxide, 
 the quantity of the triple phosphate has far exceeded that of 
 the phosphate of lime. 
 
 In briefly recapitulating the contents of the first book, we 
 may in the first place remind the reader, that we divided 
 alimentary matters, as well as the primary staminal principles, 
 of which animal bodies consist, into four great classes, viz. the 
 aqueous, the saccharine, the albuminous, and the oleaginous; 
 and that we further stated, that though each or all of the 
 primary alimentary matters were probably convertible into 
 each or all of the primary staminal principles of animals ; yet 
 that under ordinary circumstances the general rule appeared 
 to be, that the different alimentary matters are converted into 
 their similar or corresponding staminal principles, in preference 
 to the other staminal principles. 
 
 The functions by which alimentary are converted into sta- 
 minal principles are called the assimilating functions ; which 
 we divided into primary and secondary. Under the head of 
 primary assimilating functions were included all those opera- 
 tions concerned in the process of sanguification ; under the 
 
298 
 
 BOOK I. 
 
 head of secondary assimilating functions, all those operations 
 concerned in the formation from the blood, of the different 
 staminal principles or tissues of which animal bodies consist. 
 The assimilating functions are liable to be deranged in a variety 
 of ways ; but the derangements have usually a reference to the 
 chemical properties of the alimentary substances ; hence, as such 
 derangements are always accompanied by certain chemical (and 
 mechanical) changes in the staminal products formed, and 
 consequently in those excreted; the chemical changes of the 
 excretions (particularly those of the urine) may be supposed 
 to be so many indices of the assimilating derangements ; or, in 
 other words, and for the sake of convenience, the chemical and 
 mechanical deviations of the urine and other excretions, from 
 the normal state, may be supposed to constitute so many dis- 
 tinct diseases ; which diseases are naturally divided into four 
 great classes corresponding with the four classes of alimentary 
 and staminal principles. 
 
 In the first chapter we spoke briefly of the pathology of 
 aqueous assimilation and secretion. The second chapter com- 
 prised the pathology of saccharine assimilation and secretion ; 
 under which are included some of the most formidable diseases 
 to which organised beings are subject. Of these the first 
 noticed was diabetes ; a disease which was stated to essentially 
 consist in the want of power in the assimilating organs, both 
 primary and secondary, to convert saccharine aliments into 
 (corresponding) organised principles. After describing the 
 symptoms, causes, &c., we proceeded to detail the most appro- 
 priate plan of treatment. This treatment consisted chiefly in 
 a due adjustment of alimentary matters; that is to say, in the 
 recommendation of a sparing use of the saccharine principle, 
 and in its organised forms only ; (the assimilation of some por- 
 tion of this principle being apparently necessary to organic 
 existence ;) and in the more free use of albuminous and oleagi- 
 nous matters. In speaking of this part of the subject, how- 
 ever, we omitted to notice, so completely as we ought to have 
 done, a point of considerable importance in all derangements 
 
RECAPITULATION. 
 
 299 
 
 of the assimilating processes, but more especially in diabetes, 
 viz. the employment of aliments containing matters incapa- 
 ble of being assimilated and intended only for excremental 
 purposes.^^ 
 
 Excremental matters may be classed under three heads ; 
 first, matters incapable, under any circumstances, of being 
 assimilated ; secondly, matters capable of being assimilated, 
 but which, on account of some derangement of the system, are 
 only partially or imperfectly assimilated ; and thirdly, super- 
 fluous alimentary matters, not required by the economy at 
 all, and therefore not assimilated. On each of these we shall 
 make a few remarks. 
 
 First, with regard to matters incapable of being assimilated, 
 we need scarcely observe, that those matters only are included 
 under this head which usually form a natural constituent of 
 leommon aliments ; such, for instance, are the principle termed 
 lignin, and the green colouring matter of the leaves of plants, 
 in all their numerous forms and varieties, among vegetable 
 aliments ; and the cartilaginous and incidental mineral matters 
 among animal aliments. 
 
 In those forms of dyspepsia, and more especially in diabetes, 
 in which the reducing powers of the stomach are morbidly ac- 
 tive, so that every soluble substance is immediately acted on, 
 and withdrawn from the alimentary canal, the bowels are apt 
 to become unusually torpid ; unless provision be made to take 
 with the food a certain proportion of matters incapable of 
 solution, but which, at the same time, while they gently sti- 
 mulate, do not over excite, or otherwise derange the functions 
 of the alimentary canal. Among matters suited for such a 
 purpose, none, perhaps, surpass the vegetable proximate ali- 
 
 * We also omitted to notice the effects of gum as an aliment in diabetic 
 affections. From the chemical properties and analogies of this principle, 
 it is probable that it is neither conv^erted (at least so readily) into sugar 
 or oxalic acid, as farinaceous matters. I am not yet able to state the 
 effects of gum as an aliment in diabetes so satisfactorily as I could wish ; 
 and therefore omitted to touch on the subject. 
 
300 
 
 BOOK I. 
 
 ment termed lignin ; a modification of the saccharine principle, 
 which, though readily dissolved by the stomachs of some of the 
 inferior tribes of animals, resists in general, and in all its 
 forms, the powers of the human stomach. Of the numerous 
 shapes assumed by lignin, the best adapted for excremental 
 purposes is undoubtedly the external covering of the seeds of 
 the cerealia, and particularly of wheat. Bread, therefore, 
 made with undressed flour, or even with an extra quantity of 
 bran, is the best form in which farinaceous and excremental 
 matters can be usually taken ; not only in diabetes, but in most 
 of the other varieties of dyspepsia, accompanied by obstinate 
 constipation. This is a remedy, the efficacy of which has been 
 long known and admitted ; yet, strange to sa}^, the generality 
 of mankind choose to consult their taste rather than their 
 reason ; and by officiously separating what nature has bene- 
 ficently combined, entail upon themselves much discomfort and 
 misery. In stating above, that most individuals subject to 
 constipation obtain relief by the use of brown bread, I wished 
 to imply, that there are some exceptions ; and that not only 
 among the various forms of dyspepsia, but even in diabetes. 
 In such instances, the mucous membrane of the stomach and 
 intestines is often so irritable, that the mechanical excitement 
 produced by furfuraceous matters cannot be borne ; and in a 
 few of such instances, (not in all,) the second great class of ex- 
 cremental matters, those, namely, consisting of the green 
 matter of the leaves of plants, are sometimes found to be most 
 useful. The green matter of plants is in general little acted 
 on by the stomachs of the higher animals ; and hence may in 
 most cases safely form a portion of the food of diabetic indivi- 
 duals, as first, I believe, recommended by Dr. B. G. Babing- 
 ton ; though on very different principles. In many cases of 
 common dyspepsia also, more especially connected with de- 
 rangements of the lower intestines, and with irritable states of 
 the mucous membrane ; the green matter of plants contributes, 
 as above mentioned, to the action of the bowels by its excre- 
 mental properties. In dyspeptic affections, however, more im- 
 
RECAPITULATION. 
 
 301 
 
 mediately connected with the stomach, it is apt to disagree by 
 producing acidity and flatulence, and their consequences ; and 
 as such forms of dyspepsia are by far the most common ; herba- 
 ceous vegetable matters in general are much less suited for 
 dyspeptic individuals, than farinaceous. Other excremental 
 matters, consisting chiefly of modifications of the lignin prin- 
 ciple, are the fibrous or membranous coverings of many seeds 
 and fruits ; as of the grape, apple, &;c., all of which are inso- 
 luble, and contribute by their mechanical stimulus to promote 
 the action of the bowels. On the same principle, also, the 
 mustard seeds so generally recommended a few years ago, 
 appear to act ; although it is probable, that in this case, 
 the stimulating properties of the mustard may likewise con- 
 tribute its share in producing the desired effect. 
 
 Among animal aliments, the tendinous and cartilaginous 
 fibres and membranes form the chief of organised excremen- 
 tal matters. These matters are capable of being acted on 
 to a considerable extent, when the reducing energies of the 
 stomach are strong, as in cases of unusual abstinence or starva- 
 tion ; but under the ordinary circumstances of satiety in which 
 mankind in a state of civilised society usually exist, such 
 matters escape solution altogether, and consequently pass off" 
 as excremental matters. Viewed in this light, however, they 
 appear to be vastly inferior to the lignin principle ; not only 
 on account of their less excitent powers, but from the diffi- 
 culty there is of comminuting them ; on which account they 
 are apt to be swallowed in masses, which embarrass and im- 
 pede the operations of the intestinal canal, rather than promote 
 their due performance. Nearly the same remarks are appli- 
 cable to the incidental mineral elements of organised products. 
 From the small proportion in which such matters exist in 
 common organised products, and from the facility with which 
 they are dissolved in the acid secretions of the stomach, &;c., 
 such matters rarely appear as excremental principles. In 
 substances, indeed, in which earthy matters form a larger pro- 
 portion as in bones, the earthy matters are found among the 
 
302 
 
 BOOK I. 
 
 excrements ; but from the difficulty with which such matters 
 are pulverised they are scarcely adapted for, or employed as 
 human aliments ; and are confined to the carnivorous classes of 
 animals, whose teeth are expressly made to reduce them to pow- 
 der. In the condition of powder, the solvent powers of the sto- 
 mach, in this class of animals, appear capable of removing their 
 nutritious portion from the mere earthy matters ; which thus 
 constitute the natural excremental matters in carnivorous 
 animals, in the same way that the different varieties of lignin 
 and the green foecula of plants form the chief excremental 
 matters of vegetable feeders ; and even of man himself 
 
 The second great class of excremental matters, those, namely, 
 capable of being assimilated, but which, from some defects in 
 the digestive processes, are only partially or imperfectly assi- 
 milated, requires very few remarks. Indeed this class of ex- 
 cremental subjects is so mixed up with the third class men- 
 tioned, viz. superfluous alimentary matters, or alimentary 
 matters taken in excess, and not digested, because not re- 
 quired, that the little we think it necessary to say regarding 
 both classes, is best given in conj unction. 
 
 A stomach habitually weakened from any cause, and parti- 
 cularly from overwork, when oppressed with a variety of 
 superfluous aliments, naturally selects for its operations those 
 matters most easily assimilated; while the remainder are 
 either partially, or not at all touched, according to circum- 
 stances. In such cases, the imperfectly or unchanged matters 
 become excremental ; and often by their unnatural properties 
 produce great derangements of the alimentary canal, and more 
 especially of the functions of the caecum and colon — derange- 
 ments which, independently of local discomfort, sometimes 
 give occasion to remote and severe sufferings ; instances of 
 which were alluded to in a former chapter.^ Nearly the same 
 remarks are applicable to the class of superfluous aliments, 
 which are not assimilated, because not required. Indeed, as we 
 have stated, this class differs little from the preceding, except 
 
 * See page 74. 
 
RECAPITULATION. 
 
 303 
 
 in degree ; tliat is, tlie excremental matters contain a larger pro- 
 portion of un assimilated matters ; or, in some instances, consist 
 of little besides. It is proper to observe, before concluding 
 these remarks, that the effects produced under the above cir- 
 cumstances differ remarkably, according to the degree of acti- 
 vity and irritability of the assimilating organs. If the stomach, 
 be active, and perform its part of the duty, the super- 
 fluous matters assimilated are taken up with the chyle into 
 the system ; where, by contributing to plethora and congestion 
 more especially of the abdominal circulation, they give occa- 
 sion to bilious attacks in all their forms and varieties, as for- 
 merly mentioned. If, on the contrary, the primary assimilat- 
 ing organs be weak, and at the same time irritable or sluggish, 
 derangements of the 'primes vice and their consequences result. 
 If the bowels, for instance, be irritable, distressing diarrhoea, 
 (fee, takes place ; if sluggish, obstinate congestion of the bowels 
 and costiveness arise. Lastly, if the bowels be passive, or at 
 least are neither irritable nor sluggish, as is often the case in 
 middle-aged strumous individuals ; unassimilated matters pass 
 off almost in unlimited quantities without producing much 
 inconvenience. Such individuals usually constitute the enor- 
 mous eaters alluded to in a former chapter."^ 
 
 The preceding observations on the means best adapted for 
 counteracting habitual constipation of the bowels have been 
 given as we have stated, once for all ; and as applicable, not 
 only to Diabetes, but to all the most common forms of dyspep- 
 sia, accompanied by such tendency. We now resume our 
 recapitulation. 
 
 In noticing the results of the mal-assimilation of the saccha- 
 rine principle, we particularly dwelt on the elimination of the 
 oxalic acid, which was stated to be apparently at the head 
 of a numerous class of complementary substances, some of 
 them probably of a more deleterious nature than even oxalic 
 acid itself; and the causes or concomitants of various formidable 
 diseases. The presence or development of oxalic acid in the 
 
 * See page 77. 
 
304 
 
 BOOK I. 
 
 primary assimilating processes were shown to be more imme- 
 diately connected with the formation of the oxalate of lime 
 calculi ; the presence or development of this acid during the 
 secondary assimilating processes, was stated, besides being 
 occasionally connected with oxalic acid concretions, to have 
 reference more especially to a variety of degrees and forms of 
 organic disease of the skin and cellular tissue ; from simple 
 scaly eruptions and boils, down to malignant affections and 
 carbuncles. In speaking of the exciting causes of the oxalic 
 acid in the system, we particularly dwelt on the influence of 
 malaria, especially when concurring with unwholesome farina- 
 ceous food or saccharine matters in excess ; or with strong pre- 
 disposing causes — circumstances throwing some light on the 
 nature of malarious operation ; and showing its tendency, by 
 fastening on the gelatinous tissues, to sap the very foundations 
 of organic life. In addition to what was formerly stated, we 
 may remark, that the lime (of oxalate of lime calculi) is pro- 
 bably derived from the same tissue as the oxalic acid ; this 
 earth being, either in common with phosphorus, (or phos- 
 phoric acid,) apparently one of the incidental mineral matters 
 essentially necessary to the existence of the tissue ; by the mal- 
 ^ssimilation or destruction of which the lime becomes elimi- 
 nated. The insoluble nature of the oxalate of lime, of course, 
 determines the deposition of the lime ; which, were it not from 
 the accidental development of the oxalic acid, would doubtless 
 pass off in a state of solution ; probably in conjunction with 
 phosphoric acid. 
 
 Having spoken of oxalic acid, and alluded to other delete- 
 rious matters of an ill-defined or unknown character, which 
 are apparently sometimes developed with it, we proceeded to 
 notice the lactic acid ; another acid most usually developed 
 from the saccharine principle, both during the primary and 
 secondary assimilating processes ; and which, like the oxalic 
 acid, apparently stands at the head of rather a numerous group 
 of analogous or complementary substances. The development 
 of this acid in excess by the primary organs of assimilation. 
 
RECAPITULATION. 
 
 305 
 
 was stated to constitute one of the most common and trou- 
 blesome forms of dyspepsia, and its consequences. The 
 development of lactic acid during certain forms of secon- 
 dary mal-assimilation was supposed to give occasion to many 
 serious and most painful affections ; of which rheumatic and 
 neuralgic affections are among the most remarkable. 
 
 The above instances of deficient and of mal-assimilation of the 
 saccharine principle were given as examples or illustrations 
 of the subject, rather than as a complete history of its patho- 
 logy. A complete history of the pathology of this most im- 
 portant radical would occupy volumes, and comprehend a 
 great number of diseases excluded from my present design. 
 Moreover, the completion of such a history will require the 
 united aid of many skilful observers, and consequently many 
 years of patient investigation. The attempt, therefore, must 
 be left to a future generation. 
 
 In the third chapter, the pathology of the assimilation of 
 albuminous matters occupied our attention ; and the first 
 point considered with reference to this subject was, the 
 diseases connected with an excess and deficiency of urea. 
 Urea claimed the earliest notice, from its presumed relation to 
 the vegetable and animal saccharine or gelatinous principle, on 
 the one hand ; and from the relation of the animal saccharine 
 or gelatinous principle to albumen, on the other. That is, 
 the animal saccharine or gelatinous principle is supposed 
 to be resolvable into urea, and all the forms of the vege- 
 table saccharine principle, by the intervention of water. Dis- 
 eases connected both with an excess and deficiency of urea are 
 commonly of a deep-seated character, on account of their inti- 
 mate relation to the gelatinous tissues ; moreover, diseases con- 
 nected with these tissues are usually complicated with diuresis ; 
 — a circumstance which seems to be peculiar to such affections, 
 and which of itself produces a serious train of secondary symp^ 
 toms, characterised by debility ; and often terminating in dia- 
 betes, or in organic disease. The treatment of these diseases, 
 
306 
 
 BOOK I. 
 
 therefore, requires discrimination and perseverance ; as a single 
 false step, or inattention in their early stages, may cause them 
 to lapse into one or other of their incurable extremes ; a 
 termination which, with every care, cannot, in all instances, 
 be avoided. 
 
 The second section included an account of the important 
 class of diseases in which the urine contains albuminous 
 matter. This albuminous matter was considered to be of 
 two kinds, viz. chylous and serous : that is, albuminous mat- 
 ter similar to that which exists in chyle ; and albuminous 
 matter similar to that which exists in the serum of the 
 blood. The presence of the albuminous matter of chyle in the 
 urine was supposed to depend, partly on some imperfection 
 in the assimilating processes, owing to which, the chyle is 
 not raised to the blood standard ; and partly on an imperfec- 
 tion in the function of the kidney, by which such imperfectly 
 assimilated chyle is not, as in the healthy condition of the 
 kidney, converted into the lithate of ammonia. In illus- 
 tration of chylo-serous urine, instances were given of a rare 
 and peculiar form of disease, little known in this country ; 
 but said to be of more frequent occurrence in people of 
 ^ colour in hot climates. Among other remarkable circum- 
 stances connected with this affection, its compatibility with 
 life for a great number of years, and its non-interference 
 with a state of pregnancy and subsequent lactation, were 
 particularly mentioned. 
 
 In speaking of the most important section of diseases com- 
 prised under the head of serous urine, we commenced with 
 some general observations on the vague and indiscriminate 
 senses in which the term inflammation is employed by patho- 
 logists ; and endeavoured to show that organisation is suscep- 
 tible of changes distinct from those induced by inflammation, 
 and terminating in derangements which, as compared with 
 the healthy condition of organs, may be termed degenera- 
 tion. We then proceeded to show that the accident inflam- 
 mation may happen to degenerated, as well as to healthy 
 
RECAPITULATION. 
 
 307 
 
 organs ; but that the effects of inflammation in the two cases 
 are very different. The inflammation of healthy structures 
 may be either acute or chronic; but the inflammation of 
 degenerated structures most generally partakes of the chronic 
 character. Now the important class of diseases connected 
 with serous urine may be associated, not only with the 
 healthy and degenerated conditions of the kidneys, in their 
 quiescent state ; but with the healthy and degenerated con- 
 ditions of the kidneys in their inflamed state. After discussing 
 the question — whether serous urine can exist in a healthy 
 condition of the kidney in its quiescent state ? we proceeded 
 to consider the severe and acute forms of serous urine con- 
 nected with the healthy kidney in its inflamed state. 
 
 As instances of inflammatory action producing the acute 
 forms of serous urine in question, an account was given of the 
 peculiar species of dropsy termed inflammatory anasarca ; and 
 the dropsy (nearly allied to the preceding) which occasionally 
 follows scarlatina. After stating that cold is the most fre- 
 quent exciting cause of both these forms of disease, it was 
 inferred ; that though inflammation of the kidney be one 
 of the concomitant circumstances, yet that such inflamma- 
 tion cannot be said to constitute the whole disease; 
 because simple nephritis is not necessarily accompanied 
 by dropsy, nor yet, in all instances, by serous urine. The 
 dangerous tendency of these acute forms of serous urine, and 
 the best means of counteracting them, were then pointed 
 out ; though it was at the same time admitted that in spite 
 of all our efforts, the first form of the disease generally 
 proves fatal ; or if it does not prove fatal, too often terminates 
 in disorganisation of the kidneys, and in the chronic form 
 of serous urine. We then proceeded to consider the subject 
 which has so much occupied of late the medical world, viz. 
 serous urine as connected with a degenerated condition of the 
 kidney, at first in its quiescent, and afterwards in its in- 
 flamed state. As preliminary, the subject of degeneration 
 
 x2 
 
308 
 
 BOOK I. 
 
 was briefly investigated. This we stated to be of two kinds, 
 gradually running into each other ; but, in their well-marked 
 forms, strikingly contrasted by the absence or presence of 
 (red) blood in the degenerated structures. Hence, the terms 
 ancemotrophy and hcBmotrophy , expressive of these phenomena, 
 were chosen to represent the two forms of degeneration in 
 question. In speaking of the relations of these forms of de- 
 generation we remarked, that anaemotrophy most frequently 
 occurs in early life as the consequence of a strong inherited 
 predisposition; or as the effect of various baneful habits, 
 and particularly of the habit of dram-drinking : while hsemo- 
 trophy is rather the disease of middle age, and the result 
 of overfeeding and plethora. After these general remarks, 
 we proceeded to speak of the forms of serous urine con- 
 nected with ansemotrophy of the kidney in its quiescent 
 state, which we divided into two sub varieties ; viz. ansemotro- 
 phy connected with invisible derangements of the kidneys ; 
 and anaemotrophy connected with visible lesion of these organs. 
 In the next place we described the condition of the urine and 
 of the kidney ; the constitutional symptoms ; and the causes, 
 predisposing and exciting, peculiar to each subvariety. The 
 forms of serous urine connected with haemotrophy of the kid- 
 ney in its quiescent state, were then reverted to ; which were 
 similarly divided into two subvarieties, gradually running into 
 each other ; but in their well-marked forms distinguished- — the 
 one by being connected with no visible disorganisation ; the 
 other by being connected with visible disorganisation of the kid- 
 neys. The conditions of the urine and of the kidneys ; the 
 constitutional symptoms ; and the causes peculiar to each sub- 
 variety, were then described, as before. These details enabled 
 us to define and contrast in a more striking manner the diag- 
 nostic differences between the diseases connected with anaemo- 
 trophy and haemotrophy ; and after attempting this, we finally 
 spoke of the prognosis and treatment of the four subvarieties 
 in conjunction. 
 
RECAPITULATION. 
 
 309 
 
 Having considered the subject of serous urine with reference 
 to the kidney in its ansemotrophied and haemotrophied forms of 
 degeneration, and in its quiescent state ; we proceeded to consider 
 the subject of serous urine with reference to the same degenerat- 
 ed conditions of the kidney in their inflamed state. As before, we 
 first pointed out the conditions of the urine and of the kidney; the 
 constitutional symptoms ; and the causes peculiar to each of the 
 four subvarieties, into which the anaemotrophied and hsemotro- 
 phiedforms of degeneration were divided, when thus complicated 
 with inflammation ; and afterwards briefly detailed the diag- 
 nosis, prognosis, and treatment. The section on diseases con- 
 nected with serous urine was then closed with a brief sketch 
 of the recent arrangement of these diseases by M. Rayer and 
 Dr. Christison ; in which sketch, references were given to M. 
 Rayer's Atlas, for the precise illustrations of the different dis- 
 eased appearances presented by the kidney after death in these 
 affections. 
 
 In the third section, the subject of lithicacid depositesin all 
 their usual forms was considered. Lithic acid deposites were 
 divided generally into amorphous and impalpable sediments ; 
 and crystallized ^ndi massive sediments; each of which was 
 subdivided into three varieties, viz. the amorphous sediments 
 into the yellow, the red, and the pink sediments ; and the mas- 
 sive, into crystallized sand or red gravel, amorphous concretions, 
 and pisiform concretions. After pointing out the condition of 
 the urine and of the general health, together with the causes, 
 &c., of each of these varieties of lithic sediment, we discussed 
 the subject of the prognosis and treatment of the chief va- 
 rieties. In this section the modus operandi of alkaline reme- 
 dies, and the principles on which they ought to be administered, 
 were fully considered. 
 
 The fourth section , included a brief statement of the little 
 that is known respecting the rare form of calculus, termed 
 cystic oxide. The fact recently established, that the cystic oxide 
 contains sulphur, was noticed ; and the inference was drawn 
 
310 
 
 BOOK I. 
 
 from this and its other properties, that the cystic oxide was eli- 
 minated from the albuminous principle. The properties of the 
 urine, constitutional symptoms, &c., were then detailed as far as 
 known ; and after noticing that the prognosis seemed to be 
 generally unfavourable in this form of disease ; the few facts 
 that have been observed respecting the treatment were then 
 given ; among which it was mentioned, that the nitro-muriatic 
 acid appeared to possess the power of arresting the formation 
 and deposition of this substance. 
 
 With this section we concluded the subject of the diseases 
 connected with the albuminous principle ; and the observations 
 offered appear to illustrate and confirm the following cir- 
 cumstances already alluded to in the introduction : 
 
 First, that urea is not formed from the albuminous prin- 
 ciple, strictly so called, but from the gelatinous principle ; 
 which may be considered as a substance intermediate in its 
 nature, between the saccharine and the albuminous princi- 
 ples, and partaking of the properties of both. Further, that 
 the urea may or may not be formed by the kidney ; but that 
 in general it is eliminated in conjunction with other mat- 
 ters from the gelatinous principle, during the secondary 
 assimilating processes constantly going on in all parts of 
 the system ; from whence it is removed, as fast as formed, 
 by the healthy kidney, and thus makes its appearance in the 
 urine. 
 
 Secondly, That in cases of albuminous urine, the selecting 
 and disorganising functions of the kidneys may apparently be 
 separately suspended, but not separately destroyed. Thus in 
 chylous urine, the kidney, as in health, selects the chyle for 
 separation, but does not disorganise it ; that is, the chyle passes 
 through the kidneys unchanged, instead, as in health, of being 
 converted into the lithate of ammonia. On the other hand, 
 when the kidney is actually diseased, both the selecting and 
 disorganising functions of this organ are destroyed ; and the 
 urea and other unnatural matters, instead of being selected for 
 
RECAPITULATION. 
 
 31] 
 
 separation, are left in the mass of blood, and only escape in 
 small proportions, in common with the unaltered serum of the 
 blood. When the liidneys are thus diseased, other organs, 
 and particularly the hepatic system, always participate in the 
 affection. 
 
 Thirdly, Lithic acid is undoubtedly of albuminous, and not, 
 like urea, of gelatinous origin ; since the lithate of ammonia 
 may be traced in favourable specimens of urine through all 
 intermediate grades, up to albuminous matter itself The 
 presence of crystallized lithic acid in the urine does not neces- 
 sarily indicate an excess of that principle ; but merely the col- 
 lateral presence in the urine of some free or associated, 
 but not neutralized, acid principle ; which, by combining with 
 the ammonia of the lithate of ammonia, separates the lithic 
 acid in its pure and crystallizable form. 
 
 Lastly. That cystic oxide is an albuminous product, is evident 
 from the fact, that it contains sulphur ; a substance incidental 
 to albumen, but not to gelatine, at least in any perceptible 
 quantity. Moreover, from the composition and history of 
 cystic oxide it appears to chiefly result from the primary mal- 
 assimilation of the albuminous principle, and particularly from 
 derangement of the hepatic system ; since this principle has 
 been observed, like the lithate of ammonia, and in conjunction 
 with it, to be most abundant in the urine, after eating. 
 
 In the fourth chapter we considered the pathology of 
 the oleaginous assimilation and secretion. After making some 
 general remarks on obesity and leanness, and their import 
 and consequences ; we proceeded to illustrate the pathology 
 of the oleaginous principle, by entering on the history and 
 medical treatment of biliary concretions, or gall stones. The 
 chapter was terminated with reflections on the important, 
 but very little understood, oflices the oleaginous principle 
 performs in the animal economy — reflections suggested 
 and rendered evident by the fact, that one-fourth of the 
 very substance of the nervous tissue itself consists of prin- 
 
312 
 
 BOOK I. 
 
 ciples analogous to, if not identical with, the oleaginous prin- 
 ciple. 
 
 The fifth and last chapter contained an account of the patho- 
 logy of the mineral matters incidental to organic products. 
 These were divided into the insoluble and the soluble. The 
 insoluble comprised magnesia and lime, and their compounds 
 with the phosphoric and carbonic acids ; the soluble, potash, 
 soda, and ammonia, and their compounds with the same acids, 
 and particularly with the carbonic acid. The states of the 
 urine, constitutional symptoms, and causes of the diseases con- 
 nected with these incidental matters, separately and in con- 
 junction with each other, were then pointed out ; and their 
 formidable character insisted on. This led to the considera- 
 tion of the prognosis, and the treatment of the different forms 
 of disease connected with the appearance of these incidental 
 matters in the urine and elsewhere ; with which the book was 
 terminated, 
 
 With respect to the origin of the different incidental mat- 
 ters, it was observed, that a notion may be formed, from the 
 properties of the incidental matters, of the general nature of 
 the tissues, &;c., particularly affected. Thus the presence of 
 magnesia (in the urine or elsewhere) is supposed to indicate 
 the destruction or mal- assimilation of a tissue intimately con- 
 nected with the nervous tissues, and probably of an albuminous 
 character ; the presence of lime to denote the destruction of a 
 tissue belonging to the dermoid textures, and partaking of a 
 gelatinous character ; the presence of phosphorus and its 
 compounds to denote the destruction of the nervous tissue ; 
 the presence of potash and soda to denote the destruction of 
 the mucous membrane, and the exudation of the serum of the 
 blood from the tissue immediately below it ; and the presence 
 of ammonia (originally derived from the gelatinous tissues 
 through urea,) from the decomposition or malformation of 
 the urea, from which the carbonate of ammonia is immediately 
 produced. 
 
RECAPITULATION. 
 
 313 
 
 Finally, it was observed, that whether the above views be 
 admitted regarding the origin of the incidental elements ; or 
 whether, with some, we suppose such incidental mineral mat- 
 ters to be generated by organic operations on the spot ; still, 
 on this last supposition, as the formation of the earthy matters 
 is beyond the reach of common chemistry, and therefore must 
 be a vital act ; a great and extraordinary expenditure of nervous 
 action in either case, must be indicated ; particularly when the 
 phosphates of magnesia and of lime are in excess. Hence a 
 plausible explanation is offered of the distressing symptoms, 
 and particularly of the nervous exhaustion and debility, which 
 usually accompany the extrication of an excess of the inci- 
 dental matters of organised beings ; either in the urine or else- 
 where. 
 
BOOK IL 
 
 OF MECHANICAL DISEASES. 
 
 COMPREHENDING THE DESCRIPTION AND TREATMENT OF DISEASES 
 ARISING FROM OBVIOUS LESIONS OF THE KIDNEY AND BLAD- 
 DER ; AND PARTICULARLY FROM THE PRESENCE OF CONCRE- 
 TIONS IN THESE ORGANS. 
 
 We come now to consider the important class of diseases 
 arising from visible organic lesions of the urinary organs ; and 
 particularly from the presence of mechanical irritants in the 
 kidney and bladder. These diseases vary exceedingly in their 
 nature and symptoms ; and many of them fall exclusively 
 within the province of the surgeon. The most important of 
 these diseases connected with our present subject may be 
 classed under the following heads : 
 
 Chap. I. Of the origin and increase of calculi in the kid- 
 neys ; comprising a sketch of the symptoms 
 produced by the presence of such foreign 
 bodies in the kidney and ureter ; and of the 
 appropriate medical treatment. 
 Chap. II. Of diseases of the kidneys, produced by, and 
 liable to be confounded or associated with 
 calculus in these organs ; and of the treat- 
 ment of such diseases. 
 
BOOK II. CONTENTS. 315 
 
 Chap. III. Of the origin and increase of calculi in the 
 bladder ; and of the symptoms and treatment 
 of vesical calculi in general. 
 
 Chap. IV. Of diseases of the bladder and its appendages, 
 produced by, and liable to be confounded or 
 complicated with vesical calculi. 
 
 Chap. V. Of haemorrhage from the urinary organs in 
 general. 
 
 Chap. VI. Of incontinence and retention of urine. 
 
 Chap. VII. Observations on the removal of calculi from the 
 bladder ; comprising remarks on the effects of 
 solvents for the stone ; and on the operations 
 of lithotomy and lithotrity ; with a review of 
 the circumstances which ought to determine 
 the choice of one of these means in preference 
 to the other ; or which render all of them in- 
 applicable or dangerous. 
 
 Appendix. 
 
 Containing various Tables illustrative of the subjects treated of 
 in the preceding parts of the volume. 
 
316 
 
 CHAPTER I. 
 
 OF THE ORIGIN AND INCREASE OF CALCULOUS DEPOSITES IN 
 THE kidneys; COMPRISING A SKETCH OF THE SYMPTOMS 
 PRODUCED BY THE PRESENCE OF SUCH FOREIGN BODIES IN 
 THE KIDNEY AND URETER ; AND OF THE APPROPRIATE MEDI- 
 CAL TREATMENT. 
 
 The subjects of this chapter are naturally divided into two 
 sections — 
 
 Section I. Of the origin and increase of renal concretions ; 
 and Section II. Of the symptoms and treatment of renal con- 
 cretions. 
 
 Section I. — Of the Origin and Increase of Renal Concretions. 
 
 The chemical properties of the substances of which the dif- 
 ferent varieties of urinary calculi are composed, materially 
 influence their mode of formation in the kidney ; we shall, 
 therefore, briefly consider the formation of each variety of con- 
 cretion separately ; and as the lithic acid is by far the most 
 frequent variety of renal calculus ; and as its formation in the 
 kidney best illustrates the principles on which renal calculi 
 in general appear to be produced ; instead of the oxalate of 
 
ORIGIN OF RENAL CONCRETIONS. 
 
 317 
 
 lime, which, according to our arrangement, should have the 
 precedence, we shall commence with the lithic acid calculus. 
 
 1. Of the Origin of Lithic Acid Renal Concretions. — For an 
 account of the condition of the urine and the constitutional 
 symptoms attending the lithic acid deposite, the reader is re- 
 ferred to a former chapter.*' Taking it for granted, therefore, 
 that the subject is so far understood, we shall resume the his- 
 tory where we then left off ; and proceed at once to describe 
 the symptoms usually attendant on the formation of a lithic 
 acid calculus. 
 
 The urine of those individuals who possess a tendency to 
 form lithic acid concretions, continues almost constantly, for a 
 great length of time, to deposit lithic acid in some shape or 
 other. This, being accompanied by no very remarkable or 
 severe symptoms, often escapes their observation ; they pro- 
 ceed, therefore, in their usual habits, while the disease insidi- 
 ously continues to gain ground daily. At length, about the age 
 of forty, the affection begins to assume its most aggravated form ; 
 and both crystallized and amorphous sediments appear in the 
 urine ; occasionally in enormous quantities. At the same time, 
 a peculiar state of the system, accompanied by fever, and closely 
 resembling the condition of the system in gout, (to which it is 
 generally referred,) comes on. The urine is now very much di- 
 minished in quantity, (often amounting almost to suppression) ; 
 its specific gravity unusually great ; its colour very deep ; the 
 sediments unusually large, (or occasionally they disappear alto- 
 gether ;) and under these circumstances lithic acid is separated 
 by the kidney in the state of a semi-fluid hydrate ; which be- 
 coming solid, gives occasion to renal caculus. During the 
 above state, there is commonly a sense of dull pain, or weight 
 in the region of the kidney, and just above the pubes ; but as 
 these symptoms are not very severe, they are little attended to ; 
 and after a few days, the w^hole gradually subside, or perhaps 
 terminate in an attack of gout. Sooner or later after the 
 above symptoms, but commonly not before they have subsided, 
 and the urine has begun to be secreted in its usual quantity, 
 
 * See page 194. 
 
318 
 
 ORIGIN OF RENAL CONCRETIONS. 
 
 the patient is seized all at once, and perhaps without the least 
 warning, with a most acute pain in the region of the kidney ; 
 accompanied by violent sickness and vomiting, and other 
 symptoms to be presently described, when we come to treat 
 of the mechanical effects of urinary concretions. 
 
 Such is the history of the formation of a lithic acid calculus 
 in the kidney, as I am convinced I have seen it. Of course I 
 cannot positively assert that the nucleus is generated during 
 the existence of the symptoms above described ; but I have 
 met with such strong evidence of it, that no doubt on the sub- 
 ject has been left in my mind. I do not see also how it is 
 possible to account for the sudden nephritic attacks which fre- 
 quently take place, during perfect health ; except on the suppo- 
 sition that the calculus had been formed before, and had lain 
 for some time in the kidney ; which it very frequently appears 
 to do, without producing much pain or even uneasiness. I 
 admit that it is extremely difficult to get at the truth, on these 
 points ; the attention of patients being generally too much 
 taken up with their present sufferings to attend to what took 
 place some time before ; and particularly to what was slight, 
 perhaps, compared with the present suffering ; and in their 
 estimation little connected with it. Besides, the calculus 
 might have been formed months or years before, and thus the 
 symptoms attending its formation have altogether escaped 
 from their memory. 
 
 In the preceding narrative of the circumstances attending 
 the formation of a lithic acid calculus in the kidney, to prevent 
 confusion, we barely mentioned the hydrated form which 
 this acid is capable of assuming, and the part it plays in the 
 formation of the calculus. We have now to illustrate this 
 and the collateral circumstances a little more in detail. 
 
 That renal calculi of lithic acid are most likely to be formed 
 when the lithic acid abounds in the urine, is sufficiently ob- 
 vious ; yet when we consider how common such a condition of 
 the urine is, compared with the infrequency of renal calculi, 
 it is equally obvious, that the mere presence of lithic acid in 
 
ORIGIN OF RENAL CONCRETIONS. 
 
 319 
 
 the urine cannot be the only cause. The fact is, that though 
 the above conditions of the urine and of the health strongly 
 predispose, and are even necessary, to the deposition of calcu- 
 lous nuclei ; the presence of other circumstances are likewise 
 required for their immediate formation. Some of these cir- 
 cumstances may be occasional, and purely accidental; but 
 generally it is probable that they are the result of disease, and 
 somewhat analogous to the following : 
 
 We have shown that lithic acid is capable of existing in a 
 semi-fluid state, or as a hydrate, for some time before it 
 undergoes the process of crystallization. This may be illus- 
 trated by dissolving a little lithic acid in an alkaline solution, 
 and precipitating it, when cold, by the addition of muriatic 
 acid. The lithic acid is separated in the form of a bulky 
 gelatinous mass ; which after a while begins to diminish ra- 
 pidly in size, and at the same time to assume the crystallized 
 form. Now the lithic acid and the lithate of ammonia may 
 be often seen deposited in great abundance in human urine, in 
 this hydrated and gelatinous form, before it assumes the crys- 
 tallized or pulverulent condition. The lithate of ammonia 
 also, voided by birds, serpents, &;c., and the lithate of soda 
 formed in the human subject during gout, when first secreted, 
 exist in this semi-fluid or plastic state ; and afterwards become 
 hard ; apparently by undergoing an imperfect kind of crys- 
 tallization, by which they are separated from the water with 
 which they are combined and held in imperfect solution. 
 
 The kidney is made up of a congeries of smaller parts, or of 
 little kidneys, if we may use the expression ; each one of which is 
 independent of the others in its structure, and may, therefore, 
 probably become, independently of the others, deranged in its 
 functions. Let us suppose one or more of these little kidneys 
 similarly deranged to the others, but in a greater degree, so 
 as to secrete very little water, but a large proportion of lithic 
 acid. In such a case, the lithic acid must be obviously sepa- 
 rated in the peculiar hydrated condition above mentioned. In 
 this state it is bulky, and a small portion may thus occupy the 
 
320 
 
 ORIGIN OF RENAL CONCRETIONS. 
 
 whole of the infimdibulum in which it has been deposited ; or 
 the quantity may be supposed to be so great, as to be partly 
 protruded into the common receptacle or pelvis of the kidney. 
 After remaining in these positions for some time, crystalliza- 
 tion may be supposed to take place ; the semi-fluid mass will 
 now be much diminished in bulk, and perhaps reduced to the 
 form of a mass of crystals easily separable from each other ; 
 and thus pass off in the form of red gravel. Or what may be 
 easily imagined to take place, especially when the lithic acid 
 is very impure and combined with a larger portion than usual 
 of other matters ; the gelatinous mass of hydrated lithic acid 
 may assume the form of an imperfectly crystallized or amor- 
 phous solid mass ; and thus constitute a nucleus for a future 
 calculus possessing these characters. Or something between 
 these two extremes may take place ; the plastic mass of lithic 
 acid may partly separate into crystals, and partly remain in 
 the form of an amorphous mass enveloping these crystals ; in 
 which case a mixed kind of nucleus will be formed. 
 
 2. Of the Origin of Oxalate of Lime or Mulberry Renal Con- 
 cretions.— T2^m^ it for granted, as before, that the reader is 
 acquainted with the condition of the urine, and the constitu- 
 tional symptoms attending the oxalic acid diathesis ; we shall 
 proceed at once to consider the symptoms and modes of forma- 
 tion of oxalate of lime renal concretions. 
 
 It may at first sight appear difficult to conceive how a sub- 
 stance like the oxalate of lime can form a calculus at all ; 
 since in our hands, this salt exists only in the form of a pow- 
 der, little soluble in water, and quite incapable of concreting, 
 or of assuming the massive crystallized form. That the oxalate 
 of lime, however, is not only capable of forming amorphous, 
 but crystallized concretions of considerable magnitude, is suffi- 
 ciently obvious, from a very superficial examination of mul- 
 berry concretions ; and perhaps the following observations may 
 throw some light on the modes in which these varieties are 
 produced. 
 
 Whether the oxalic acid be taken as food, or eliminated 
 
ORIGIN OF RENAL CONCRETIONS. 
 
 321 
 
 during the assimilating processes, still the quantity compared 
 with the bulk of the articles with which it is mixed, is 
 comparatively small, and in all ordinary cases, it seems to pass 
 off, whether associated with lime or not, in a state of solution 
 in the acid urine with which it is secreted. When, however^ 
 the proportion of the oxalic acid is greater than usual, or when 
 from any cause the urine becomes alkaline, the oxalate of 
 lime, no longer under vital control, and becoming incapable 
 of being held in solution in the urine, is precipitated in 
 the kidney ; and when once, even the most minute solid parti- 
 cle is thus deposited, it is quite sufficient to constitute 
 a nucleus, around which future accretion will take place. 
 This is one of the modes in which renal concretions of the 
 oxalate of lime may be supposed to be formed ; but the most 
 frequent mode in which such concretions are formed, appears 
 to involve another principle. We have elsewhere stated, that 
 in certain states of the system frequently connected with cu- 
 taneous disease, and with the presence of oxalic acid, the 
 mucous membranes of the urinary organs, and particularly of 
 the kidneys, are disposed to throw off large quantities of lime, 
 either in the shape of carbonate or phosphate of lime, or a 
 mixture of the two.^ Now, when this is the case, and when 
 oxalic acid, in any state of combination, is at the same 
 time eliminated by the kidney, the formation of an oxalate of 
 lime concretion is inevitable ; for from the great excess of lime 
 present, and from the tendency in the urine to alkalescence on 
 such occasions, the oxalate of lime formed, no longer capable 
 of being retained in solution, is deposited in the solid form; 
 and thus, as before, affords a nucleus around which other por- 
 tions of the salt either rapidly concretes in the amorphous 
 form ; or more slowly in the crystallized form ; according as 
 the oxalic acid and the lime may happen to be more or less 
 abundant. Such appears, as just stated, to be the most fre- 
 quent mode in which the formation of an oxalate of lime con- 
 cretion is formed in the kidney. In other instances, a particle 
 * See pages 273 and 292. 
 
 Y 
 
322 
 
 ORIGIN OF RENAL CONCRETIONS. 
 
 of blood, or perhaps of tlie epithelium of the mucous mem- 
 brane lining the cavities of the kidney, may constitute the 
 primary nucleus of the concretion. This may be supposed to 
 be the mode in which renal oxalate of lime concretions are 
 produced, after inflammatory attacks or injuries of the kid- 
 ney, of which I have seen repeated instances ; for during such 
 conditions or injuries of the kidney, blood, &:c., are not un- 
 frequently thrown off from the excited or injured mucous mem- 
 brane. In all these, and other instances that might be re- 
 lated, the formation of an oxalate of lime concretion obviously 
 requires the concurrence of other causes besides the mere pre- 
 sence of oxalic acid in the urine ; and hence, as elsewhere stated, 
 the formation of such concretions is, for the most part, purely 
 accidental, and by no means commensurate with the frequency 
 of the diathesis in different individuals. 
 
 The cystic oxide form of calculus is so rare that we can say 
 but little respecting it ; but from the history we have given 
 of cystic oxide concretions, as well as from the peculiar proper- 
 ties of the substance, there can be little difficulty in con- 
 ceiving how concretions can be formed from it in the kidney. 
 The plastic nature of cystic oxide, while it favours the forma- 
 tion of concretions, is unfavourable to their escape ; for a 
 substance of moderate size and hardness may be supposed to 
 pass much more readily through a muscular canal, than a 
 plastic mass yielding to pressure, and capable of assuming the 
 irregular forms of the canal itself. 
 
 Nephritic calculi composed of the phosphates are not of 
 common occurrence, and in almost all instances their imme- 
 diate nucleus consists of the carbonate or phosphate of lime, 
 or a mixture of both. In general also these two substances 
 predominate throughout the calculus ; and, except in a few 
 rare instances, the proportion of the triple phosphate present 
 in such calculi is far below the average. The rationale of 
 these remarks will be readily understood by those who have 
 perused the foregoing pages, and borne in mind what has been 
 said on the subject of the pathology of incidental principles. 
 
ORIGIN OF RENAL CONCRETIONS. 
 
 323 
 
 1 have seen very few instances of renal calculi composed of the 
 phosphates, in which the mucous membrane lining the cavities 
 of the kidney has not been in that peculiar state of disease 
 formerly noticed, in which it throws off calcareous matter 
 either in the state of carbonate or phosphate and though 
 phosphatic renal calculi may be occasionally of urinary origin, 
 yet I am satisfied that such an origin of these concretions is of 
 uncommon occurrence ; and that they are most usually formed 
 from the mucous membrane lining the cavities of the kidney 
 in the manner stated. On these grounds we can account for 
 the comparative absence of the triple phosphate of magnesia 
 and ammonia; which is most frequently of urinary origin; 
 and only begins to be associated with the calcareous salts, 
 when they have formed a mass so large as to disturb the 
 functions of the kidney ; and thus to cause the urine to abound 
 in, or rather to deposit, the triple phosphate.f In two or three 
 renal calculi composed chiefly of the triple phosphates, which 
 I have seen, there appeared to be a foreign nucleus, around 
 which the triple phosphate was collected. I am ignorant of 
 the history of these cases ; but think it not improbable that 
 the patients, among other things, had been taking alkalies 
 too freely ; which caused an excess of the triple phosphate to 
 abound in the urine. 
 
 * See pages 273 and 292. 
 
 f Many years ago I examined the body of a gentleman who during the 
 greater part of his life had suffered from renal disease, remarkable for being 
 attended by the secretion of large quantities of the earthy phosphates. 
 Both kidneys were not only extensively disorganised ; but most of the 
 natural cavities, as well as many cysts, were found distended with nume- 
 rous earthy concretions of various sizes and composition. The concretions 
 found in those cavities to which the urine had access, consisted of the phos- 
 phate and carbonate of lime, and more or less of the triple phosphate of 
 magnesia and ammonia ; while those cavities or cysts distinct from the 
 renal structure, and to which, therefore, the urine had no access, consisted 
 of the calcareous phosphate and carbonate only, without any admixture 
 of the triple phosphate. This case forcibly arrested my attention at the 
 time ; and hideed was one of the first circumstances that led me to the 
 views advanced in this treatise respecting the pathology of the phosphates. 
 
 Y 2 
 
324 
 
 SYMPTOMS, kc, OF REXAL CONCRETIONS 
 
 Such is a summary account of tlie formation of the different 
 varieties of renal calculi, as founded partly on their structure, 
 and partly on the pathology of the principles of which they are 
 composed. Did our space allow, innumerable illustrations of 
 the general accuracy of the opinions above advanced might be 
 given; but I hasten to consider the subject in another point 
 of view. 
 
 Section II. — Of the Symptoms and Treatment of Renal 
 Concretions in general. 
 
 The subject of renal concretions is naturally diyided into two 
 parts, yiz. the symptoms, kc, they produce while in the kid- 
 ney ; and the symptoms they produce during their passage 
 from the kidney down the ureter to the bladder. 
 
 Of the Symptoms produced hy the presence of Concretions in 
 the Kidney. — The most frequent symptoms produced by the 
 presence of foreign bodies in the kidney, are — pain in the 
 region of the organs ; disturbance of the functions of the 
 stomach, usually accompanied by nausea and yomiting ; un- 
 easy sensations, and painful retraction of the testes ; and 
 bloody urine. Each of these symptoms is liable to be very 
 much modified according to the size and nature of the concre- 
 tion, the peculiar constitution of the patient, and a variety of 
 other circumstances ; as in the next place we shall attempt to 
 show. 
 
 The pain produced by the presence of renal concretions 
 differs almost infinitely both in kind and degree. I haye 
 known patients who were constantly passing renal concretions 
 of considerable magnitude, declare that they felt no pain from 
 them whatever ; and that if they had not seen the concretions, 
 tbey would have been unconscious of their existence. I have 
 seen other instances, in which the presence of a small concre- 
 
SYMPTOMS, &C., OF RENAL CONCRETIONS. 
 
 325 
 
 tion in the kidney has gi\^en occasion to very great suffering 
 or uneasiness about the back, for a long time before it has de- 
 scended from that organ into the bladder. In these cases the 
 differences could neither depend on the nature of the concretion, 
 nor on its size ; for the concretion has in both instances consist- 
 ed of lithic acid, and the least concretion produced the greatest 
 pain. Still the nature of the concretion and its magnitude, 
 other things being equal, have doubtless a great effect in modi- 
 fying the nature and the degree of the pain. Generally speak- 
 ing, perhaps, concretions of the lithic acid produce least pain ; 
 and the pain, when it does occur from such concretions, is often 
 dull and oppressive, with a sense of weight ; of the gouty and 
 rheumatic kind ; and accompanied by fever and derangement of 
 the hepatic system. Indeed the pain in general from lithic acid 
 concretions, may be said to bear a certain relation to the consti- 
 tutional disturbance ; that is, to the activity of the gouty or rheu- 
 matic diathesis, and to the hepatic derangements present ; es- 
 pecially about the middle period of life, when such affections, 
 as was formerly stated, first begin to make inroads on the sys- 
 tem. The presence of concretions of the oxalate of lime in 
 the kidney often produces great pain and constitutional de- 
 rangement ; but the pain and derangement usually assume 
 different characters from the pain and derangement attending 
 lithic acid concretions. The pain is generally of a more acute 
 character ; and though principally referred to a particular spot 
 over the region of the kidney, is often discursive, and shoots in 
 the direction of the ureter, epigastrium, or shoulder. The 
 constitutional symptoms also partake of the irritable, rather 
 than of the congestive and inflammatory character — in short, 
 present all the peculiarities of the oxalate of lime diathe- 
 sis formerly noticed ; and which need not be repeated. 
 I am not aware of any peculiarity in the pain of the back, 
 produced by cystic oxide concretions in the kidney ; further 
 than that it is often severe and distressing, and not neces- 
 sarily characterised either by gout, rheumatism, or irritability. 
 The existence of concretions of the phosphates in the kidney 
 
326 SYMPTOMS, &C., OF RENAL CONCRETIONS, 
 
 is sometimes attended by great suffering. The pain, which is 
 almost unremitting, is apt at intervals to assume an aggravated 
 form, so that the affection becomes paroxysmal. I have more 
 frequently noticed this form of concretion to be accompanied 
 by a distressing sense of burning heat in the back, than either 
 of the other forms of calculus ; though this is a symptom occa- 
 sionally occurring in all the varieties. In other respects, the 
 pain and phenomena attendant on concretions of the phos- 
 phates closely resemble those attendant on the oxalate of lime, 
 to which form of concretion they are for the most part patho- 
 logically related ; as stated in a former chapter. 
 
 The next most constant symptom produced by the presence 
 of concretions in the kidney is, disturbance of the gastric 
 functions, usually accompanied by nausea and vomiting. 
 This symptom, like the pain produced by renal concretions, 
 withwhichit is ina certain degree commensurate, is subject to the 
 greatest possible variety in different instances. Those in whom 
 lithic acid concretions do not produce pain, often escape 
 gastric disturbance ; and, as above stated, the chief disturbance 
 in such cases usually lies below the stomach. When lithic 
 acid renal concretions produce pain, the stomach generally 
 sympathises in some way ; and most usually by producing great 
 acidity and its consequences. Nausea, and even vomiting, are 
 not unfrequently occasioned by renal lithic concretions ; but most 
 commonly, when this is the case, the individuals labour at the 
 same time under what they call a bilious attack ; that is, ab- 
 dominal congestion, accompanied by gouty irritation. The 
 presence of oxalate of lime concretions in the kidney usually 
 produce great gastric disturbance of various kinds, among 
 which, however, nausea and vomiting, though they occasionally 
 occur, are not the most frequent symptoms. The most frequent 
 symptoms are, great flatulence, and its consequences, gastro- 
 dynia, palpitations of the heart. Sec. ; in short, disturbances not 
 only of the stomach, but of the whole system, partaking of the 
 irritable characters, formerly described as characteristic of 
 the oxalic acid diathesis. I know of no peculiar gastric dis- 
 
SYMPTOMS, kc, OF RENAL CONCRETIONS. 
 
 327 
 
 tiirbances occasioned by the presence of cystic oxide concre- 
 tions in the kidney. Renal concretions of the phosphates 
 often produce considerable gastric derangements ; which gastric 
 derangements, for the reasons mentioned, usually partake more 
 of the irritable character of those produced by the oxalate of 
 lime, than of the congestive character of those produced by 
 lithic acid renal concretions. 
 
 The third symptom, most usually produced by the presence 
 of renal concretions, are painful sensations, accompanied by 
 retraction of the testes. This symptom assumes a variety of 
 forms in different instances. Sometimes, instead of pain and 
 retraction of the testes, there is a sense of numbness, coldness, 
 or relaxation. These, and a variety of other anomalous sensa- 
 tions, are not confined to the testes, but occasionally extend 
 down the inside and front (more rarely the outside) of the 
 thighs, and even to other parts of the body. Sometimes also, 
 when the pain is of long duration, the testicle chiefly affected 
 becomes swollen and tender to the touch. Indeed, I have seen 
 several instances in which pain and swelling of the testicle 
 constituted one of the first and most prominent symptoms pro- 
 duced by a renal concretion. I am not aware of the causes 
 of these differences in this symptom ; or whether this symptom be 
 liable to be otherwise much modified by the nature of the 
 renal calculus. I have seen many of these modifications, both 
 present and absent, in all the varieties of concretion, and in 
 almost every possible grade. Sometimes they have constituted 
 one of the most troublesome indications ; at other times they 
 have been altogether absent ; and that without any reasons 
 that I could discover. Certainly, at least, neither the size nor 
 the kind of concretion appeared to account for the modifica- 
 tions of the symptoms, nor for their presence or absence. It 
 is probable, therefore, that these symptoms are connected with 
 some accidental nervous sympathies or communications not at 
 present understood. The passage of flatulence along those 
 portions of the colon, in near contact with the kidney, is some- 
 times attended by darting pains in the testes. 
 
328 SYMPTOMS, &C., OF RENAL CONCRETIONS. 
 
 The last characteristic symptoms of renal concretions to be 
 briefly noticed is bloody urine. This, like the preceding, is 
 subject to great modifications. In a variety of cases of renal con- 
 cretions, blood is never observed at all ; in others it is almost 
 constantly present. In congested and gouty subjects who 
 suffer from lithic acid renal concretions, the blood often appears 
 in the urine under the form of a dark coffee-coloured sediment, 
 mixed with lithic acid gravel ; which, after a time, subsides to 
 the bottom of the vessel, and leaves the urine apparently little 
 coloured. This haemorrhage is sometimes produced by very 
 slight causes ; as, for instance, by an active cathartic which had 
 perhaps been taken to relieve a bilious attack. Occasionally 
 the blood is more abundant, and in this case the colour is more 
 florid ; and the urine remains red, after subsidence has taken 
 place. Perhaps, on the whole, renal concretions of the oxalate 
 of lime are more apt to produce haemorrhage than any other 
 variety. This may arise in part from their rough and angular 
 forms ; but the peculiar characters of the diathesis have like 
 wise something to do with the phenomena. Thus, during the 
 prevalence of certain epidemics, in which the tendency of this 
 form of concretion seems to be augmented, I have seen bloody 
 urine very common.* At other times, in sporadic cases of the 
 oxalate of lime concretion ; and in those cases in particular 
 in which oxalic acid appears to have been formed (or intro- 
 duced) into the stomach, very large crystallized concretions of 
 the oxalate of lime, presenting sharp angular points in all 
 directions, have been voided ; during the formation, or even the 
 passage, of which, no haemorrhage had been observed. I have 
 never seen bloody urine accompany cystic oxide renal concre- 
 tions. Renal concretions composed of the phosphates are 
 sometimes accompanied by bloody urine ; but if I were to 
 speak from my own experience, I should say, much less fre- 
 quently than some other forms of concretion. 
 
 In concluding this part of our subject, it need scarcely be 
 observed, that the preceding remarks apply to those cases in 
 * See page 23. 
 
SYMPTOMS, kc, OF RENAL CONCRETIONS. 
 
 329 
 
 which the degree of exercise is supposed to be moderate and 
 equal. Violent exercise, in every instance, seldom fails to 
 produce all the above symptoms in a greater or less degree. 
 In these remarks, also, the concretions are supposed to be of 
 moderate size, and not in any way connected with organic 
 disease ; circumstances which much aggravate the symptoms, 
 and produce others to be now briefly recited. Renal calculi, 
 under favourable circumstances, make their escape from the 
 cavities of the kidney, and descend into the bladder, from 
 whence they are discharged with the urine. During their 
 transit they produce a train of symptoms to be presently de- 
 scribed. In the mean time, however, we shall make a few 
 remarks on the presence of concretions in the kidney too large 
 to be thus got rid of ; and which, from their retention in that 
 organ, and their gradual increase in magnitude, finally destroy 
 its functions. 
 
 The symptoms produced by concretions in the kidneys, too 
 large to escape, are by no means commensurate with the mag- 
 nitude of the concretions. Their increase being in general 
 very slow, the organs become accustomed to the stimulus, 
 and gradually accommodate themselves to their pressure. 
 During all this time, however, one or more of the symptoms 
 above mentioned are seldom absent, particularly after exercise 
 or exertion of any kind ; and at those periods when the func- 
 tions of the digestive organs and bowels are, from any cause, 
 disturbed. The patient, in fact, is conscious that something is 
 wrong about the kidney ; and that he cannot take those liber- 
 ties with impunity, which a perfectly healthy person can do. 
 Yet, as just observed, an individual may pass the greater part 
 of a long life with a very large concretion in one kidney at 
 least, (sometimes even in both,) without being a remarkable 
 sufferer. When the concretion, or concretions, (for sometimes 
 there are several,) are large, they necessarily destroy, in a 
 greater or less degree, the organisation, and consequently the 
 functions, of the kidneys. In such cases the properties of the 
 urine are always disturbed, and besides blood, which is fre- 
 
330 
 
 SYMPTOMS, &C., OF RENAL CONCRETIONS. 
 
 quently present, there are often large quantities of other unna- 
 tural matters in the urine ; the appearances and properties of 
 which vary somewhat according to the nature of the concre- 
 tion. The nature of the concretion may be conjectured with 
 tolerable certainty from fragments previously passed, and from 
 the prevalent characters of the diathesis ; of which the urine, 
 both in health and disease, generally presents the most striking 
 characteristics. Thus, when the concretions in the kidney 
 consist of the lithic acid, this principle, in an impure or imper- 
 fectly developed condition, is generally mixed with the bloody and 
 muco-purulent discharge. On the other hand, when the concre- 
 tions consist of the mulberry variety, the lithic acid is not only 
 entirely absent, but the mucous deposite, when not mixed with 
 blood, usually assumes the form of a transparent gelatinous 
 mass of a greenish colour ; the urine also has generally a 
 greenish whey-like tint, and is of moderate, or even low specific 
 gravity. When blood is present in small quantity, this is apt 
 to be almost black ; and even when present in large quantity, 
 it is usually darker coloured than the blood produced by lithic 
 acid concretions. I have seen no instance of the presence of a 
 large cystic oxide concretion in the kidney, but presume, that 
 when such exists, the urine will be always found to con- 
 tain more or less of this peculiar principle. When large con- 
 cretions of the phosphates exist in the kidneys, the tendency 
 of the urine to alkalescence, and the earthly deposites inva- 
 riably present in a greater or less degree, are, in conjunction 
 with the other symptoms, sufficiently characteristic of the cir- 
 cumstance. 
 
 The above remarks apply to the quiescent condition of large 
 renal concretions. When, from severe exercise, or from other 
 accidental circumstances, the concretions become dislocated, 
 they sometimes produce inflammation of the kidney and death 
 in a very short time ; and this, perhaps, is one of the most 
 dangerous accidents to which they are liable. Thus, I have 
 known individuals with large concretions in the kidney, after 
 a slight fall or strain of the lumbar muscles, immediately 
 
SYMPTOMS, (fee, OF RENAL CONCRETIONS. 
 
 331 
 
 seized with the most excruciating pain in the region of the 
 kidneys, attended by agonising gastric distress and vomiting, 
 which nothing would allay. At length, after a few hours, sup- 
 pression of urine, at first partial, and then complete, has super- 
 vened, and the patient has become comatose ; in which condi- 
 tion he has expired, in spite of every attention, in a day or two 
 after the accident. At other times such an accident terminates 
 more slowly, but not less surely, in extensive suppuration and 
 destruction of the kidney; under the effects of which the 
 patient ultimately sinks exhausted. 
 
 After what has been stated above and elsewhere, on the 
 formation and existence of concretions in the kidneys, we need 
 not dwell on the causes, diagnosis, or prognosis, in such affec- 
 tions. We shall proceed, therefore, to consider the symptoms 
 usually attendant on the passage of renal concretions from the 
 kidney to the bladder ; and afterwards speak of the treatment 
 of the whole subject of renal concretions in conjunction. 
 
 Of the descent of renal concretions from the Mdney to the 
 bladder. — As the effects produced by the descent of renal con- 
 cretions from the kidney depend chiefly on the mechanical 
 irritation they occasion, the symptoms produced by the dif- 
 ferent varieties of concretion closely resemble each other. We 
 shall commence, therefore, with a detailed account of the 
 symptoms produced by the most common variety of renal con- 
 cretion, viz. the lithic and renal concretion ; and afterwards 
 point out the most striking differences in the symptoms pro- 
 duced by the other concretions. 
 
 At a greater or less period after the formation of a lithic 
 acid calculus in the kidney, but generally not till after the 
 peculiar symptoms accompanying the formation of such a 
 concretion have subsided, and the flow of urine has begun to 
 assume its natural condition ; the little concretion, under fa- 
 vourable circumstances, quits the cavity of the kidney, and 
 entering the ureter, gives occasion to the train of symptoms 
 to be now considered. The attack usually commences with a 
 sudden aggravation of all the symptoms formerly described 
 as produced by a calculus in the kidney, viz. a most acute pain 
 
332 
 
 SYMPTOMS, Sec, OF RENAL CONCRETIONS. 
 
 in the loins, accompanied by nausea and a tendency to faint- 
 ing or rigor, which soon terminate in violent vomiting, and 
 more or less of fever. The pain usually assumes the paroxysmal 
 form ; and, together with the sickness which accompanies it, is 
 of such an overwhelming nature as to paralyse the stoutest 
 individual.* During the paroxysm the bowels are apt to be 
 much disturbed with flatulence, amounting to what has been 
 termed nephritic colic ; and the pain shoots in all directions, 
 but particularly forward to the groin, or downward to the 
 bladder, and even to the end of the penis. The testicle on the 
 side affected is painfully retracted, and there is a sense of 
 numbness or uneasiness down the inside and front of the thigh. 
 There is a frequent tendency to pass the urine, which is 
 usually scanty, high-coloured, or bloody, voided with pain and 
 difficulty, and not unfrequently serous, even when blood or 
 gravel are absent. These symptoms continue sometimes for a 
 few hours only — sometimes for several days or even weeks ; 
 and when thus protracted, the progress of the concretion can 
 be often gradually traced down the ureter by the shifting of 
 the seat of the pain, and by certain modifications in its cha- 
 racters. On account of the peculiar form of the ureter, 
 which is narrowest below, particularly where it communi- 
 cates obliquely with the bladder, the stone usually sticks in 
 this part with the greatest obstinacy ; and produces, by its 
 complete stoppage of the flow of urine, the most distressing 
 symptoms. At length, during a violent paroxysm of retching, 
 the patient experiences a sudden sensation, as if he were 
 stabbed ; and from that moment his acute pains commonly 
 cease, the stone having then slipped suddenly into the bladder. 
 Such is the usual history of the first descent of a lithic acid 
 calculus from the kidney to the bladder. In subsequent 
 attacks, the symptoms are usually milder, and considerably 
 modified ; the ureter either having become expanded ; or accus- 
 tomed to the stimulus of a foreign body. Sometimes even in 
 first attacks the symptoms are so slight as to escape notice; 
 
 * I have known nephritic attacks accompanied by syncope, and in one 
 or two instances by epilepsy. 
 
SYMPTOMS, (fee, OF RENAL CONCRETIONS. 
 
 333 
 
 even when severe, they often gradually subside without any 
 crisis ; so that we are unable to determine with certainty whe- 
 ther the concretion has left the ureter or not. In such cases 
 it is probable that the urine escapes by the side of the calculus ; 
 as many of the symptoms produced by the descent of renal 
 calculi appear to depend more upon the suppression of urine 
 they occasion, than upon their mechanical irritation. In some 
 instances lithic acid concretions become broken or disinte- 
 grated during their passage from the kidney ; and in this case 
 they are voided as gravel with little inconvenience. 
 
 The symptoms produced by the descent of an oxalate of lime 
 concretion from the kidney, in most respects resemble the 
 above, produced by a lithic acid renal concretion. The nature 
 of the concretion may be generally inferred from the former 
 history of the patient, and from the prevalent diathesis. The 
 absence of lithic acid gravel in the urine, the dark colour of 
 the blood usually present, the marked and peculiar constitu- 
 tional irritation, and the severe and often protracted character 
 of the attack, assist our diagnosis, and usually leave little doubt 
 on the subject. I have generally observed, also, that the pain 
 and worry produced by the descent of an oxalate of lime con- 
 cretion often remains much longer after the descent and escape 
 of the calculus, than after the descent and escape of lithic acid 
 concretions ; so that the patient can be scarcely persuaded that 
 others do not remain behind — a circumstance of rather un- 
 common occurrence in this form of concretion ; which is 
 usually solitary, and, even under ordinary circumstances, does 
 not recur, except after considerable intervals. 
 
 I have known great suffering produced by the descent of a 
 renal calculus composed of the cystic oxide ; but am not aware 
 of any peculiarity in the symptoms. The nature of the con- 
 cretion can without much difficulty be determined by the state 
 of the urine. The descent of renal concretions composed of 
 the phosphates often gives occasion to great and protracted 
 misery. I once saw an attack continue for upwards of three 
 weeks, almost without remission. At length the concretion 
 
334 
 
 SYMPTOMS, (fee, OF RENAL CONCRETIONS. 
 
 made its escape into the bladder ; from which organ it was 
 shortly afterwards voided with some difficulty on account of 
 its magnitude. It is not easy in all instances to form a correct 
 opinion of the nature of the concretion, when it consists of the 
 phosphates ; for the irritation and excitement usually present, 
 often cause the urine to be loaded with the lithate of ammonia. 
 The constitutional history of the patient may throw some light 
 on the subject. Whether the absence of blood in the urine 
 be characteristic or not of phosphatic renal concretions, I 
 cannot state ; but it has so happened that in the few instances 
 I have seen of such attacks, the urine, though sometimes serous, 
 has not contained blood. 
 
 After what has been stated, we need not dwell on the causes or 
 diagnosis of nephritic attacks occasioned by the descent of renal 
 calculi.* With respect to the prognosis, it may be stated, that 
 viewed mechanically, or with reference to the possibility of their 
 entering and passing down the ureter, everything depends on the 
 size and shape of the concretion. Small concretions, though pro- 
 ductive of severe pain, are seldom dangerous ; large concre- 
 tions, on the contrary, by sometimes permanently sticking in 
 the ureter, produce great constitutional irritation, and even 
 the death of the patient. Such instances, however, are very 
 rare, and have most usually occurred when there has been dis- 
 ease of the kidney ; or when there has been a calculus in both 
 ureters at the same time, and there has been from this cause 
 a total suppression of urine. When suppression of urine takes 
 place, the patient usually becomes comatose ; in which state he 
 expires ; sometimes in convulsions. A scanty or suppressed 
 condition of the urine, therefore, is always to be considered 
 as a formidable symptom in nephritic attacks. Concretions too 
 
 * The reader is referred more especially to page 260^ where the symp- 
 toms produced by biliary concretions, which occasionally somewhat 
 resemble those produced by renal concretions, are pointed out. The 
 diagnostic differences between the symptoms produced by the descent of 
 renal concretions, and other affections of the kidney likely to be mistaken 
 for such an accident, will be more fully considered in the next chapter. 
 
SYMPTOMS, (fee, OF RENAL CONCRETIONS. 
 
 335 
 
 large to enter the ureter, produce a peculiar train of conse- 
 quences already noticed ; but to be more fully illustrated here- 
 after. 
 
 Of the Treatment of Renal Concretions. — The treatment of 
 renal concretions, like their symptoms, may be conveniently 
 considered under two heads, viz. the treatment to be adopted 
 while they are comparatively quiescent in the kidney ; and the 
 treatment to be adopted to alleviate the acute symptoms they 
 produce during their passage down the ureter. 
 
 When the symptoms formerly recited appear to denote the 
 presence of concretions in the kidney, and when, from the phe- 
 nomena exhibited by the urine, and from the absence of other 
 circumstances denoting organic disease of the organ, there is 
 reason to hope that these concretions are not of such a magni- 
 tude that their escape is impossible ; one of the first circum- 
 stances to be attempted, is to cause their expulsion from the 
 kidney. The means to be adopted for this purpose in the dif- 
 ferent forms of calculi are essentially the same ; but vary in 
 some minor particulars. When the concretions are of the lithic 
 acid variety, as is by far most frequently the case, one of the 
 earliest circumstances to be attended to, is the reduction of that 
 congested condition of the abdominal viscera, which is usually 
 present in this form of concretion. This may be accomplished, 
 should the symptoms be strongly marked, by cupping freely 
 over the loins at the outset ; and afterwards by active pur- 
 gatives, including calomel (and colchicum or henbane if gout 
 be suspected, or spasmodic irritation present) conjoined with 
 alkaline and diuretic remedies ; among which the tartrate of 
 potash, or tartarized soda, is perhaps the most efficient. When 
 the symptoms denoting congestion have become subdued, the 
 patient should be put upon the plan of diet and treatment for- 
 merly mentioned, as adapted to the lithic acid diathesis ; and 
 be directed to take simple diluents freely, (such as the Mal- 
 vern or effervescing waters,) in conjunction with foot or horse 
 exercise. The degree of exercise must be always carefully 
 
336 SYMPTOMS, See, OF RENAL CONCRETIONS. 
 
 limited by the degree of pain and constitutional excitement 
 produced. Without attention to this precaution, exercise is dan- 
 gerous from its liability of exciting inflammation and its conse- 
 quences ; when, however, the inflammatory state of the system 
 has been previously reduced, exercise may be generally taken 
 freely, and often with the effect of bringing away the concretions, 
 with comparatively little inconvenience. Under this plan of 
 treatment, sometimes alternated with the cautious use of diu- 
 retics of the terebethine kind, I have seen almost incredible 
 quantities of sand, and numerous lithic acid concretions, of 
 various magnitudes, brought away, to the great relief of the 
 patient. If the concretions be too large to descend the ureter, 
 which may be usually inferred from the phenomena pre- 
 sented by the urine ; the congested state of the system, if 
 it exists, is to be reduced as before, but with more caution ; 
 and our object should be to maintain the flow of water, 
 but not by forcing medicines to unduly increase it ; as the 
 use of active diuretic medicines under such circumstances, is 
 highly improper, and often dangerous. In the preceding 
 cases, however, two great objects of the treatment will be similar ; 
 viz. to prevent the formation of new concretions in the one 
 instance ; and their increase in magnitude in the other. The 
 means by which these objects are to be attained are the same, 
 and have already been pointed out in our chapter on the 
 lithic acid diathesis ; to which, therefore, we refer the reader.^ 
 When, from the history of the patient and from the characters 
 of the urine, the concretions are presumed to be of the oxalate 
 of lime variety; the same general principles of treatment are to. 
 be kept in view ; but the means to be employed are somewhat 
 different. That peculiar congested condition of the abdominal 
 viscera, so usually present in middle-aged individuals labouring 
 under lithic acid concretions, is seldom so remarkable 
 (indeed is usually absent) in renal concretions of the oxalate of 
 lime. Cupping and other depleting remedies, therefore, are 
 rarely necessary, to much extent, in this form of concretion ; 
 
 * See page 194. 
 
SYMPTOMS, (fee, OF RENAL CONCRETIONS. 
 
 337 
 
 and the symptoms we have to deal with are rather those of 
 irritability. If the state of the urine and other circumstances 
 denote the absence of serious organic disease, and that the cal- 
 culus is of small size, means may be taken to dislodge it, if 
 possible, from the kidney. These means may, as before, con- 
 sist of diuretic purgatives ; or of diuretics alone, as for instance 
 dilute nitro-muriatic acid with nitrous aether. Sedatives, as 
 henbane, &;c., will be proper ; and the warm bath, conjoined with 
 plenty of exercise, on foot or horseback, (always stopping short 
 of severe pain, haemorrhage, or constitutional irritation,) should 
 be perseveringly persisted in, till the enemy be dislodged. 
 When there is obvious organic disease in the kidney, all these 
 means, as in the preceding case, will be improper ; and our 
 attention must be directed to prevent, as well as we can, the 
 further increase of the calculi, by the means best calculated 
 to obviate their formation.^ 
 
 When the renal concretions consist of the cystic oxide, or of 
 the phosphates, the same general principles of treatment should 
 be kept in view. Inflammatory symptoms, if present, which is 
 rarely the case, should be subdued ; and if there be no signs 
 of organic disease in the kidney, and the concretions be ap- 
 parently of small size, the means adapted to remove them from 
 the kidney should be cautiously applied. On the other hand, 
 should symptoms of organic disease be evident, our attempts 
 must be limited to the prevention of the future increase of the 
 calculi, and to the counteraction of chronic inflammation. For 
 the former of these purposes the expedients already recommended 
 should be resorted to ;t while for the latter, an issue or seton 
 over the loins is often of great benefit ; as will be more parti- 
 cularly pointed out in the next chapter. 
 
 * See page 67, where these means are pointed out. 
 
 t When the phosphatic renal concretion, as is often the case, is con- 
 nected with skin disease, an alterative course of sarsaparilla, or other 
 means adapted to the peculiar character of the cutaneous affection, may, 
 in addition to the means formerly pointed out as adapted to this pe- 
 culiar diathesis, be often superadded with excellent effect. See pages 
 273 and 292, 
 
 z 
 
338 
 
 SYMPTOMS, kc, OF RENAL CONCRETIONS. 
 
 The treatment to be adopted during the actual descent of 
 concretions from the kidney is essentially the same in the dif- 
 ferent species of calculi ; but occasionally requires to be modi- 
 fied according to the presence or absence of particular symp- 
 toms. In plethoric individuals labouring under renal concre- 
 tions of the litliic acid variety, the symptoms sometimes run so 
 high, that free cupping over the loins is in the first place re- 
 quisite. This may be followed by a full dose of calomel and 
 opium ; and when these means have begun to sensibly afiect 
 the system, warm fomentations, or the warm bath, may be 
 generally recommended with great advantage. After some 
 time, diuretic purgatives (combined with colchicum, and given 
 in the effervescing form, if the stomach continues very irritable,) 
 may be resorted to ; for it is in this particular stage of the 
 attack that diuretic purgatives, more than any other remedies, 
 seem to promote the escape of the concretion. 
 
 When the concretion consists of the oxalate of lime, the con- 
 stitutional symptoms are seldom so urgent, as when it consists 
 of the lithic acid. Antiphlogistic remedies, therefore, are not 
 required in the same degree, and often not at all ; and we 
 must trust more to sedatives and diluents. The warm bath 
 and sedatives may, in such cases, be often employed at the very 
 commencement of the attack ; while the diluents may con- 
 sist of citrate of ammonia or nitre, given in the effervescing 
 form, and dissolved in considerable quantities of tepid water. =^ 
 Much alleviation from the pain produced by renal concretions, 
 is also sometimes obtained, by the free injection of warm water 
 into the bowels. This remedy may be administered at first, 
 with the view of clearing the bowels ; and afterwards, if neces- 
 sary, repeated with the addition of sedatives. In protracted 
 cases of suffering from renal calculi composed of the oxalate of 
 lime and of the phosphates, I have occasionally known the 
 
 * Perhaps the best mode of administering this form of remedy is to 
 heat a small quantity of a strong solution of the citrate of ammonia or 
 nitre nearly boiling hot_, and then to add to it such a quantity of some 
 effervescing Avater as shall make the mixture bloodwarm. 
 
SYMPT03IS, &;C., OF RENAL CONCRETIONS. 339 
 
 greatest relief from that intolerable burning sensation of which 
 patients sometimes complain in these forms of concretion, ob- 
 tained by the application of pounded ice to the region of the 
 kidney. I first took the hint from a patient who always ap- 
 plied it in his own case with the best effect. I apprehend, 
 however, that the practice should be limited to the forms of 
 calculus mentioned ; and should hesitate to have recourse to it 
 in plethoric gouty individuals labouring under lithic acid renal 
 calculi. In such, and indeed in all cases, the application of 
 fomentations as hot as the skin will tolerate them, are the 
 safest medicines, and seldom fail to give temporary relief. 
 
 Such are the most usual means to be resorted to during the 
 descent of renal calculi from the kidney. As already stated, 
 these symptoms often terminate of their own accord by the 
 escape of the calculus into the bladder ; sometimes, however, it 
 happens, with the lithic acid calculi more especially, that when 
 one calculus escapes, others follow in quick succession, so as 
 to constitute a number of attacks more or less acute. In cases 
 also of the oxalate of lime and phosphatic concretion, uneasi- 
 ness often prevails about the kidney and bladder long after the 
 calculus has escaped from the latter organ ; so that the patient 
 is apprehensive that others remain. Nor is it easy, in all in- 
 stances, to determine this point ; though, as already stated, 
 the probability with regard to the oxalate of lime concretion 
 in particular, is against the supposition that other concretions 
 remain. 
 
340 
 
 CHAPTER II. 
 
 OF DISEASES OF THE KIDNEY PRODUCED BY, AND LIABLE TO 
 BE CONFOUNDED OR ASSOCIATED WITH, CALCULUS IN THESE 
 ORGANS ; AND OF THE TREATMENT OF SUCH DISEASES. 
 
 The disease most likely to be produced by, and confounded or 
 associated with renal concretions, is inflammation of the kid- 
 ney, either in its acute or chronic form ; this, therefore, will 
 occupy our attention in the first place. We shall afterwards 
 briefly consider, under a second general head, the diseases re- 
 sulting from acute and chronic inflammation of the kidney ; 
 and from the mechanical irritation produced by a calculus, or 
 other degenerating influences on that organ. 
 
 Of Acute Inflammation of the Kidney. — All writers agree 
 that idiopathic nephritis, or acute inflammation of the substance 
 of the kidney, is a very rare disease, at least in this country. 
 This accords with my experience ; for during the long time my 
 attention has been directed to these diseases, I have only seen 
 two or three well- marked instances, and am not able to speak 
 with much precision of more than one case.* Like other 
 
 * Unfortunately the memoranda of this case, which occurred to me 
 many years ago, have been mislaid; so that I can only state the general 
 circumstances. The patient was a servant, a young man about thirty 
 years of age, not subject to gout or rheumatism, and apparently sober 
 and healthy. The affection was stated to have commenced with the 
 symptoms recited in the text. After it had existed for some time, medi- 
 
INFLAMMATION OF THE KIDNEY. 
 
 341 
 
 acute attacks of inflammation, acute nephritis usually com- 
 mences with rigor, which is soon followed by all the usual con- 
 comitants of fever. This fever is sometimes of a highly phlo- 
 gistic character ; sometimes only moderate ; but in all instances 
 is marked by decided hardness of pulse. There is acute 
 burning pain in the region of one or both kidneys, accompanied 
 by thirst, anxiety, restlessness, colicky pains with constipation 
 of the bowels for the most part, and sickness and vomiting. 
 The urine, which at first is of a deep red colour, is said, as the 
 disease proceeds, to become limpid and colourless ; and in the 
 height of the disease, there is a frequent desire to pass it, but 
 with very little effect ; and sometimes, when both kidneys are 
 alfected, there is a total suppression; in which case a fatal 
 coma soon supervenes. 
 
 Such are the most frequent symptoms stated to be produced 
 by acute nephritis ; and though they resemble in some respects 
 the symptoms formerly pointed out as accompanying the ne- 
 phritis attended by acute anasarca, yet there are many points 
 of distinction.* That acute nephritis can exist without ana- 
 sarca, I have not, from what I have seen, the least doubt. It 
 is evident, therefore, that the cause producing acute anasarca 
 involves the whole system, and the kidneys among the rest ; 
 while simple inflammation, if confined to the kidneys alone, 
 does not necessarily produce anasarca. The urine in acute 
 
 cal aid was called in, and he was actively treated. I then saw him for 
 once, I believe, only. At that time he complained of constant acute 
 burning pain in the region of the kidney. There was no anasarca; nor, 
 as far as I recollect, any other striking- symptoms. The urine was not 
 remarkably scanty ; but it was of a deep blood red colour, transparent, 
 and little if at all serous. He died some days after ; and the body was 
 examined. The kidneys alone were found to be affected, and these were 
 both much enlarged, and in a most intense state of inflammation throughout 
 their whole substance. So much I remember ; but I regret that I cannot, 
 for the reasons stated, safely enter further into details, either as to the 
 cause, symptoms, circumstances attending the fatal result, or the ap- 
 pearances found after death; all of which, however, I remember generally 
 to have been interesting and instructive 
 + See page 128, et scq. 
 
342 DISEASES PRODUCED BY RENAL CALCULUS, &:C. 
 
 nephritis is said by some, like the urine in acute anascarca, to 
 be serous. On this point I regret that I cannot speak with 
 much certainty. The urine in the case of acute nephritis, of 
 which a few particulars have been given in a preceding note, 
 was very little if at all serous, at the time I examined it. 
 Whether it had been albuminous before, or whether it became 
 albuminous in subsequent stages of the affection, I am unable 
 to state. M. Rayer observes, that a serous condition of the 
 urine in simple nephritis is accidental and occasional only.=^ 
 Authors speak of gouty and rheumatic nephritis, as opposed 
 to simple or idiopathic nephritis. That such modifications of 
 the disease exist both in the acute and chronic form, there can 
 be no doubt. Indeed what may be, and is, usually called 
 chronic nephritis, is most commonly connected with a gouty 
 diathesis, and the formation of lithic acid gravel or concre- 
 tions ; and in different instances of such affections the symp- 
 toms vary in every possible degree, from those of simple 
 irritation or low chronic inflammation of the kidney, up to the 
 most acute forms of nephritis above described.f The presence 
 of gouty nephritis may be generally ascertained from the 
 previous history and. age of the patient ; and these circum- 
 stances, and the symptoms usually attending it, are commonly 
 so unequivocal as to leave little doubt about the diagnosis. 
 Gouty nephritis almost always terminates in the formation of 
 renal concretions of lithic acid ; even if the patient had never 
 before been subject to the affection. Moreover, when gouty 
 individuals in early life have suffered from inflammatory 
 attacks about the kidneys arising from mechanical injuries, or 
 from any other cause, they are almost certain, in middle age, 
 to get nephritic attacks more or less of the inflammatory kind, 
 and attended by the formation of lithic acid gravel or concre- 
 
 * Vol. i. p. 303. 
 
 f The reader is referred to what has been already stated at pages 201 
 and 324, for the symptoms usually accompanying nephritic attacks 
 accompanied by lithic acid gravel and concretions. 
 
INFLAMMATION OF THE KIDNEY. 
 
 343 
 
 tions. In most of these cases the uneasiness about the back 
 is increased by pressure or percussion. 
 
 Rheumatic nephritis, if it exists at all, is a very rare disease, 
 and I am not sure if I have ever seen a case which could with 
 propriety be classed under this head. I have indeed, in a 
 great many instances, seen attacks of lithic acid gravel, &;c., 
 accompanied by more or less of nephritis in individuals who 
 were subject to what they called rheumatism ; but, for the 
 reasons formerly stated, I have in all these cases considered 
 the attacks to partake of the gouty, rather than of the rheu- 
 matic character.* The nearest approaches to what I have 
 considered as rheumatic nephritis, have occurred in some of 
 the milder cases of anasarca, accompanied by serous urine, 
 and produced by exposure to cold. In such cases the anasar- 
 cous swellings are often tender to the touch, and shift about 
 from one place to another, without reference to the laws of 
 gravity, very like rheumatic oedema. Such cases I have consi- 
 dered to partake of the rheumatic character ; and have some- 
 times thought that even acute anasarca itself, might not be 
 unreasonably referred to the universal inflammation of the 
 same tissues which are usually the seat of common rheuma- 
 tism. 
 
 Other forms of nephritis both acute and chronic are men- 
 tioned by authors ; but the few remarks to be offered respect- 
 ing them, will perhaps be more appropriately made under 
 
 * See page 210, where I have considered gout as connected with albu ^ 
 minous, and rheumatism with gelatinous disease or derangement ; and 
 the one consequently, as manifested more especially by the lithic, the 
 other by the lactic, acids. It may be remarked, however, that one of 
 these tissues is seldom affected alone, without involving the other ; and 
 hence the frequency of what is perhaps properly called rheumatic gout. 
 Moreover, it may be remarked that the deposition and formation of free 
 lithic and lactic acids in the urine, &c., are not to be considered as neces- 
 sarily commensurate with the severity of the affections ; these two acids 
 being generally more or less neutralised, after, or at the commencement 
 of their formation, by the ammonia derived from urea, or by the soda 
 derived from the blood. 
 
344 DISEASES PRODUCED BY RENAL CALCULUS, kc. 
 
 the head of the causes of nephritis to be in the next place con- 
 sidered. 
 
 Nephritis occurs most frequently, as we have stated, in those 
 who labour under gouty and rheumatic predisposition ; and 
 the immediate exciting cause, in by far the greater number 
 of instances, is exposure to cold. Other predisposing, as well 
 as exciting causes, are various accidents or injuries affecting 
 the kidney or its neighbourhood, and more especially the 
 bladder. Also certain febrile diseases, particularly those of the 
 exanthematous kind, as scarlatina, measles, certain fevers of 
 the typhoid form. Sec, in all which the kidneys often become 
 deeply involved. Among the causes operating from within, 
 may be mentioned stimulating articles, as cantharides, tur- 
 pentine, the different balsams, &;c. Also the free or habi- 
 tual use of ardent spirits ; the effects of which, more especially 
 on the kidneys^ have been already pointed out, under the head 
 of serous urine. Another fertile exciting cause of nephritis, 
 is bladder affections ; as we shall show in a future chapter. 
 
 Inflammation of the kidney in favourable cases naturally 
 terminates in resolution, sometimes accompanied by a discharge 
 of blood, &c. ; but it isu liable to be followed by all the usual 
 consequences of inflammation in other parts of the body ; 
 such as suppuration and abscess ; obliteration of structure ; gan- 
 grene, kc. ; on which we have in the next place to make a few 
 remarks. 
 
 Suppuration and Abscess of the Kidney. — Inflammation of 
 the kidney, when about to terminate favourably, is sometimes, 
 as above mentioned, accompanied by a discharge of blood, or 
 other matters of an indefinable, but critical, nature, in the urine. 
 When this desirable event does not take place, and when, in 
 spite of all the means employed to prevent such a termination, 
 nephritis ends in suppuration or abscess, the circumstance is 
 usually indicated by rigors followed by febrile exacerbations and 
 sweatings — in short, by all the symptoms of hectic. The urine, 
 at the same time, becomes loaded with pus, or purulent looking 
 mucus; which frequently, by its unnatural properties, pro- 
 
SUPPURATION AND ABSCESS OF THE KIDNEY. 345 
 
 duces much irritation in the bladder and urethra ; as will be 
 shown more particularly in the next chapter. In other in- 
 stances, the urine remains for some time clear, and the patient 
 complains of a dull pain with a sense of fulness and weight 
 in the loins, and more or less of gastric disorder. In this case 
 the presence of an abscess in the kidney may be suspected ; 
 which after a time commonly bursts suddenly into the cavity of 
 the kidney ; when large quantities of pus, occasionally mixed 
 with blood, gravel, &c., appear in the urine, and, during their 
 passage, occasion considerable suffering to the patient. 
 
 We have already stated, that suppuration and abscess of the 
 kidney are almost always associated with, if not produced by, 
 inflammatory excitement of the kidney caused by urinary con- 
 cretions ; and that, in such instances, the calculi often go on 
 increasing in magnitude, till the kidney is wholly destroyed. 
 Sometimes in these and similar cases, the ureter becomes par- 
 tially or entirely obliterated either by the presence of concre- 
 tions or other causes. In such cases of course the pus cannot 
 escape, at least in any quantity ; and the patient is either cut 
 off after a short illness ; or sometimes continues to suffer for 
 years a variety of distressing symptoms. In a few such cases 
 the abscess has been known to point outwardly to the loins or 
 back, where its purulent contents, sometimes mixed with calculi, 
 have been discharged ; and the patient, after much protracted 
 misery, has either sunk under the affection, or occasionally ex- 
 perienced a partial recovery.^ In a few instances, the abscess 
 
 * I once saw an instance of this kind in a young man of a strumous 
 habit, in whom the affection of the kidney, I believe, had been first 
 brought on by a neglected stricture. In this case an immense abscess 
 over the region of the kidney made its appearance after a severe and 
 decided nephritic attack, accompanied by serous and purulent urine. 
 This abscess was not absolutely ascertained to be connected with the 
 kidney, but every appearance indicated that it was so connected. The 
 abscess was opened artificially, and an immense discharge of foetid pus 
 took place. After a long state of suffering, the abscess gradually healed, 
 and the patient recovered ; the kidney probably having become quite 
 obliterated. Sir B. Brodie observes, that when the ureter from any cause 
 
346 DISEASES PRODUCED BY RENAL CALCULUS, &C. 
 
 has been known to burst into the abdominal cavity and prove 
 quickly fatal. In the majority of cases of the present de- 
 scription, the ureter remains more or less pervious ; and the 
 patient continues to discharge purulent matter, almost con- 
 stantly, during the remainder of his life. Instances of this kind 
 have been already alluded to in a former part of the present 
 volume ; to which the reader is referred for further particulars 
 respecting the properties of the urine and the phenomena found 
 after death, in these and similar affections.* 
 
 Indurated Obliteration of structure is another consequence 
 of nephritis, mentioned by different authors. Such appear- 
 ances have been found after death; but the characteristic 
 symptoms attending them are unknown. 
 
 Violent inflammation of the kidney has also been known to 
 end in gangrene, in some very rare instances. This unfortu- 
 nate event is indicated by the usual symptoms of the same 
 termination in other parts of the body. The pain ceases more 
 or less suddenly, the pulse sinks, and the fatal termination of 
 the disease is speedy and inevitable. 
 
 The above varieties of inflammation are principally confined 
 to the substance of the kidney itself, and only secondarily 
 involve the membranes covering the organ externally, or lining 
 it internally. M. Rayer, I believe for the first time, has given 
 the appellation of Pyelitis to inflammatury excitement of the 
 mucous membrane lining the pelvis and other cavities of the 
 kidney, and accompanied by an increased discharge of mucus, 
 or of epithelium, in the urine — a disease, the existence of which 
 
 becomes obliterated, the kidney may be expanded by the urinous and 
 purulent accumulation into a large bag or cyst^ and thus form a tumour 
 which may be felt externally in thin persons ; and further, that tumours 
 having this origin may occasionally disappear, their contents, after a time, 
 being removed by absorption. In such cases the enlarged cyst gradually 
 contracts till it becomes a mere capsule, in which the calculus, that per- 
 haps, originally caused the affection, remains imbedded. I think I have 
 seen an instance of such a series of changes. — Lectures on Diseases of 
 the Urinary Organs, page 200. Second Edition. 
 * See page 169. 
 
PYELITIS. 
 
 347 
 
 has been long suspected, or rather known, but which had not 
 been distinguished by any peculiar appellation. M, Rayer's 
 name is a very good one, and I shall adopt it. 
 
 Pyelitis assumes various forms according to its degree and 
 other circumstances. It most usually accompanies catarrhus 
 vesic(s, or inflammation of the mucous membrane of the blad- 
 der, especially when severe ; it seems also to occur occa- 
 sionally in some forms of gonorrhoea, particularly when they 
 have been suddenly checked by astringent injections, &c. The 
 symptoms are usually more or less of pain, uneasiness, and 
 sense of heat in the back, which are accompanied by low 
 febrile action, and by nausea and sympathetic irritation of the 
 testicles ; particularly when the secretion of mucus is unusually 
 large. When the affection is complicated with catarrh of 
 the bladder, the symptoms above mentioned are usually re- 
 ferred to that affection ; and indeed, they are with difficulty dis- 
 tinguished from the symptoms produced by the bladder disease. 
 Pyelitis, therefore, is in general seen in its most characteristic 
 and best marked forms, when the cause is local, or lies in the 
 kidney itself ; as, for instance, when the affection arises from the 
 irritation caused by renal concretions ; or is connected, as it 
 sometimes is, with certain cutaneous affections, remotely allied 
 to syphilis, or the oxalic acid diathesis, and more especially 
 affecting the neighbourhood of the urinary organs. 
 
 When pyelitis arises from the presence of calculous con- 
 cretions in the kidney, the usual symptoms produced by these 
 bodies are present ; but the properties of the urine, and parti- 
 cularly of the mucous deposite, vary considerably. When 
 the concretion consists of the lithic acid, the quantity of 
 mucus in the urine, though considerable, is not so striking and 
 characteristic, as it sometimes is when the concretion consists 
 of the oxalate of lime. This arises partly, perhaps, from the 
 diminished quantity of mucus secreted ; and partly from the 
 quantity of lithate of ammonia and other matters usually present, 
 which involve and conceal it. When the calculus consists of 
 the oxalate of lime, the mucus is occasionally voided in large 
 
348 DISEASES PRODUCED BY RENAL CALCULUS, &C. 
 
 transparent greenish gelatinous masses or lumps of consider- 
 able tenacity, which sometimes, in passing down the ureter, 
 excite all the acute symptoms and suffering produced by a 
 renal concretion. When the renal concretion consists of the 
 phosphate of lime, the symptoms are much the same, and the 
 mucus often contains the earthy matter intermixed with it in 
 considerable quantity. As the cutaneous affections above 
 alluded to are often connected with oxalate of lime or phos- 
 phatic concretions, it is not easy to say whether such concre- 
 tions be, or be not, the immediate cause of the inflammatory 
 excitement, I think, however, I have seen many instances of 
 large mucous discharges from the kidneys, when the cause has 
 not been concretions ; but some chronic disease of the mucous 
 membrane lining the pelvis, &;c., of the kidney, and occa- 
 sionally alternating with external cutaneous affections. The 
 sufferings from pyelitis, particularly when complicated with 
 diseased kidney, and permanently serous urine, are often, in 
 common with these symptoms, referred to the neck of the 
 bladder or urethra ; and are little felt in the region of the 
 kidneys ; as will be more particularly shown in a subsequent 
 chapter. 
 
 With respect to the inflammation of the external membrane 
 of the kidney, I am not aware that there is such a specific 
 disease. This membrane is indeed often involved in inflam- 
 mation spreading from the kidney to the neighbouring parts, 
 and vice versa ; but I have seen no instance in which the 
 inflammation could be said to have originated in this mem- 
 brane. 
 
 Besides these affections of the kidney, which constitute the 
 usual forms and consequences of inflammation, a variety of 
 other chronic diseases of that organ have been noticed by 
 different authors, the peculiar symptoms and formidable cha- 
 racters of which are so obscure, and urgent, that little with 
 certainty can be predicated of them ; except that nothing can be 
 done towards their cure, and that they must inevitably prove 
 fatal. Such are the various forms of malignant disease, — fun- 
 
PAINS IN THE BACK. DIAGNOSIS. 
 
 349 
 
 gus hsematodes, cancer, &c. Occasionally also tlie kidneys are 
 found to contain hydatids, worms, hairs, &c. ; and the nature of 
 these affections are sometimes rendered evident during life by 
 the discharge of such animals and matters with the urine.* In- 
 stances of all these and of many other rare and anomalous affec- 
 tions of the kidneys will be found in the works of the authors 
 referred to below, as well as of other writers ; which it w ould be 
 foreign to our present object to detail. We shall briefly allude 
 to some of these affections, in the next paragraph ; in which, 
 in conjunction with a group of affections, about which medical 
 men are often consulted under the familiar appellation of 
 Pains in the hack, the subject of diagnosis will be generally 
 considered. 
 
 Patients often complain of pain and uneasiness about the 
 back and loins, accompanied by various anomalous sensations, 
 which cause them to apprehend that stone, or some worse 
 affection, exists in the kidneys. Many of these sensations are 
 often symptomatic, or of a muscular character only ; others are 
 of so doubtful or anomalous a description, that in many in- 
 stances it is very difficult to determine what they indicate; 
 and it is with a view of discriminating among these various 
 symptoms, that I have thought it proper to consider the sub- 
 ject of diagnosis in the present somewhat unusual form. 
 
 When there is acute pain of recent origin in the region of 
 the kidneys, increased by pressure, and accompanied by severe 
 symptomatic fever and derangement of the stomach, with 
 scanty, high-coloured, and acid urine, there is reason to sus- 
 pect the presence of inflammatory action, either in the kidneys 
 or their -immediate neighbourhood. When, in conjunction 
 with more or less of the above symptoms, the pain extends 
 downwards and forwards towards the groin, and is accom- 
 panied by retraction of the testicle, and numbness in the thigh 
 of the same side, with pain or tenderness just above the pubes, 
 and bloody urine, there is reason to suspect the presence of a 
 
 * See Baillie's Morbid Anatomy. Chopart Traite des Maladies des 
 Voies Uriiiaires, &c. 
 
350 DISEASES PRODUCED BY REXAL CALCULUS, kc. 
 
 calculus in the kidney or ureter. If the patient has never 
 passed gravel of any sort ; if he be subject more especially to 
 irritable stomachic dyspepsia accompanied by much flatulence 
 and irregular action of the heart ; if he labours under eruptions 
 of the scaly kind, or troublesome indolent boils ; if the urine 
 be generally transparent and of a citron tint, rather copious, 
 and not remarkably acid, there is reason to suspect that the 
 calculus is of the mulberry variety. If in conjunction with 
 the usual symptoms of renal calculus the urine is found to 
 contain the cystic oxide, the calculus will probably consist of 
 this substance. Lastly, if the constitutional irritation be 
 unusually urgent, and the pain of a burning character : if the 
 patient labours under cutaneous disease about the scrotum 
 or its neighbourhood ; if the urine be pale coloured, alka- 
 lescent, and abounding in the phosphates, the calculus will 
 be most probably found to consist chiefly of the phosphate 
 of lime. 
 
 The above symptoms render the presence of calculus in the 
 kidney or ureter either unequivocal or very probable ; but 
 there is a o-reat variety of anomalous affections in which, from 
 the absence frequently of one or more of the characteristic 
 symptoms, it becomes almost impossible, to arrive at any cer- 
 tain determination on the point. Among such affections, 
 one perhaps of the most striking, as well as the most common, 
 is the following : 
 
 A middle aged individual, who has lived an indolent and 
 luxurious life, after some slight disorder of the bowels or ex- 
 posure to cold, begins to complain of uneasiness in the region 
 of the kidneys, which gradually increases and extends forwards 
 and downwards to the groin and testicle. The stomach now 
 frequently sympathises, and there is either absolute nausea, or 
 at least inability to take food. The tongue is much furred ; 
 there is thirst ; the pulse is fall, strong and usually accelerated ; 
 and there is a tendency to drowsiness and headache. In con- 
 junction with these symptoms the patient complains of a fre- 
 quent desire to pass his urine ; which is scanty, high-coloured. 
 
PAINS IN THE BACK. DIAGNOSIS. 
 
 351 
 
 unusually acid, often loaded with bile ; and deposits large 
 quantities of the lateritious sediments. Under these circum- 
 stances the urinary symptoms sometimes increase to a great 
 degree of severity ; and the secretion is passed in small quan- 
 tities at a time, and with burning urgent sensations of the most 
 painful kind. All these symptoms may go on for several days 
 without intermission, if not interfered with ; but if appropriately 
 treated, they usually yield immediately and completely, and 
 very often without the passage of gravel, or any other apparent 
 critical discharge with the urine. Attacks of this description 
 constitute modifications of what are called bilious attacks, and 
 most usually occur in those who inherit, or who have produced 
 for themselves, a strong predisposition to gout. In such at- 
 tacks it is often extremely difficult to arrive at a just conclu- 
 sion ; for during precisely similar conditions of the system, 
 lithic acid concretions are usually deposited in the kidney ; as 
 formerly mentioned.^' It should always, therefore, be borne 
 in mind, that such attacks denote at least a tendency to form 
 a calculus ; and consequently that during their continuance, 
 a lithic acid nucleus may be quietly deposited in the kidney, 
 which may descend from that organ at some future time. 
 
 In such perplexing cases, the following points will perhaps 
 in some degree assist us in forming our diagnosis as well as 
 prognosis ; — first, the unremitting character of the pain, &c., 
 and the obviously congested state of the abdominal viscera ; 
 in short, the unequivocal bilious nature of the attack, — a con- 
 dition of things which, though present during the deposition 
 of a lithic acid calculus ; is most usually absent during 
 a simple nephritic attack, produced by the mere descent of a 
 concretion from the kidney. Secondly, with regard to the 
 prognosis, much will depend on the period and mode, at 
 which the attack has been treated. If promptly met at the 
 very outset by the appropriate treatment, the deposition of 
 lithic acid in the kidney will be either prevented or brought 
 away in a state of hydrate or small grains ; on the contrary, 
 
 ♦ See page 317. 
 
352 
 
 DISEASES PRODUCED BY REXAL CALCULI'S, kc. 
 
 if the attack be permitted to go on for some days, or be inju- 
 diciously managed, the deposition of litliic acid in tbe kidney 
 vr'i]l have time to consolidate, and tlie formation of a renal 
 calculus will be almost inevitable. 
 
 Other symptoms of a still more equivocal character, and 
 which may or may not be connected with renal calculus, par- 
 ticularly of the mulberry variety are — a constant sensation of 
 soreness, heat, or chilliness about the spine, loins, sacrum, kc, 
 in some instances much increased by pressure, and accom- 
 panied by shooting pains and a sense of heat or flushing ex- 
 tending to various parts of the body ; sometimes by an occa- 
 sional sensation of a rush of blood to the head, with tinnitus 
 aiirium ; also with various nervous affections in different parts 
 of the body, as pain and soreness in the epi^-astric region, 
 along the course of the nerves of the arm. thigh, kc. These 
 and a variety of similar symptoms are always accompanied by 
 great derangement of the assimilating functions, and a very 
 unnatural condition of the urine ; of which, however severe 
 they may appear to be. they are often only symptomatic. 
 They occiu' most frequently in middle-ao'ed individuals, labour- 
 ing under hvpochondriasis, and are often connected, or alter- 
 nate with, cutaneous indications ; and in those who have never 
 had gout, but who inherit a disposition to that affection. I 
 have known similar sym2:)toms also frequently. occur in indivi- 
 duals who have spent a large portion of their lives in warm 
 climates ; and in such, the right side in particular has been 
 most frequently affected. Hence the idea that the affection 
 was connected with hepatic disease, and mercuiy has been 
 given freely, but too frequently with very little advantage, 
 and often with decidedly bad effects : especially in those cases 
 in which the affection has been obviously connected with de- 
 rangement of saccharine assimilation. 
 
 The symptoms above mentioned are sometimes associated 
 with, or assume the form of lumbago or neuralgic disorder of 
 the muscles or nerves of the back. In this case, they are 
 o-enerallv much increased on motion. There are many ex- 
 
PAINS IN THE BACK. DIAGNOSIS. 
 
 353 
 
 ceptions, however, to this remark, and frequent instances 
 occur in which, after the first excitement of exercise has sub- 
 sided, the continuance of it has removed, for the time, the pain 
 altogether. In such cases, one would hardly suspect the pre- 
 sence of calculus in the kidney; yet I have known the above 
 circumstance occur, when, in conjunction with the other symp- 
 toms, those of the presence of a calculus seemed unequivocal. 
 I mention this to show how exceedingly diificult it is to form 
 a satisfactory notion of the precise nature of the affection in 
 many of these cases ; and how guarded we should be in our 
 diagnosis, as well as prognosis. I have known such, or similar 
 sensations about the back and loins, continue in a greater or 
 less degree for many years in spite of every remedy ; and have 
 generally observed that they have ultimately terminated cri- 
 tically, and often unfavourably. Thus they have occasionally 
 terminated (sometimes fatally) by a sudden determination of 
 blood to the head, or some other part ; or by an irregular 
 attack of gout. I have seen a few such cases terminate in 
 spinal and psoas disease ; and once or twice have known analo- 
 gous symptoms precede or accompany the early development of 
 a malignant tumour in the neighbourhood of the kidney ; which 
 has ultimately involved, not only the kidney, but the whole of 
 the neighbouring viscera, and, after the most intense suffer- 
 ing, proved fatal.^ In some cases, such indications have been fol- 
 
 * All the instances I have seen of such cases, have occurred in indivi- 
 duals of cachectic habit, and obviously predisposed to such diseases. I 
 have had no opportunity of determining with absolute certainty, which 
 organ has been primarily affected ; but I believe in every instance the 
 kidney has been first involved, and that the disease has spread or been 
 propagated from this organ. Certainly, at least, the urinary symptoms 
 have long preceded the other symptoms ; and in one or two of the cases, 
 had not only existed from a very early period, but were of such a kind as 
 to place a diseased state of the kidney beyond a doubt. In the case of 
 malignant disease alluded to, I had foretold the nature of the affection 
 from the properties of the urine, long before (judging from symptoms) it 
 had spread to the neighbouring organs — an event subsequently marked 
 by great and overwhelming aggravation of all the patient's sufferings. 
 In another case terminating in spinal and psoas disease, the history of 
 
 A A 
 
354 DISEASES PRODUCED BY RENAL CALCULI, &C. 
 
 lowed by tlie escape of a small mulberry calculus ; and in one 
 instance, after no less than eleven years of suffering from symp- 
 toms of the above description, the case terminated in this man- 
 ner, and the patient became comparatively well for a time ; till 
 another calculus evidently began to be formed in the kidney. 
 
 A great many symptoms closely resembling the above, 
 and even accompanied by the pretended evacuation of gravel 
 or concretions, are met with in hysteric females. I allude to 
 the subject here, with the view of drawing attention to it ; 
 some further details will be given in a subsequent chapter on 
 vesical diseases. 
 
 The previous history of the patient, and the condition of the 
 urine, will in a great many cases throw more light on their 
 nature, than any of the other circumstances. But when from 
 all these, and from the other symptoms, it is impossible to come 
 to any certain conclusion respecting the presence or absence 
 of calculus in the kidney ; the facts should be always borne 
 in mind, — that such symptoms may indicate the presence of a 
 calculus in that organ ; or at any rate, that they render t\\e fu- 
 ture formation of a calculus in that organ very probable. Hence 
 the attention should be particularly directed to these points; and 
 the constitutional derangements, as well as the derangements 
 of the urinary secretion, should be corrected as far as possible, 
 according to the principles laid down in the preceding and 
 subsequent pages, so as to prevent the formation of a calculus ; 
 or if a calculus be already formed, to prevent its increase in 
 magnitude. 
 
 the patient and the state of his urine clearly showed that kidney disease 
 had existed from an early period of his life. 
 
 It is remarkable how fallacious and deceptive these sympathetic pains 
 about the back and loins sometimes prove. I have seen, for instance, 
 the whole pain and uneasiness referred to the side opposite to that in 
 which the disease lay ; and have actually known more than once, a seton 
 applied over the sound kidney. Again, the spinal and psoas diseases some- 
 times creep on so imperceptibly, and are so mixed up with the urinary 
 symptoms, that they have been entirely overlooked, not only by others, 
 but by myself. These incidents are mentioned with the view of showing 
 the propriety of the caution in diagnosis and prognosis alluded to in 
 the text. 
 
TREATMENT. 
 
 355 
 
 Treatment. — We shall now make a few remarks on the 
 general principles of the treatment of the heterogeneous class 
 of diseases briefly noticed in the present chapter. In acute 
 inflammation of the kidney, in young and vigorous subjects, 
 copious and sometimes repeated abstractions of blood, both from 
 the arm, and locally by cupping or leeches, are necessary ; but 
 in milder cases, and in pyelitiSy for instance, general bloodlet- 
 ting is seldom requisite ; though cupping to a certain extent 
 may be useful. These means should be immediately followed 
 by the use of the warm bath, and by the exhibition of active 
 doses of calomel, conjoined with opium, henbane, colchicum, 
 &c., according to the severity and nature of the symptoms. 
 When by these or other means the irritation of the stomach 
 usually present has subsided, or will permit, diuretic purga- 
 tives may be administered ; of which, in gouty individuals more 
 especially, the vinum colchici, or some other preparation of this 
 drug, should form a constituent part. In gouty subjects, also, 
 warm mustard cataplasms may be applied to the feet. Some 
 object to the use of blisters in this disease, and in the earlier 
 stages they are useless at least, and may do harm ; but when 
 the disease has begun to yield under the more active treat- 
 ment above recommended, the judicious application of blisters 
 is not only safe, but beneficial. Large emollient clysters also, 
 with or without opium according to circumstances, are some- 
 times particularly useful in the decline and less active stages 
 of nephritis. Throughout the attack the strictest antiphlogis- 
 tic regimen is to be adopted ; and when the functions of the 
 kidneys have begun to return, warm emollient drinks, as lin- 
 seed tea, barley or gum water, kc, may be taken plentifully, 
 and with advantage. 
 
 When there is obviously a calculus in the kidney, and the 
 circumstances warrant a trial of the means formerly mentioned 
 for its expulsion, these may be cautiously resorted to. But 
 when from the length of time the disease has existed, or from 
 other circumstances, its expulsion appears hopeless, and the 
 affection has assumed a chronic form, recourse can be only 
 
 A A 2 
 
356 DISEASES PRODUCED BY RENAL CALCULUS, kc. 
 
 had to preventives and palliatives. Thus if in the kidney, we 
 may still hope to prevent the future enlargement of the calcu- 
 lus by attention to the circumstances already pointed out for 
 obviating the different calculous diatheses ; while, to prevent 
 the chronic inflammation too easily induced under such cir- 
 cumstances, the introduction of a seton or issue near the part 
 affected, is often attended by the best effects. When the 
 chronic inflammatory action is accompanied by pyelitis, small 
 doses of balsamic remedies, or of the infusum diosmce are 
 often particularly useful. 
 
 In cases of chronic suppuration and abscess of the kidney, 
 when inflammation is absent, and the nature of the disease is 
 evident by the purulent condition of the urine, &;c. ; in addition 
 to the other means, and with the view of alleviating the pain, 
 anodynes, either internally, or in the form of suppository or 
 clyster may be had recourse to. If gouty irritation be sup- 
 posed to be present, the anodynes may be often combined with 
 small doses of the acetous extract of colchicum, to the great 
 relief of the patient. In these complaints, also, the uva ursi is 
 sometimes of great benefit. It may be given in the form of infu- 
 sion, decoction, or extract, according to circumstances. Some 
 have also recommended the use of small doses of copaiba and 
 other balsamic remedies, but their effects must be watched ; 
 and they are less safe as well as less beneficial, according to my 
 observations, than the infusum diosmce, the mildest perhaps of 
 the remedies referable to this class. 
 
 In all renal affections of the chronic character, the acidity 
 and alkalescence of the urine should be particularly attended 
 to ; as neglect on this point often leads to unpleasant conse- 
 quences, and to the decided aggravation of the disease. We 
 shall content ourselves, however, with barely mentioning the 
 circumstance here ; as this subject, together with the general 
 subject of mineral waters, will more particularly occupy our 
 attention in the subsequent chapters. 
 
 When the affection of the kidney is supposed to be of a 
 scrofulous character, the same general principles of treatment 
 
TREATMENT. 
 
 357 
 
 are to be kept in view ; but in conjunction with them, the 
 tonic and restorative plan usually adopted in that form of 
 cachexia may be applied as far as circumstances will permit. 
 In particular, warm sea-bathing may be sometimes employed 
 with considerable advantage. 
 
 Lastly, the diet should be light and easy of digestion, and free 
 from all stimulating condiments. In some instances, a milk 
 diet has been found particularly beneficial. Hard waters 
 never fail to increase the uneasiness and pain in the back, and 
 hence should be particularly avoided. The subject of mineral 
 waters we have already postponed till we come to speak of 
 bladder affections in a subsequent chapter. It may, however, 
 be observed here, that many of the milder effervescing alka- 
 line and chalybeate waters, as the Seltzer, Pyrmont, &;c., are 
 often highly beneficial in many chronic renal affections, when 
 properly directed. 
 
 With respect to the other affections of the kidney above 
 alluded to, viz. cancerous disorganisation, hydatids, kc, even 
 if the evidence of their existence be unequivocal, which is not 
 always the case, no specific plan of treatment can be recom- 
 mended. In such unfortunate cases, the general principles 
 above mentioned must be kept in view, so as to do no mischief 
 if we can do no good. Symptoms as they arise must be com- 
 bated by the palliatives best suited to the case ; and opiates 
 in particular, especially the preparations of Morphia, must be 
 so administered as to alleviate as much as possible the patient's 
 sufferings, and preserve the general health unimpaired. 
 
358 
 
 CHAPTER III. 
 
 OF THE ORIGIN AND INCREASE OF CALCULI IN THE BLADDER; 
 AND OF THE SYMPTOMS AND TREATMENT OF VESICAL CON- 
 CRETIONS IN GENERAL. 
 
 A VERY large proportion of the symptoms connected with con- 
 cretions in the bladder, as well as with diseases of the prostate 
 gland and bladder in general, fall within the province of the 
 surgeon. With his duties it is not my intention to interfere ; 
 but, in this and the following chapter, shall content myself with 
 relating, in as concise a manner as possible, the leading symp- 
 toms produced by the presence of concretions in the blad- 
 der ; and by the most common organic diseases of the bladder 
 and prostate ; chiefly with the view, in the first place, of 
 pointing out the diagnostic relations or differences between 
 them ; and secondly, with reference to the general principles 
 of treatment, according to the views attempted to be esta- 
 blished in the former part of this volume. 
 
 The formation of a stone in the bladder without the inter- 
 vention of a foreign nucleus, is comparatively of rare occur- 
 rence. Indeed, it may be doubted whether lithic acid and 
 oxalate of lime concretions are ever formed in the bladder ; 
 for how much soever these principles may abound in the urine, 
 they are generally retained in solution till the urine is voided. 
 The case is different with phosphatic and perhaps with cystic 
 oxide calculi ; which may be, and occasionally are, formed on 
 nuclei of their own substance, deposited in the bladder itself. 
 
 The most frequent origin of vesical calculi, as before stated, 
 is the retention of a renal calculus in the bladder ; where it con- 
 
ORIGIN AND INCREASE OF VESICAL CALCULI. 
 
 359 
 
 ^titutes a nucleus, around which a further concretion of cal- 
 culous matter takes place. Sometimes, though much more 
 rarely, the nucleus consists of a clot of blood or mucus ; some- 
 times of a foreign substance introduced into the bladder, &c. 
 
 As to the future increase of vesical concretions, this, like their 
 origin, is well understood. That is, the increase of vesical 
 concretions can happen only by the gradual precipitation 
 of that excess of the principles composing them, which is 
 incapable of being retained in solution in the urine. There 
 are, however, some trifling varieties in the modes in which 
 the precipitation of calculous matter takes place from the 
 urine, in the different varieties of calculi ; which will be 
 briefly mentioned after we have considered the general na- 
 ture of the supersaturated condition of the urine alluded to. 
 
 Saturation in a saline solution of a constant temperature 
 may be defined to be the point at which a solvent, in contact 
 with a salt, can neither take up any more, nor deposit any 
 more of that salt. Hence every saline solution which deposits 
 a salt without any change of temperature, obviously contains 
 more of that salt than is necessary to saturate it ; or such a 
 solution is said to be supersaturated. 
 
 The point of supersaturation is unfixed, and depends on 
 many extraneous causes ; but the point of saturation, although 
 for the most part it varies with the temperature, is supposed to 
 be as fixed and constant at any given temperature, as the points 
 at which water freezes or boils. Hence when the solution of 
 a salt is supersaturated, the excess is always sooner or later 
 deposited ; and the solution arrives at the point of satura- 
 tion.^ 
 
 * M. Gay Lussac, Ann. de Chimie et de Physique, xi. 296. Annals of 
 Philosophy, xv. 1. Such is a simple and probably a correct exposition of' 
 the law of saturation and its consequences. But this law is apparently 
 liable to be considerably modified in many instances, by particular 
 forms of aggregation ; and by the properties which many bodies possess 
 of combining with water, or of formhig hydrates. Thus in the hydrated 
 condition, lithic acid is comparatively soluble in water and in the urine ; 
 but such is the molecular force of aggregation among the molecules of pure 
 
360 ORIGIN AND INCREASE OF VESICAL CALCULI. 
 
 Let US apply these remarks to the subject in question. A 
 calculus in the kidney or bladder may be considered as a sub- 
 stance placed in a solution of various principles in a certain 
 quantity of water. If any of the more insoluble of these prin- 
 ciples exist in this solution in a state of supersaturation, the 
 calculus will afford a nucleus around which the excess will be 
 deposited. But if no salt exists in excess, of course none can 
 be deposited, and the calculus will not increase in bulk. 
 
 Such is the general nature of the increase of urinary calculi 
 both in the kidney and bladder ; but a great deal of additional 
 light is thrown on this subject, by a careful attention to the 
 structure of urinary concretions. Thus some of them, as we 
 have stated in the introduction, have a crystallised structure, 
 indicating purity. Others exhibit an amorphous or earthy 
 fracture when broken, indicating for the most part impurity 
 or mixture. In all cases, however, the general structure of 
 urinary calculi is laminated : indicating, as we shall attempt 
 to show, that their formation has been interrupted, or has 
 taken place at different intervals. This is particularly the 
 case with calculi composed of lithic acid, which constitutes the 
 most frequent species. 
 
 If calculi were constantly increasing, even though the rate 
 of deposition might be variable, their texture ought to be 
 homogeneous, or at least not laminated ; for as their increase 
 under such circumstances, though it might be a little faster or 
 slower, would never cease entirely, the law of continuity, on 
 which homogeneity of structure depends, would not be 
 broken. The laminated structure of calculi, therefore, dis- 
 tinctly shows that the law of continuity, as regards their 
 formation, has been broken : in other words, that the different 
 
 lithic acid, that these molecules detrude the combined water, and unite 
 with one another in preference, in the solid or crystallised form. Hence 
 water containing newly precipitated and hydrated lithic acid, retains for a 
 considerable time a much larger quantity of this prhiciplein solution, than 
 water can be made to dissolve by merely digesting or even boiling in it 
 crystallised lithic acid. Remarks somewhat similar might be made 
 respecting most of the other ingredients of which calculi consist. 
 
SYMPTOMS, &C., OF VESICAL CALCULI. 361 
 
 laminae have been formed at different intervals ; between 
 which intervals, periods have intervened during which no 
 deposition has taken place. This remark not only applies to 
 the different laminae of a heterogeneous calculus ; but to the 
 different laminae of calculi composed of the same substance ; 
 as for instance to the different laminae of which lithic acid 
 concretions usually consist. This explanation is in perfect ac- 
 cordance with the circumstances attending the formation of 
 calculi, which often, as is well known, remain in the bladder 
 for a great number of years, without attaining any remarkable 
 size. Moreover, the constant state of change alone to which 
 the urine in all individuals is liable, almost precludes the 
 notion of homogeneity in a calculus. We may suppose, 
 therefore, that certain changes take place in the urine, during 
 which the law of continuity of deposition is suspended, and 
 the surface of the concretion becomes as it were, water worn, 
 and less apt for future accretion ; — in short, assumes all the 
 properties of a heterogeneous substance. Under these cir- 
 cumstances, when a tendency to deposition recurs, it will have 
 to commence de novo, and, as it were, upon the surface of a 
 foreign body. The consequence will be, that the adhesion 
 between the new and the old coats or laminae will be less firm 
 than in the intermediate parts; and that a calculus thus 
 formed, will be disposed when broken to separate into con- 
 centric laminae. 
 
 Some other curious and important changes which urinary 
 calculi appear to undergo during their continuance in the 
 bladder, from changes induced in the urine, and from other 
 causes, will be deferred till a future chapter ; when we come 
 to consider the subject of their removal from that organ. 
 
 Of the Symptoms of Calculus in the Bladder, — The symp- 
 toms produced by concretions in the bladder cannot be tho- 
 roughly understood without a competent knowledge of the 
 constitutional symptoms attendant on the different calculous 
 diatheses. This knowledge, therefore, we shall take for 
 
362 
 
 SYMPTOMS, kc, OF VESICAL CALCULI. 
 
 granted the reader possesses, and proceed at once to our sub- 
 ject. 
 
 The leading symptoms produced by urinary concretions in 
 the bladder, may be considered under the heads of — pain and 
 irritation in the bladder itself, either alone or accompanied by 
 sympathetic pains in contiguous or remote organs ; and the 
 presence of blood, or of some other morbid derangement, in 
 the urine. 
 
 The degree of pain and irritation in the bladder occasioned 
 by the presence of concretions in that organ, other things 
 being equal, usually varies, in the first place, according to the 
 size and other circumstances incidental to the stone itself; 
 and secondly, according to the prevalent diathesis. 
 
 AA'hen a small concretion of any kind descends from the kidney 
 into the bladder, the great and immediate relief which follows is 
 apt to cause its retention in the bladder to be overlooked; and 
 any little uneasiness that may be occasioned by it is considered 
 by the patient as the mere consequence of the preceding attack, 
 that will subside after a while, like the rest of the symptoms. 
 Indeed the degree of irritation produced by small lithic acid 
 concretions, in the greater number of instances, is so trifling, 
 that if it attracts the patient's attention at all, it rarely alarms 
 him. The irritation, if any, for it cannot be called pain, is 
 indicated by a peculiar sensation at the end of the penis. This 
 irritation is more especially felt just as the bladder is emptied, 
 and assumes various forms in different instances. Sometimes 
 it is described as a sense of titillation or itching ; at other times, 
 as a dull sensation of weight or numbness ; at other times, as a 
 slight scalding, as if a drop or two of urine were left behind in 
 the urethra, kc. These symptoms, which are generally accom- 
 panied by a more frequent desire to pass water than natural, 
 usually come on just as the bladder has been emptied ; occa- 
 sionally, however, (particularly after exercise, or if the patient 
 be standing,) they are suddenly felt during the act of passing 
 water ; and the stream at the same time becomes broken or 
 
SYMPTOMS, (fee, OF VESICAL CALCULI. 
 
 363 
 
 obstructed. When this latter occurrence takes place, there 
 can be little doubt about the presence of a small concretion in 
 the bladder, to which the mechanical obstruction of the urine 
 can alone be referred. Moreover, in a very large majority of 
 instances, it will be found, both from the patient's previous 
 history, as well as from the properties of the urine, that under 
 the above circumstances the concretion consists of the lithic 
 acid. When the preceding symptoms are accompanied by a 
 sharp pricking sensation about the neck of the bladder, as well 
 as at the point of the penis, the small concretion will be pro- 
 bably of the mulberry variety. This circumstance, however, 
 is not to be considered as absolutely characteristic ; but if the 
 history of the patient and the properties of the urine coincide 
 in favour of the same view, the probability will be almost con- 
 verted into a certainty. I am not aware of any modification 
 in the above symptoms produced by the presence of small 
 cystic oxide or phospliatic calculi in the bladder, except, per- 
 haps, occasionally in the degree of their severity. The nature 
 of the concretion, therefore, must be inferred from other symp- 
 toms, and particularly from the properties of the urine ; which 
 are commonly so characteristic as to leave little doubt on the 
 subject. 
 
 These observations are more especially applicable to the pre- 
 sence of concretions in the bladder of such a small size that 
 there is every probability of their coming away, either spon- 
 taneously, or by the aid of appropriate medicines, without any 
 mechanical assistance. The presence of such small concre- 
 tions in the bladder is seldom accompanied by the other 
 characteristic symptoms mentioned, viz. by sympathetic pains 
 in contiguous or remote organs, or by a bloody state of the 
 urine — symptoms, therefore, which when present, usually denote 
 that the concretions have become too large to pass away spon- 
 taneously ; and that the confirmed state of the disease, to be in 
 the next place considered, is fairly established. 
 
 When a calculus exists in the bladder too large to pass ofi' 
 spontaneously, the preceding symptoms of pain or irritation 
 
364 
 
 SYMPTOMS, (fee, OF VESICAL CALCULI. 
 
 become gradually more and more decided. The desire to pass 
 urine is, in tlie first place, more frequently felt, and is often 
 urgent ; particularly after change of position, or under exercise. 
 The sensation or pain at the end of the penis, after emptying 
 the bladder, is more severe and continues longer. Frequently, 
 also, a feeling of weight about the perinaeum, and a sympathetic 
 uneasiness, allied to tenesmus, about the rectum, accompany 
 the sensation at the end of the penis. As the stone increases in 
 magnitude, the whole of these symptoms gradually become 
 more and more urgent, and at length assume their most dis- 
 tressing forms. At the same time, the patient's health, which 
 had been hitherto but little affected, now begins to suffer ; and 
 the last stage of the disease, to be presently described, becomes 
 established. 
 
 During the above incipient and earlier stages of the disease 
 the urine undergoes various changes ; but on the whole ac- 
 quires a more unnatural appearance as the calculus becomes 
 larger ; so as to form a tolerable index of the progress of the 
 affection. The first circumstance which strikes our notice is 
 in general the absence from the urine, in the solid form at 
 least, of the materials of which urinary calculi usually consist. 
 Thus if the patient had for years before been in the habit of 
 passing lithic acid gravel, it will be generally found that when 
 a calculus exists in the bladder, this deposit disappears from 
 the urine. At the same time it may be noticed, particularly 
 after exercise, that an increased deposition of mucus takes 
 place. This mucus is at first diffused through the urine, and 
 renders that secretion more or less opalescent ; but after a time it 
 begins to collect into rusty coloured floccules, which subside to 
 the bottom of the vessel. This mucus contains involved in it, 
 a considerable quantity of the yellow colouring matter of the 
 urine, as well as of lithic acid ; and one of its characteristic 
 features is, that it rarely adheres together in tenacious masses, 
 like the mucus from the bladder in its more excited or inflamed 
 condition. I do not know that the above description will 
 convey to the inexperienced reader a sufficient idea of the 
 
SYMPTOMS, &C., OF VESICAL CALCULI. 
 
 365 
 
 circumstance in question, so as to enable him to distinguish it ; 
 but rightly understood, I regard this appearance as one of the 
 earliest, as well as one of the most striking and unequivocal indi- 
 cations that I am acquainted with, of the presence of a small 
 or moderately sized lithic acid concretion in the bladder. The 
 presence of a mulberry concretion in the bladder is often accom- 
 panied by an excess of mucus in the urine ; but the mucus, in- 
 stead of assuming the yellow rusty tint above mentioned, is often 
 nearly transparent and of a greenish colour. The lithate of am- 
 monia also, which from a slight cold, or other cause, occasionally 
 makes its appearance in the urine in the oxalic acid diathesis, 
 assumes, instead of a red or yellow, a dirty ash colour. In the 
 few instances of vesical calculi composed of the cystic oxide, 
 which have fallen under my observation, the urine has always 
 contained this principle. So also when the concretions consist 
 (even externally) of the phosphates, the urine is always alka- 
 lescent, and abounds in ropy mucus, enveloping more or less 
 of the earthy salts. In all these cases, the urine frequently 
 contains blood, as well as other unnatural ingredients, particu- 
 larly after exercise ; and this appearance of blood is generally 
 (not always) accompanied by an increase of pain or irritation 
 about the bladder. The worst cases of haemorrhage I have 
 seen, have happened to plethoric individuals labouring under 
 the lithic acid diathesis, and in whom the abdominal viscera 
 seemed to be particularly congested ; and in a few of such 
 cases I have noticed periodic haemorrhage to recur every few 
 weeks, whether exercise was taken or not. Considerable 
 haemorrhage also is occasionally produced by oxalate of lime 
 concretions, particularly when haemorrhoidal congestion is 
 present ; which is not very uncommon in this diathesis. In 
 such cases the blood is usually dark coloured. Were I 
 to give an opinion from the little I have seen of cystic oxide 
 concretions, I should say, haemorrhage is not of common oc- 
 currence in this diathesis. The same is also the case with 
 respect to phosphatic calculi ; for though the urine and the 
 mucus it contains are often tinged with blood, when phos- 
 
366 
 
 SYMPTOMS, &C., OF VESICAL CALCULI. 
 
 phatic calculi exist in the bladder ; yet, according to my obser- 
 vations, decided liaemorrhage from this form of concretion is 
 comparatively rare — a circumstance probably arising, in part 
 at least, not only from the absence of abdominal congestion, 
 but from the incapacity of the patient, under these circum- 
 stances, to take the necessary exercise. 
 
 The length of time during which the above symptoms may 
 continue in a moderate form, particularly when the concre- 
 tions consist of the lithic acid, is in some instances surprising. 
 I occasionally see two gentlemen, the one of whom nearly 
 twenty, and the other at least ten years ago, obviously laboured 
 under all the symptoms of lithic acid concretions in the blad- 
 der ; and who still go on, suffering very little inconvenience 
 from their presence in that organ, except occasional slight 
 irritation and haemorrhage after exercise. Both these indivi- 
 duals, during the whole of the long periods mentioned, have 
 rigidly adhered to the prophylactic regimen. Sec, prescribed for 
 them ; and there is every reason to believe, with so much suc- 
 cess, that the calculi have been very little augmented in size. 
 In these and similar instances, it is probable that the calculi 
 in some way become fixed, either behind the prostate, or in a 
 fold or cyst of the bladder ;^ for I have seen repeated instances, 
 in which under these circumstances all the miseries of stone 
 in their worst form have been suddenly induced by a severe 
 jerk or fall ; or by the introduction of the finger into the rec- 
 tum — accidents which have probably dislocated the stone, and 
 rendered it free in the bladder.f 
 
 This immunity from suffering may happen with all the 
 varieties of calculus. In one of the cases referred to in the 
 
 * Some have maintained that calculi adhere to the bladder, but this 
 is a very rare occurrence ; and is principally confined to phosphatic con- 
 cretions. 
 
 t In some instances, the direct counterpart of this accident takes 
 place, and an individual who has for years laboured under all the symp- 
 toms of stone suddenly ceases to be troubled for a time ; or even for the 
 whole of his life afterwards. Sir B. Brodie gives instances of this kind. 
 See Lectures on the Urinary Organs, pp. 222 and 254, second edition. 
 
SYMPTOMS, &C., OF VESICAL CALCULI. 
 
 367 
 
 note, the calculus I believe was of the phosphatic kind; but 
 this is probably a rare occurrence ; and most of the instances 
 of quiescent calculi that have fallen under my observation 
 have been of the lithic acid variety. Next to lithic acid con- 
 cretions, perhaps the mulberry varieties are capable of being 
 longest retained in the bladder ; notwithstanding their rough- 
 ness. This is inferred from the size such calculi often assume, 
 as well as from their purity. In such cases it is probable that 
 the concretion may be fixed ; and that the oxalic acid is princi- 
 pally formed during the primary assimilating processes. For, 
 as already noticed, in the oxalic acid diathesis, the general health 
 is often but little involved, when the primary digestive organs 
 or the skin are more especially affected. 
 
 Another peculiarity almost confined to the lithic acid form 
 of concretion, is the numher in which they occasionally exist in 
 the bladder. Patients in advanced life, who are in the habit 
 of passing the pisiform variety of lithic renal calculi, are, from 
 this cause liable to have a plurality of concretions in the blad- 
 der ; and in some of these cases forty or fifty or moje concre- 
 tions of all sizes, from that of a pin's head to that of a nutmeg, 
 are contained in the bladder at the same time. In such cases, 
 the larger concretions have usually a polygonal form, arising 
 from their contact or attrition with each other. A plurality 
 of mulberry concretions in the bladder is rare. Of a plurality 
 of cystic oxide concretions I cannot speak. Nor have I seen 
 a plurality, i. e. more than two or three large concretions of 
 the phosphates in the bladder at the same time ; though the 
 presence in that organ of small irregular fragments, consisting 
 of the phosphates, in an imperfectly crystallised form, or in a 
 plastic mortary state, are very common. 
 
 It remains to make a few remarks on the third and last 
 stage of suffering induced by the presence of calculi in the 
 bladder. -4When a calculus of considerable magnitude exists 
 loosely in the bladder, and when, from any unfortunate com- 
 bination of circumstances, the general health as well as the 
 bladder have become impaired and susceptible, all the dis- 
 
368 
 
 SYMPTOMS, &C., OF VESICAL CALCULI. 
 
 tressing symptoms above mentioned, become aggravated and 
 assume their worst form. The stone by its weight naturally 
 gravitates to the sensitive and irritable neck of the bladder, 
 where it produces constant pain and desire to pass the urine ; 
 and at the same time, by obstructing the passage, deprives the 
 unfortunate sufferer of the power of relieving himself ; at 
 least in the vertical position.^ Hence he naturally throws 
 himself into some other attitudie ; and in extreme cases pa- 
 tients under these circumstances have been known, with the 
 view of removing the weight and obstruction about the 
 neck of the bladder, to pass their urine with their head 
 downwards. The patient, however, seeks in vain for relief, 
 by passing his urine. On the contrary, all his sufferings 
 are augmented by the act ; for the moment the irritable 
 bladder is emptied, it spasmodically grasps the stone, and 
 the most acute sympathetic pains dart to the rectum, down 
 the thighs, and even to the bottom of the feet. All these 
 pains, however, are tolerable, compared with the agony ex- 
 perienced in the glans penis, which the patient squeezes vio- 
 lently to mitigate his sufferings — an act instinctively imitated 
 by children, who thus tell by their actions what they want 
 words to describe. Exercise is now rendered intolerable ; 
 rest impossible. Under these circumstances, further inroads 
 are daily made in the general health ; large quantities of 
 bloody mucus appear in the urine ; and the diathesis, what- 
 ever it was before, decidedly changes to the phosphatic. 
 Finally, the coats of the bladder become diseased and thick- 
 ened; the mucus gradually gives way to pus; every bad 
 symptom begins to assume its most aggravated form ; till at 
 
 * Sir B. Brodie has well observed, that when the prostate is enlarged, 
 the tumour prevents the stone from falling down to the neck of the blad- 
 der, and thus not only obviates the mechanical stoppage of the urine, 
 but also the contact of the foreign body with the most irritable part of 
 the bladder. Hence individuals with an enlarged prostate, instead of 
 suffering more, often suffer less than other individuals. Lectures on the 
 Urinary Organs, p. 229, second edition. 
 
TREATMENT OF VESICAL CALCULI. 
 
 369 
 
 length, sometimes after a short calm, welcome death closes the 
 scene of misery. 
 
 For reasons already alluded to, and which need not be more 
 fully explained here, calculi are much more rare in women 
 than in men.* Calculi in the female bladder produce symp- 
 toms analogous to the above ; that is, there is a frequent desire 
 to pass water ; there is pain, particularly after passing water, 
 referred to the extremity of the urethra ; the urine is liable to 
 be tinged with blood after exercise ; and as the disease proceeds, 
 the diathesis, whatever it was originally, finally assumes the 
 phosphatic form. 
 
 After what has been stated, we need not dwell on the diag- 
 nosis or prognosis in calculous affections. The subject of prog- 
 nosis in particular, will be much more properly considered 
 when we come to speak of the means of removing calculi from 
 the bladder. It remains, therefore, only to make a few re- 
 marks on the medical treatment of urinary calculi. 
 
 Treatment. — The treatment of urinary calculi, in the light 
 we are now considering the subject, may be said to consist of 
 two indications, viz. the removal of small concretions from the 
 bladder, as fast as they are deposited in that organ ; and the 
 mitigation of the sufferings of the patient in those cases in 
 which the stone cannot be safely removed by surgical, or by 
 other expedients. 
 
 As a general rule it may be remarked, that whatever passes 
 down the ureter, can pass through the urethra. The moment, 
 therefore, it is ascertained that a small concretion has entered 
 the bladder, no time should be lost, nor no means spared, to 
 remove it as quickly as possible — a rule, which if it were uni- 
 formly attended to, would probably prevent altogether the 
 formation of vesical calculi. 
 
 When a small concretion enters the bladder from the ureter, 
 
 * Sir B. Brodie informs us that the proportion of females to males 
 who have suffered from calculi in the bladder, according to his own ob- 
 servation, has been about one to fifteen or twenty. Lectures on the Uri- 
 nary Organs, p. 235. 
 
 B B 
 
370 
 
 TREATMENT OF VESICAL CALCULI. 
 
 it is often retained for a few days, even under tlie most favour- 
 able circumstances, till tlie excitement occasioned by the ne- 
 phritic attack has somewhat subsided. If it does not then 
 come away, the following principles of treatment, properly 
 directed, seldom fail of removing it from the bladder. The 
 principles of treatment alluded to are very simple, and consist 
 in nothing more than attempting to allay, by antispasmodics, 
 that irritable state of the sphincter of the bladder, which often 
 exists under these circumstances, and prevents the calculus 
 from entering the urethra ; and afterwards, or rather at the 
 same time, to favour the expulsion of the calculus by the ex- 
 hibition of simple diuretics, or diuretic purgatives, with the 
 view of increasing the flow of urine. When the calculus con- 
 sists of the lithic acid, diuretic purgatives containing the 
 Rochelle salts, and colchicum or henbane, or a mixture of the 
 two sedatives, are perhaps, in conjunction with the free use of 
 diluents, the most efficient means we can employ. The diluents 
 may consist of barley water, linseed tea, kc, assisted by the 
 common soda or potash water, or even plain distilled water ; to 
 which may be added small quantities of the spiritus cetheris 
 nitrici, or the spiritus juniperi comp. When the concretion 
 consists of the oxalate of lime, henbane or opium may be em- 
 ployed as before, to allay irritation ; but I have found a very 
 dilute solution of the nitro-muriatic acid in distilled water, the 
 best diuretic diluent in this case. Concretions formed of the 
 phosphates usually require the decided use of sedatives ; and 
 the best diluents are either simple aerated water, e. g. the 
 soda water of commerce ; or a very dilute solution of the nitro- 
 muriatic acid, lemon juice, or the spir. cEtheris nitrici. 
 
 In conjunction with the above expedients, the patient should 
 be instructed when he passes his water to lean forward, so as to 
 favour the escape of the concretion. He may be also directed 
 to distend the urethra with urine, by grasping the penis ; and 
 then, by suddenly removing the obstruction, to let the water 
 flow off in a prone position. Should these expedients fail, the 
 urethra may be cautiously expanded by bougies ; and when 
 
TREATMENT OF VESICAL CALCULI. 
 
 371 
 
 this has been accomplished, the bladder may be emptied as the 
 bougie is withdrawn ; the patient at the same time favouring 
 the exit of the calculus, as before, by leaning forward. Under 
 these circumstances, the calculus will sometimes follow the bou- 
 gie, and entering the urethra, make its escape."^ Small concre- 
 tions are apt to make their escape in the water-closet, and to 
 be thus lost. The patient, therefore, should be either directed 
 to empty his bladder before sitting down ; or so to apply a mus- 
 lin strainer as to retain anything solid that may pass from the 
 bladder. I dwell on these points, because it is always of the 
 utmost importance to get ocular evidence of the escape of the 
 concretion. 
 
 The next point to be considered, is the treatment of those 
 cases, in which from any cause it may not be desirable to at- 
 tempt the removal of a calculus from the bladder. Such cases, 
 since the practice of lithotrity, may be said to be much more 
 rare than formerly ; for there are very few instances, in which 
 small or moderately sized concretions, particularly of the lithic 
 acid variety, may not at once be crushed and removed. When 
 from any cause it may not be deemed advisable to attempt the 
 removal of calculi from the bladder, and when the symptoms 
 are moderate, our attention should be chiefly directed, in the 
 first place, to restore the natural condition of the urine, so as 
 to prevent the increase of the concretions ; and in the second 
 place, when nothing else can be done, to alleviate, as far 
 as we are able, the sufferings of the unfortunate patient. 
 
 With respect to the first of these points, the treatment will 
 depend on the nature of the calculus ; a point which in general 
 can be determined with tolerable certainty by means of the 
 phenomena detailed in the preceding pages. When the cal- 
 culus obviously consists of the lithic acid, we must commence 
 by reducing, as far as we are able, by the use of alteratives, col- 
 chicum, and purgatives, that congested state of the abdominal 
 viscera, which usually accompanies the formation of this species 
 of concretion ; and in the next place, must not only lay down 
 * Sir B. Brodie's Lectures^ page 241. 
 
 B B 2 
 
372 
 
 TREATMENT OF VESICAL CALCULI. 
 
 such a system of diet and regimen, as shall prevent congestion 
 for the future ; but, at the same time, attempt so to influence 
 the properties of the urine, by the judicious use of alkaline re- 
 medies, as to counteract, without impairing the functions of the 
 stomach, the further deposition of lithic acid. The means 
 by which these indications are to be best fulfilled have been 
 already explained, and need not be repeated. 
 
 Similar remarks may be made with respect to the treatment 
 of the other forms of calculous affections ; it only remains there- 
 fore, in the last place, to consider the second general point of 
 treatment above alluded to, viz. the means best calculated to 
 relieve the patient's sufferings, when, in the last stages of the 
 disease, we can hope to do nothing more. 
 
 We have already stated that the last stages of calculous 
 affections are almost always accompanied by disease of the 
 bladder, an alkaline condition of the urine, and by the deposition 
 of the phosphates. These circumstances should be constantly 
 borne in mind with the view of preventing the exhibition of 
 improper remedies ; and thus of doing evil, when we cannot 
 reasonably hope to do good. At the same time, sedatives, 
 which are the chief means of relief we possess, should be asso- 
 ciated, as far as possible, with those means which have a ten- 
 dency to improve the properties of the urine, or to arrest the 
 formidable disease of the bladder. Thus the use of opiates 
 (of which, perhaps, the muriate of morphia conjoined with 
 hemlock or henbane is one of the most efficient,) may be given 
 with the decoction or infusion of the Lythrum, Pareira hrava, 
 diosma, or alchemilla, all of which may be acidulated or not, 
 according to circumstances. Should the muriate or acetate of 
 morphia disagree, Battley's sedative solution, the black drop, 
 the meconiate of morphia, kc, may be substituted. Some- 
 times sedatives agree best when conjoined with a small quan- 
 tity of some alkali, as magnesia or soda ; and in such cases the 
 alkalies not only counteract that acidity of the stomach fre- 
 quently produced by opiates, but sometimes prevent their con- 
 stipating effects on the bowels. The constipating effects of 
 
TREATMENT OF VESICAL CALCULI. 
 
 373 
 
 opiates are principally occasioned by deranging the balance be- 
 tween secretion and absorption ; and may be ranked among 
 their most troublesome consequences. Constipation must 
 be obviated in the best manner we are able. Castor oil is 
 an appropriate purgative in such cases ; but when this can- 
 not be borne, various purgative pills, of which the compound 
 extract of colocynth and scammony may form constituents, must 
 beresortedto. Sometimes laxative injections suit best ; butmuch 
 depends upon whether they are all returned. When opiates are 
 largely given at the same time with laxative injections, they are 
 too apt to be retained in the bowels ; in which case their watery 
 contents are rapidly absorbed and pass off by the kidneys, 
 and thus for a time very much increase the patient's suffer- 
 ings. If opiates taken internally disagree, opiate injections or 
 suppositories may be had recourse to. This local use of opium 
 sometimes gives great relief ; and may be either trusted to 
 alone, or given over and above the ordinary internal doses. 
 The use of such expedients is particularly beneficial at night, 
 when the object is to procure sleep, as well as freedom from 
 pain. In conjunction with opiates, the warm bath, warm 
 fomentations, the sitting over the vapour of warm water, and 
 all the other well-known and analogous expedients, may be 
 had recourse to. These and every other means we can employ 
 will too often fail ; but it is well in desperate cases to have a 
 variety of resources ; and sometimes it will be found that a 
 trifling and improbable expedient will for a time bring unex- 
 pected relief Large warm poultices sprinkled with lauda- 
 num, and applied to the perinaeum, occasionally relieve the 
 severe local sufferings. In acute paroxysms also I have seen 
 great temporary relief produced by a lotion composed of the 
 liquor plumbi acetatis dilutus and tincture of opium, applied 
 as hot as possible, by means of sponge, linen cloths, &;c., to the 
 perinseum. 
 
374 
 
 CHAPTER iV. 
 
 OF DISEASES OF THE BLADDER AND ITS APPENDAGES, PRO- 
 DUCED BY, AND LIABLE TO BE CONFOUNDED OR COMPLI- 
 CATED WITH, VESICAL CALCULI. 
 
 The diseases to be briefly considered in this chapter may be 
 included under two general heads or sections, viz. 1. Diseases 
 connected with inflammation of the bladder or its appendages, or 
 resulting from such inflammation ; and 2. Diseases of an irritable 
 character, connected either with certain organic and mechanical 
 diseases of the kidneys and bladder ; or with affections of these 
 organs of a puYelj functional, or nervous character. These two 
 sections of diseases gradually pass into each other, so that it be- 
 comes impossible to define the exact limits between them. 
 Moreover, they may all arise from, or at least may be compli- 
 cated with, stone in the bladder, from which in many cases it 
 is difficult to distinguish them ; and finally, most of them re- 
 quire surgical aid, and therefore do not entirely fall within our 
 present design. On the surgeon's province we shall not in- 
 fringe ; but confine our observations chiefly to the general 
 pathology, diagnosis, and medical treatment of these affections. 
 
 1 . Of Cystitis or Inflammation of the Bladder.- — Inflammation 
 of the bladder, like that of most other parts, is usually divided 
 into the acute and chronic. In general, chronic inflammation 
 
INFLAMMATION OF THE BLADDER. CHRONIC. 375 
 
 in organs, is the result, or consequence, of acute inflammation ; 
 but in inflammation of the bladder, the chronic form of the dis- 
 ease usually (not always) precedes the more acute forms of in- 
 flammation, which is comparatively rare ; for these reasons, 
 therefore, we shalt reverse the usual order in speaking of in- 
 flammatory affections, and commence with the chronic forms 
 of inflammation. 
 
 Cystirrhoea or Catarrhus Vesicce is the term by which 
 chronic inflammation of the mucous membrane lining the 
 bladder is usually distinguished ; and the following is a sum- 
 mary history of this form of the disease : 
 
 Chronic inflammation of the mucous membrane of the blad- 
 der is much more frequently an induced, than an original 
 disease, and may be divided into two stages. The first stage 
 of the idiopathic, or original form of the disease, is said to 
 commence rather suddenly. In some instances, it is preceded 
 by a feeling of oppression at the stomach, with griping and 
 extraordinary relaxation of the bowels. At the same time 
 there are occasional lancinating pains, with a sense of burning 
 heat and spasm in the region of the bladder, which are fre- 
 quently accompanied by a feeling of weight in the perinaeum^ 
 and a tendency to hsemorrhois. With these symptoms, which 
 denote a sudden increase of excitement in the whole urinary 
 system, there is likewise, as the disease becomes more fully 
 developed, a constant and urgent desire to pass urine, gene- 
 rally accompanied with much spasm of the bladder and ure- 
 thra, and the discharge of more or less adhesive mucus. 
 A slow fever usually attends the disease, and the patient 
 complains of thirst, with a feeling of general debility, particu- 
 larly about the back and loins ; and what between the constant 
 irritation and want of rest, and the incessant drainage from 
 the system, there is always, in protracted cases, a great falling 
 off" of the strength and flesh. 
 
 The urine in slight and incipient cases of this afl*ection, when 
 first passed, generally appears of a whitish colour, and is more 
 or less opake and turbid with the appearance of flocculae, (of 
 
376 
 
 DISEASES OF THE BLADDER, &C. 
 
 epithelium) floating through it. On standing, however, for 
 some time, it becomes more or less transparent, and the mucus 
 will be found together at the bottom of the vessel. In most 
 cases at this period, the urine, abstracting the mucus, is acid, 
 and not very unnatural ; while on the other hand, the mucus 
 itself is always neutral at least, if not alkaline ; in which state 
 it continues throughout the disease. The mucus varies consi- 
 derably in its appearances in different instances ; and even in the 
 same person at different times. Sometimes it is easily diffus- 
 able through the urine ; at other times it is so tenacious, that 
 when it has been once suffered to cohere, it cannot be again 
 easily mixed with the urine ; at least by simple agitation. 
 
 As the disease proceeds, the quantity of mucus secreted is 
 sometimes enormous, amounting to several pints in the day ; 
 and in this case it not only comes away diffused through the 
 urine, but likewise in the form of large coagula, which, by 
 blocking up the urethra, and by their alkalescent properties, 
 give origin to the most distressing symptoms ; and particularly 
 to a sense of severe burning pain along the whole course of 
 the urethra. I have frequently remarked, in this extreme 
 form of the first stage of the disease, that the mucus becomes 
 firmer on cooling, by apparently undergoing a species of 
 coagulation, not much unlike that of the fibrin of the blood. 
 In this case, the mass of mucus assumes so tenacious a cha- 
 racter, that it may be drawn into strings of considerable 
 length ; and the vessel may be frequently inverted without its 
 falling out. The mucus has generally an opalescent appear- 
 ance ; or sometimes it is quite opake ; but in the more ad- 
 vanced stages of the complaint it frequently assumes a puru- 
 lent-like character, and becomes of a yellowish or greenish 
 colour, or is streaked with blood. The urine also, as the dis- 
 ease proceeds, generally loses its transparency, and becomes 
 more or less serous, glairy, and alkalescent. 
 
 The above symptoms and phenomena may be considered as 
 constituting the first stage of the disease. The second stage 
 of the afiection commences imperceptibly with the changes 
 
INFLAMMATION OF THE BLADDER. CHRONIC. 377 
 
 in the mucus and urine last mentioned, and gradually passes 
 on to the following conditions : 
 
 At the commencement of the second stage of the affection, 
 the patient often complains of low rigors alternating with heat 
 and perspiration — in short, the low fever which had attended 
 the complaint from the beginning, often begins to assume a 
 more decided hectic form. The pain in the region of the 
 bladder, particularly above the pubes, becomes more severe, 
 is increased by motion or pressure, and often extends to the 
 rectum and anus, and down the thighs. The bladder now 
 begins to be denuded of its mucous membrane ; or formidable 
 ulceration takes place. The desire to make water is more 
 frequent than ever ; and though the urine is occasionally 
 passed with less mechanical impediment, owing to the changes 
 which have taken place in the character of the mucus, &c., 
 yet little is gained in point of improvement by the change. 
 Under these circumstances, the general health of the patient 
 rapidly gives way ; the countenance becomes pale and anxious ; 
 the pulse quick and powerless ; the appetite fails ; he loses 
 altogether the capacity for exercise ; and if not cut off by the 
 disorganization of the kidneys and bladder occasioned by the 
 disease, which is its most usual termination ; the patient at 
 length dies, sometimes after a short interval of comparative 
 freedom from pain, quite exhausted. 
 
 In the second stage of the disease, the urine undergoes cor- 
 responding and very instructive changes. The quantity of 
 the mucus (in its ropy form at least) is perceptibly diminished ; 
 the mucus also becomes opalescent, and of a greenish tint, and 
 is not only less tenacious, but can in part be easily diffused 
 through the urine, rendering it glairy, or opake and milky, like 
 pus ; in short, the urine becomes muco-purulent ; i. e. the 
 mucus gives way to pus, (or to something not yet sufficiently 
 distinguished from pus, to deserve a distinct appellation,) till 
 at length all the characters of mucus, except perhaps a few shred 
 like matters, disappear. The urine now is generally deep co- 
 loured, or like the washings of flesh ; serous and alkalescent. 
 
378 
 
 DISEASES OF THE BLADDER, (fec. 
 
 When alkalescent, it has generally a strong ammoniacal smell, 
 and effervesces with an acid ; and in this case there is almost 
 always an excess of the carbonate of potash or of soda present ; 
 which are derived from the serum of the blood exuded from 
 the ulcerated inner surface of the bladder.* When these symp- 
 toms have continued for a greater or less period, the urine 
 becomes scanty, still more high-coloured, and occasionally 
 even acid ; the mucus and even the pus gradually diminish 
 or almost disappear ; and as above mentioned, after a short 
 period of comparative ease, the patient expires.f 
 
 Authors speak of inflammation, both acute and chronic, of 
 the muscular structure of the bladder. We also read of rheu- 
 matic and gouty inflammation of this organ. I have been 
 
 * See pag-e 278 et seq. 
 
 t I have repeatedly seen the urine become acid in the last stages of all 
 kinds of bladder disease, and have, in consequence, foretold the speedy- 
 death of the patient. Indeed I do not remember to have ever seen a 
 person recover, when the urine has rather suddenly become acid, in long 
 protracted and severe affections of the bladder usually accompanied by 
 alkaline urine. After death, the urine, though alkaline in the bladder, is 
 often found acid in the kidney ; provided that organ be not diseased. 
 
 Mr. Coulson, in the second edition of his work on Diseases of the 
 Bladder, describes a disease which he terms, "Acute Inflammation 
 of the Mucous Membrane of the Bladder." I am not sure if I am ac- 
 quainted with any disease of an idiopathic character deserving this 
 appellation. The nearest approach to it I have seen, has been the 
 last stages of cystirrhoea described in the text. I have seen many in- 
 stances of disease very similar to those described by Mr. C. under the 
 above title ; but in every instance they appeared to have originated m 
 disease of the kidney. In such cases, the unnatural, strumous, or 
 malignant characters of the diseased secretion from the kidney, seem to 
 have induced a similar train of diseased action, and ulceration in the 
 bladder ; to which organ the whole of the patient's sufferings have been 
 in a great measure confined. And it is remarkable that in many of these 
 cases, the mucous membrane of the bladder (instead of having its natu- 
 ral function of secreting mucus increased as in cystirrhcea) is entirely 
 destroyed, so that the urine at no time is loaded with mucus, as in 
 cystirrhoea ; which is not only, therefore, a totally different affection, 
 but, however severe it may be, is of a much less formidable nature. 
 Moreover, though cystirrhoea usually terminates in diseased kidney, it 
 seldom commences, or is necessarily connected with such affection ; like 
 the disease above alluded to. — Op. cit. page 82. 
 
INFLAMMATION OF THE BLADDER. ACUTE. 379 
 
 informed that rheumatic or neuralgic affections of the bladder 
 are well known, and not unfrequent, in malarious districts bor- 
 dering on the tropics ; and I believe that I have seen a few 
 instances of such affections in this country. In such cases it 
 is probable that the muscular and nervous structures, and 
 their appendages, are the chief seat of the affection. With 
 respect to the e^^istence of gouty inflammation of the bladder, 
 I believe there cannot be two opinions ; and if we take the 
 matter for granted, we must suppose that such inflammation 
 attacks in preference that peculiar structure of the bladder, 
 which is analogous to, or identical with, the structure at- 
 tacked by gouty inflammation in other parts of the body. 
 Whether the mucous membrane be the structure primarily 
 attacked by gouty inflammation, I do not know ; I believe it 
 is not ; but that like the skin in other parts of the body, the 
 mucous membrane (as in cystirrhoea for instance) is only se- 
 condarily affected. So far I am willing to allow, that inflam- 
 matory excitement, or something which we must denominate 
 inflammatory excitement, may chiefly be confined to the mus- 
 cular and nearly allied structures of the bladder. I can also 
 understand how ordinary inflammation may involve these 
 structures in common with the rest of the structures of the 
 bladder ; but I confess that at present I am quite unacquainted 
 with, and indeed doubt the existence of, the commencement, 
 and particularly the limitation of ordinary inflammation to 
 the muscular structure of this organ. These subjects will be 
 again alluded to, when we speak of painful and spasmodic 
 affections of the bladder. 
 
 Of general Inflammation of the Bladder. — The form of 
 inflammation we are now considering, may commence in any 
 of the structures of the bladder ; but in whatever structure it 
 may commence, it ultimately involves all parts ; and particu- 
 larly the cellular substratum of the organ, which perhaps may 
 be considered as its characteristic feature. The commence- 
 ment of the attack varies somewhat, according to the part in 
 which it originates. If inflammation commences in the mucous 
 
380 
 
 DISEASES OF THE BLADDER, kc. 
 
 membrane of the bladder ; the earlier symptoms are those of 
 cystirrhoea above mentioned. If in the muscular and nervous 
 tissues, which is probably very rarely the case, the symptoms 
 may resemble those of rheumatism or gout, before alluded to. 
 If it commences in the peritonaeal coat of the bladder, which 
 it is sometimes said to do, the symptoms are those of local 
 peritonitis, which are too well known to require recital here ; 
 lastly, if general inflammation of the bladder originates, as it 
 most frequently does, in ulceration, wounds, or injuries of the 
 bladder, prostate, or urethra, the earlier symptoms will vary 
 accordingly ; and though in this case they are totally different 
 from all the earlier symptoms above mentioned, yet such is 
 their obvious nature that they can be hardly mistaken, and they 
 therefore do not require recital. Up to this point then, the 
 earlier and initiatory symptoms attending general inflammation 
 of the bladder may be very different ; but when once general 
 inflammation becomes established, the future course of the 
 affection is nearly uniform ; and all the minor distinctions are 
 lost or absorbed in the overwhelming destruction that too fre- 
 quently ensues. 
 
 General inflammation of the bladder almost always com- 
 mences with rigor. This rigor is occasionally so slight as 
 sometimes to escape notice ; while in other instances, particu- 
 larly when the exciting cause of the disease involves the neck 
 of the bladder and prostate, the rigor is well marked and 
 severe. The rigor is accompanied and followed by malaise, 
 restlessness, nausea, and disinclination to take food. The 
 skin becomes hot and dry, or occasionally partial perspirations 
 take place ; and the pulse is increased in frequency. The 
 patient in some instances scarcely complains of pain, at least 
 of more pain than usual ; while in other instances, the pain is 
 severe, especially on pressure, and extends to all parts of the 
 abdomen and back, and particularly to the rectum.* Whether 
 
 * The pain, like the symptoms, varies in this stage of the affection 
 according to the chief seat of the inflammatory action. When the in- 
 flammation occupies the lower part and neck of the bladder, there is more 
 
INFLAMMATION OF THE BLADDER. ACUTE. 
 
 381 
 
 there be pain or not, there is always an anxiety of expression 
 and an indescribable something about the patient denoting that 
 deep-seated mischief is to be apprehended. After a time, 
 another rigor, or perhaps a succession of rigors take place, each 
 followed by symptoms more or less resembling those above de- 
 scribed, but in an aggravated form. At length all the symp- 
 toms become rather suddenly increased ; the heat of the skin 
 is greater than ever, the tongue becomes dry, the pulse acce- 
 lerated to one hundred or upwards, the anxiety and restlessness 
 are most distressing, and there is an occasional hiccough. At 
 this stage (sometimes earlier) the pulse usually begins to inter- 
 mit, at first occasionally, afterwards more frequently. The 
 abdomen becomes swollen and tympanitic, and the tenderness 
 on pressure increases, particularly over the region of the blad- 
 der. As the affection proceeds, all the symptoms become 
 augmented, the pulse is accelerated to one hundred and thirty 
 or more, and hourly assumes a more weak and unsteady cha- 
 racter. The tongue becomes brown, and sometimes a peculiar 
 state of delirium supervenes, in which the patient perfectly 
 retains his consciousness, but is constantly tossing about and 
 requesting to be removed to some other place. In this state 
 I have known patients suddenly jump up, and even get out of 
 bed and endeavour to make their escape. After such exertions 
 the vital powers usually sink still more rapidly, and the patient 
 expires, occasionally in a state of low delirium, coma, or con- 
 vulsions; at other times retaining his understanding to the 
 last.^ Collaterally with the above symptoms it may be ob- 
 
 or less retention of urine ; and the pain on introducing the catheter, at 
 the moment it enters the bladder, is severe beyond endurance. Some- 
 times the inflammation involves the mouth of the ureter ; more especially 
 when the symptoms are modified by those of suppression of urine. When 
 the posterior part of the bladder is particularly affected, the rectum 
 becomes involved, and the patient is harassed by a distressing and con- 
 stant tenesmus. 
 
 * Sir B. Brodie has graphically described this state of inflammation 
 as it occasionally occurs after the operation of Lithotomy. Lectures on 
 the Urinary Organs, p. 392, Second Edition. 
 
382 
 
 DISEASES OF THE BLADDER, &C. 
 
 served, that from the commencement of the affection, the pa- 
 tient usually rejects all food, at least in the solid state ; and 
 in the latter stages can be even scarcely prevailed on to swal- 
 low fluids. The bowels at the outset of the attack are often 
 confined ; but in the latter stages they are sometimes relaxed ; 
 or at least a short time before death the patient not unfre- 
 quently has one or more calls to empty the bowels. The state 
 of the urine at the commencement presents nothing remark- 
 able, and its quantity is sometimes rather copious. As the 
 affection proceeds, it becomes more scanty, high-coloured, and 
 acid. Frequently it remains transparent, or at least is only 
 slightly clouded by mucus till the last. At other times, it de- 
 posits a large quantity of a deep orange red or yellow sedi- 
 ment, consisting of imperfectly developed lithate of ammonia, 
 and is more or less serous ; these and other varieties in the 
 appearances of the urine, depend chiefly on the state of the 
 kidneys and mucous membrane of the bladder ; and on the 
 immediate exciting cause of the attack. It is remarkable, 
 however, that whatever may have been the nature of the pre- 
 ceding symptoms, or the properties of the urine, it almost 
 always, as before mentioned, becomes acid before death. 
 
 It only remains to observe, in conclusion, that a train of 
 symptoms very similar to the above is liable to be induced by 
 causes operating in the vicinity of the bladder, and quite uncon- 
 nected with that organ. Thus I have seen them arise after a 
 slight operation about the rectum, kc.^ I believe such symptoms 
 take place most readily in those liable to derangements of the 
 saccharine assimilation ; as in diabetic individuals, for instance ; 
 who are notoriously subject to what is called diffuse inflam- 
 mation of the cellular texture ; a form of disease nearly allied, 
 if not identical with the above. Wounds of any sort, there- 
 fore, and particularly surgical operations, are for the most part 
 very dangerous, in such states of the general health. 
 
 * Many of the continental writers assert, that affections of the bladder 
 are very apt to follow operations for haemorrhoids. I have certainly seen 
 affections of the bladder, as well as other serious affections, follow such 
 operations \ but am not prepared to state that the law is general. 
 
CONSEQUENCES OF INFLAMMATION OF THE BLADDER. 383 
 
 The appearances found after death, or, in other words, the 
 consequences of these different forms of inflammation of the 
 bladder, are, as already stated, very various. We do not think 
 it necessary to enter into detailed descriptions of them, which 
 will be found in all pathological works on the subject ; but 
 the following sketch may be deemed necessary to complete our 
 inquiry. 
 
 The slighter cases of cystirrhoea seldom prove fatal ; so that 
 opportunities rarely occur of examining the bladder in this 
 early state of the disease. The mucous membrane is said to 
 present in general an inflamed appearance ; and to be more or 
 less studded with red spots exhibiting various grades of disor- 
 ganization. In some of these spots the mucous membrane 
 remains ; in others it is partially disorganized ; while in a few 
 others it is not only entirely destroyed, but ulceration is found 
 to have commenced in the structures below. In more severe 
 cases these appearances are all increased ; and in the last stages 
 particularly, all traces of the mucous membrane are nearly 
 obliterated. In such cases the muscular structure of the blad- 
 der is exposed, and its fibres are observed to be enlarged ; 
 while the general texture of the bladder is thickened, con- 
 tracted, firmer than natural, and corrugated into folds or 
 rugae ; particularly about the fundus and posterior part of the 
 organ. As Mr. Wilson observes, " the inner membrane of 
 the bladder has not in its natural state many vessels large 
 enough to contain red blood ; but when inflamed, the trunks 
 enlarge, and the minute vessels are then found to be suffi- 
 ciently numerous to impart a florid red appearance to the 
 whole surface."* After death this florid red appearance gene- 
 rally assumes a very dark red or purplish tint ; and many of 
 the prominent portions of the bladder are not only observed to 
 be denuded of their mucous membrane, but to be more or less 
 ulcerated. The parts between the prominent muscular columnge 
 are sometimes expanded into sacs or pouches ; which appear to 
 be formed by the protrusion of the lining membrane of the 
 * Lectures on the Urinary Organs, p. 297. 
 
384 
 
 DISEASES OF THE BLADDER, (fec. 
 
 organ between the hypertrophied muscular fibres. When 
 the phosphates abound in the urine, which is often the case 
 in such instances, the sacculi thus formed not only contain 
 phosphatic concretions ; but particular spots of the diseased 
 surface of the bladder are sometimes partially incrusted with 
 earthy matters. It generally happens, also, that the above 
 thickened and diseased condition of the bladder is accompanied 
 by unnatural dilatation of the ureters ; and a diseased condition 
 of one or both kidneys. These and analogous consequences 
 of inflammation of the coats of the bladder, exist in different 
 instances in every possible degree, even to gangrene of the 
 organ ; according to the severity of the attack, and the length 
 of time it has continued. Of such cases, innumerable instances 
 will be found in the different authors who have treated on the 
 subject ; to whom the reader is referred for further particulars. 
 
 The consequences of w^hat we have termed general inflamma- 
 tion of the bladder, that is, of its cellular substratum, are still 
 more severe and extensive. Besides more or less of the pre- 
 ceding appearances, the cellular membrane everywhere con- 
 nected with the " bladder is found to be infiltrated with lymph 
 and serum, and to a greater or less degree converted into a 
 slough. If death has taken place at an early period, the 
 intestines are found distended with air, and there is a very 
 slight effusion of serum in that part of the peritoneeum which 
 descends to the pelvis. But if the patient has laboured under 
 the symptoms for many days before he dies, the peritonaeum, 
 where it is reflected from the bladder to the rectum, is seen of 
 a darker colour than natural, and encrusted with lymph ; and 
 at a still later period, there is the appearance of inflammation, 
 to a greater or less extent, throughout the peritonaeum gene- 
 rally. But the peritongeal inflammation is evidently not the 
 primary disease ; it is the inflammation and sloughing of the 
 cellular membrane, which has induced inflammation of the 
 adjoining portion of that membrane."* 
 
 Of Inflammation of the Prostate Gland. — Inflammation of 
 ♦ Sir B. Brodie. Lectures on the Urinary Organs, page 293. 
 
INFLAMMATION OF THE PROSTATE, CHRONIC. 385 
 
 this organ, like that of the bladder, may be either chronic or 
 acute ; and as the chronic form of the disease, or, at least, 
 what is so denominated, is by far the most frequent, we shall, 
 as in speaking of the inflammation of the bladder, commence 
 with a brief account of the leading symptoms of chronic in- 
 flammation of the prostate. 
 
 The disease termed chronic inflammation of the prostate, but 
 which in the greater number of instances, perhaps, rather de- 
 serves the appellation of chronic degeneration of that organ, 
 usually commences insensibly, and, apart from the mere me- 
 chanical effects to which it gives occasion, without any well-de- 
 fined symptoms. In general it begins to take place soon after 
 middle age, in conjunction with the gradual decline and con- 
 gested state of the abdominal viscera which usually mark 
 that period of life ; and to which we have so often referred in 
 this volume. There is a tendency to fulness of the haemor- 
 rhoidal vessels, sometimes accompanied by bleeding ; together 
 with a sense of heat, and oppressive weight about the pelvic 
 viscera in general, but referred more especially to the rectum 
 and perinseum. These sensations and symptoms at first come on 
 at certain periods, particularly in the spring and autumn ; but 
 as the patient gets older, the periods of intermission become 
 shorter ; and during the winter months they are seldom entirely 
 absent. The patient now begins to complain of a frequent desire 
 to pass his urine, which he accomplishes with more difficulty 
 than formerly ; and the stream, instead of being projected to 
 some distance from the body, as in health, falls almost perpen- 
 dicularly from the urethra. All these symptoms, go on 
 increasing with age, and the bladder imperceptibly becomes 
 more irritable, and the difficulty of passing the urine 
 greater ; till at length the patient is unable to empty the 
 bladder at all. During the progress of the disease, the quan- 
 tity of urine retained in the bladder gradually increases, till 
 that organ habitually remains in a distended state. Another 
 train of symptoms now commences, arising from this habitual 
 distension of the bladder ; one of the most prominent of which 
 
 c c 
 
386 
 
 DISEASES or THE BLADDER, &;C. 
 
 is incontinence of urine, or at least an involuntary discharge 
 of urine during the night ; and it will be often found that the 
 patient, after putting up with all the inconveniences of his dis- 
 ease till now, applies for the first time for medical assis- 
 tance. 
 
 When the prostate is thus enlarged, it is exceedingly apt to 
 become irritable ; the difiiculties, therefore, usually expe- 
 rienced by the surgeon, in introducing the catheter, owing to 
 the tortuous and irregular shape of the urethral canal where 
 it passes through the prostate, seldom fail, though the operation 
 relieves the patient from the immediate danger of his situation, 
 to increase his sufferings in other ways. The whole of this 
 subject, however, falls within the province of the surgeon ; 
 and the little we have to say on it will be given in a sub- 
 sequent chapter, on Incontinence and Retention of urine. 
 We proceed, therefore, in the next place, to speak of another 
 consequence of chronic inflammatory excitement of the pros- 
 tate, namely, 
 
 Prostatal Concretions. — Prostatal concretions, we have else- 
 where stated, usually consist of the phosphate and carbonate of 
 lime. Moreover, we have attempted to show that these earthy 
 salts are in most instances of the present kind, the result of de- 
 ranged action in a mucous membrane. While, therefore, the 
 chronic inflammation or degeneration of the prostate above 
 mentioned, involves chiefly the substance or textures themselves 
 of the prostate gland ; the disease now alluded to, may be sup- 
 posed to be chiefly confined to the mucous membrane lining the 
 ducts and cavities of the organ. In fact earthy deposites 
 are always found in these situations in the first place ; though, 
 as they increase in magnitude, they cause the absorption of the 
 organ, and reduce it to the form of one or more cysts of various 
 sizes, each filled or distended with one or more concretions. 
 The distinct nature of the two preceding forms of chronic 
 affection of the prostate gland, is further evident from the fact, 
 that while the former is very common, the latter is compara- 
 tively rare. That is to say, innumerable instances of simple 
 
PROSTATAL CONCRETIONS. 
 
 387 
 
 enlarged prostate occur, in which no calculi exist ; while, on 
 the other hand, concretions are sometimes found in pros- 
 tates, not remarkably, if at all, enlarged. No doubt the two 
 affections may be, and sometimes are, associated ; but there 
 is reason to believe that this association is not so common as 
 has been supposed.'^' 
 
 The quantity of earthy matter sometimes secreted by the 
 prostate gland is almost incredible. Thus Mr. Wilson informs 
 us, that he was in the habit of seeing a patient, who in the 
 course of fifteen years voided as much at different times as 
 would constitute four times the bulk of the whole gland.f As 
 before observed, prostatal concretions sometimes collect into a 
 few large masses ; but more frequently they are found detached, 
 and of all sizes, from that of a pin's head to that of a hazel nut. 
 In such cases, the number may amount to fifty or sixty or more, 
 and the prostate feel to the touch like a bag of nuts. 
 
 The symptoms produced by the presence of concretions in 
 the prostate are often obscure, and distinguished with diffi- 
 culty from the symptoms accompanying other affections of that 
 gland ; or from those of stone in the bladder. The symptoms 
 of course will vary considerably according to the size, number, 
 and situation of the calculi. " When small and not project- 
 ing, they sometimes have produced so little uneasiness, as not 
 to have been suspected during life ; they are generally, how- 
 ever, attended with some difficulty in voiding the urine, and a 
 sense of uneasiness about the neck of the bladder. This un- 
 easiness is occasionally increased by violent exercise ; but so it 
 would be, did it proceed from stone in the bladder. When they 
 project towards the urethra, or produce a difficulty of passing 
 
 * In these cases, the disease is incipient. Of course concretions of consi- 
 derable size and many in number, cannot exist in the prostate without 
 enlarging the bulk of the organ ; but in such cases the enlargement is 
 obviously the effect, rather than the cause of the disease. Chronic in- 
 flammation of the prostate, and of the mucous membrane lining the pros- 
 tatal cavities and ducts, seem to bear the same relation to each other 
 as inflammation of the bladder in general, and cystirrhoea. 
 
 f Lectures on the Urinary Organs, p. 354. 
 
 c c 2 
 
388 
 
 DISEASES OF THE BLADDER, SzC. 
 
 water, and an instrument is introduced, either to search the 
 passages, or the bladder of urine, they will in some instances 
 be found to grate against it, giving that peculiar feel to the 
 surgeon which cannot be mistaken ; but they may be pushed 
 back by the instrument into the cavity of the prostate, so as 
 not to be discoverable in several subsequent examinations."^ 
 When a number of these calculi have been lodo:ed in a cvst 
 in the prostate, they have been known to produce retention 
 of urine, and various other distressing symptoms. I have 
 seen such cases ; and many are related by authors.'!' 
 
 Of Acute Inflammation of the Prostate Gland, and its conse- 
 quences. — Acute inflammation of the prostate gland may take 
 place at all ages and under all circumstances. In early life it 
 most usually arises from neglected or maltreated gonorrhoea, 
 stricture, &c. ; in advanced age, as the consequence of the 
 chronic enlargement of the organ above mentioned ; or of the 
 use of the instruments rendered necessary by such chronic 
 disease. The symptoms differ somewhat in the two periods of 
 life, but many of them are essentially the same, and as follow : 
 
 Acute inflammation of the prostate gland in advanced life, 
 and when that organ is enlarged in the manner explained in 
 a preceding paragraph, may, as just stated, originate from 
 various causes, but most usually arises from the effect of 
 the instruments necessary to relieve the retention of urine. 
 In this case, the attack commonly commences with a rigor 
 more or less severe ; which is soon followed by fever, and a 
 sense of extraordinary heat and weight about the rectum and 
 perinaeum. To these symptoms succeeds a continued throbbing 
 pain, which is much increased by pressure, as by sitting ; or 
 by the examination of the prostate through the rectum ; or 
 by evacuations from the bowels. Generally also, after an 
 evacuation from the bowels, however complete it may be, the 
 sensation still remains of something being left behind. The 
 
 * Wilson^ op. cit. p. 382, 
 
 + See among others^ A paper by Sir B. Brodie, in the Med. Chirurg. 
 Trans, vol. xii. page 302. 
 
INFLAMMATIOxV OF THE PROSTATE. ACUTE. 
 
 389 
 
 urine is passed at short intervals, and with great pain and 
 difficulty ; and sometimes there is complete retention. The 
 urine is generally high-coloured, and occasionally contains 
 mucus, and even blood. Under these circumstances, the pulse 
 becomes accelerated ; the fever, which is often of a remittent 
 character, is much aggravated ; and there is a tendency to de- 
 lirium — in short, a train of symptoms is induced, which, if not 
 speedily checked, rapidly involves the whole bladder, and 
 terminates in suppuration and mischief, which may prove fatal 
 to the patient. 
 
 Inflammation of this organ occurring in early life, and before 
 the organ has become enlarged, is much less common than 
 the preceding forms of the disease, and usually arises from 
 gonorrhoea or stricture. This form of the disease is thus 
 described by Sir B. Brodie. The patient observes that the 
 gonorrhoeal discharge stains his linen much less than it did 
 before, or that it ceases altogether; and he experiences at the 
 same time a frequent inclination to void his urine, and a 
 difficulty in voiding it. He complains of uneasiness and pain 
 referred to the neck of the bladder, and extending forward in 
 the course of the perinseum and urethra, and aggravated in 
 each attempt to make water. In some cases there is a com- 
 plete retention of urine. The impulse to make water is then 
 violent and irresistible, and it is attended with more suffering 
 than in ordinary cases of retention, on account of the urine 
 which is accumulated in the bladder being pressed with force 
 against the inflamed and tender prostate. There is a sense 
 of fulness in the perinseum and rectum, and the prostate is 
 manifestly tender when examined from the rectum with the 
 finger. 
 
 " 'Not uncommonly, suppuration takes place, and an abscess 
 forms, of which the symptoms in the first instance are gene- 
 rally obscure. As the abscess advances, the perinaeum be- 
 comes tender, and there is a perceptible though slight tume- 
 faction and hardness in some one part of it. The abscess, if 
 left to take its own course, sometimes bursts internally — that 
 
390 
 
 DISEASES OF THE BLADDER, &C. 
 
 is, into the urethra ; more frequently it makes its way through 
 the fascia, cellular membrane, and muscles of the perinaeum, 
 and bursts through the external skin. 
 
 " These local changes are attended with no small degree of 
 disturbance of the general system. The pulse is frequent, the 
 skin hot, the tongue furred ; and the formation of matter is 
 often indicated by rigors."* 
 
 The causes of these different forms of inflammation of the 
 bladder and prostate have in a great degree been already 
 mentioned. It may not be amiss, however, to recite the lead- 
 ing circumstances in a connected form. 
 
 The causes of cystirrhoea are either predisposing or excit- 
 ing. There are some habits certainly more disposed to this 
 affection than others ; such are those of an irritable scrofulous 
 temperament, with fair skin and tendency to cutaneous affec- 
 tions; more especially if they have been accustomed to venereal 
 excesses ; or have suffered from these affections, or from gout. 
 In such individuals the disease, which is properly a disease of 
 old age, and more frequent in men than in women, may com- 
 mence early in life, and in either sex, from any of the common 
 exciting causes, and more especially from exposure to cold ; 
 such as by getting wet feet, sitting on a damp seat, &:c. 
 
 This form of disease, on the whole, is most frequent in cold 
 countries, and in cold weather ; hence many suffer from it only 
 in the winter and spring months ; and in all it is apt to be 
 much aggravated during these portions of the year. In some 
 countries it is said to be so common as to assume almost an 
 epidemic form ; while in particular instances it takes on a 
 periodic character ; especially when associated, as it frequently 
 is, with haemorrhois, and with certain affections of a gouty 
 petechial character. Other exciting causes mentioned by 
 authors, are acrid diuretics, long and excessive riding on 
 horseback, the presence of worms in the intestinal canal, kc. 
 
 This tendency to chronic disease of the bladder, in which 
 the prostate almost always participates, is, perhaps, one of the 
 * Lectures on the Urinary Organs, page 111, Second Edition. 
 
IRRITABLE BLADDER FROM KIDNEY DISORDER. 391 
 
 most frequent and strongest predisposing causes of acute 
 attacks of inflammation in both these organs. With such 
 predisposition the exciting causes may be stone in the blad- 
 der ; exposure to cold ; the use of instruments; any injury 
 or accident particularly affecting the bladder or its neigh- 
 bourhood — all of which and many similar circumstances, 
 most of which we have already mentioned, may excite acute 
 inflammation in the bladder and prostate, with their fear- 
 ful train of consequences, even in the healthy state of the 
 organs ; but more especially in the chronic state of predis- 
 position above mentioned. In females, a very frequent 
 exciting cause of acute inflammation of the bladder is some 
 disease, or other affection of the uterus or its appendages. 
 Lastly, another fertile cause of chronic inflammation, or rather 
 of irritation of the bladder, &c., are certain renal diseases. 
 These, however, more properly fall to be considered in the next 
 paragraph. 
 
 2. The second great section of diseases connected with the 
 bladder and prostate, are those of an irritable character ; and 
 resulting either, a. From functional derangement, or from 
 degeneration, natural or malignant, of the urinary organs ; 
 or, h. From nervous affections of a remote and constitutional 
 origin. 
 
 a. Diseases of an irritable character, originating in the 
 urinary organs themselves, may either depend on functional, 
 or on organic derangements of the kidneys ; or on func- 
 tional, or on organic derangements of the bladder and 
 prostate, &;c. Such aff'ections, therefore, constitute two 
 natural subdivisions ; though it may be remarked that the 
 two subdivisions seldom remain distinct ; for when the kid- 
 neys are affected, the bladder always ultimately becomes 
 involved. 
 
 Cases of irritable bladder depending on functional de- 
 rangements of the kidneys usually result from the unnatural 
 properties of the urine. Healthy urine, however heteroge- 
 neous and stimulating in its properties, and however delete- 
 
392 
 
 DISEASES OF THE BLADDEK. kc. 
 
 rioLis its action may be when brought into contact with the 
 living textures of the body in general, constitutes, nevertheless, 
 the natural and proper stimulus of the renal and vesical 
 cavities. All deviations, therefore, from the normal condition 
 of the lu'ine, whether in deficiency, in excess, or in kind, are 
 recognised by the containing organs, and may prove a cause 
 offeeIi?ig — in other words, a source of irritation in the kidneys 
 and bladder. Hence, whenever the urine is very dilute or 
 very concentrated ; or is preternaturally acid, or alkaline ; or 
 contains any unnatural ingredient ; the urinai-y organs in ge- 
 neral, and the bladder in particular, thouo:h perfectly healthy, 
 are liable to become excited and irritable ; and the individual 
 has no peace till the unnatural secretion be discharged. In 
 such cases, the fault lies, not in the bladder, but remotely in 
 the kidneys and assimilating organs ; and in this mode, and to 
 this extent, the bladder may occasionally become irritable in 
 all individuals at all ages ; but in the young and healthy, such 
 irritation is temporary only, and subsides with the operation 
 of the causes. The dyspeptic sutr'er most, of com'se ; and those 
 whose powers of assimilation are weak, and who pay no regard 
 to diet, gradually lay for themselves the foundation of much 
 suffering in after life. In this way, in short, a great number 
 of cases of permanent derangement of the bladder, kc, are 
 acquired ; the organs in time (participating perhaps in the 
 natural staminal defects of the system) becoming more or less 
 diseased, either superficially. /. e. as regards the mucous mem- 
 brane ; or substantially, as regards the organs in general. 
 
 Cases of irritable bladder depending on organic aftections of 
 the kidney, are in general of a very formidable kind, and come 
 in the next place to be briefly considered. Organic diseases 
 of the kidney assume a great variety of forms ; and we have 
 already entered considerably into the subject in our section on 
 serous urine. What has been there -tated we shall not 
 repeat : but shall merelv ob-erve that some of the affections 
 formerly described as connected with anaemotrophy, are so 
 nearly related to, or so imperceptibly graduate into the class 
 
IRRITABLE BLADDER FROM KIDNEY DISEASE. 393 
 
 of affections to be now briefly described, that it becomes im- 
 possible to draw the line of distinction between them. The 
 class of diseases to be more especially considered in this place, 
 exists in various forms ; but there is one form of disease 
 which seems to constitute the groundwork of the greater part 
 of them. This, in the first place, we shall attempt to describe ; 
 and afterwards point out some of its most remarkable varieties, 
 complications, and consequences ; all of which, it may be ob- 
 served, sooner or later involve the bladder as well as the 
 kidneys. 
 
 The most simple condition of the disease to be now consi- 
 dered, appears to be principally confined to early and middle 
 age ; and is comparatively of rare occurrence in advanced 
 life. 1 believe, in almost all instances, that it is connected 
 with an inherited cachexia, of which struma constitutes one of 
 the ingredients, and very frequently a remote syphilitic, or 
 malignant taint another. Hence in early life more especially, 
 it is often connected with the oxalic acid diathesis, and witli 
 angemotrophy of the system ; nor have I ever seen it connected 
 with a decided lithic acid diathesis ; or with that peculiar 
 haemotrophic tendency which usually accompanies this diathe- 
 sis. The diseased action usually commences imperceptibly, 
 and at first attracts but little of the patient's attention ; but 
 as it proceeds, the symptoms gradually become more urgent, 
 and the patient is induced to apply for medical assistance ; 
 when the following phenomena and symptoms, in various 
 degrees of intensity and variously modified, are usually found 
 to be present : 
 
 First as regards the urine. The urine is generally acid ; 
 of a pale greenish, whey-like colour; opalescent, from 
 the presence of minute fiocculi, or particles of diseased epi- 
 thelium or mucus ; of low specific gravity ; (that is, generally 
 below 1-020;) often serous, but rarely bloody. Sometimes, on 
 being heated, it deposits the phosphates ; but the lithate of 
 ammonia is seldom so abundant as to be spontaneously sepa- 
 rated on the cooling of the urine; and when this circumstance 
 
394 
 
 DISEASES OF THE BLADDER, &C. 
 
 does take place, the colour of the sediment, instead of being 
 yellow or red, is usually of a greyish ash tint. After standing 
 for some time, the urine becomes clearer, but seldom acquires 
 perfect transparency even by filtering ; and the peculiar sedi- 
 ment in general is very easily remixed on shaking. 
 
 In conjunction with these appearances of the urine, the 
 patient usually complains of the following symptoms. There 
 is a frequent and urgent desire to pass water; the period 
 varying from one to three hours, and the quantity from one 
 to two or three ounces, both by night and by day. At the 
 moment of passing water, and for some time afterwards, there 
 is an uneasiness, sometimes amounting to severe pain, felt 
 along the whole of the urethra, but particularly just behind 
 the scrotum ; and of this uneasiness or pain, a sense of burning 
 or scalding is one of the elements. There is no mechanical 
 impediment to passing the water ; and in the earlier stages, after 
 a short time, the whole uneasiness subsides, and the patient 
 remains quite well, till the period arrives when he is 
 called upon, as before, to empty the bladder. As the disease 
 advances, all these symptoms become augmented. The unna- 
 tural properties of the urine, and of the mucous deposit, in- 
 crease ; the symptoms, and particularly the calls to pass the 
 urine, are more urgent and frequent ; the general health and 
 strength, which from the commencement had been disordered 
 and enfeebled, now daily decline, and the patient becomes 
 emaciated, weak, and irritable, and more than ever susceptible 
 of the influence of atmospheric changes. During the whole 
 of this period there is but little uneasiness felt in the region 
 of the kidneys, and what little there may be, is usually referred 
 to weakness. On minute inquiry, patients will sometimes 
 admit the existence of a dull aching sensation in the loins, and 
 occasional darting pains down the course of the ureter, and 
 even to the testicles. Sec. ; but these are so trifling compared 
 with the bladder sensations, that they are seldom complained 
 of, unless particularly inquired after. The termination of the 
 complaint is various ; most frequently perhaps as follows : 
 
IRRITABLE BLADDER FROM KIDNEY DISEASE. 
 
 395 
 
 The pulse gradually becomes more quick and feeble, and 
 the stomach, from being weak and disordered, often rejects 
 what is taken, so that the patient is very apt to be sick after 
 eating. At the same time the urine, though not improved in 
 quality, is diminished in quantity, and the calls to pass it are 
 in consequence less frequent. The patient complains of no- 
 thing, but he daily becomes more indifferent and drowsy ; as the 
 sickness increases, the urine is still further diminished in quan- 
 tity ; at length every thing is rejected, the secretion of urine 
 ceases altogether, and the patient expires, generally in a coma- 
 tose state. Occasionally the termination is more sudden and 
 unexpected ; and in such instances, inflammatory symptoms 
 have been generally superinduced from exposure to cold, or 
 some other exciting cause.^ INow and then the patient becomes 
 phthisical — in short, the fatal termination, though always 
 certain, may be various, and depend upon the peculiarities of 
 the patient's constitution, and accidental circumstances. 
 
 I have described this form of disease as we most frequently 
 meet with it. But it may be remarked, that instances of this, 
 or some very similar affection, occur, in which everything else 
 is present, except the irritability of the bladder ; which is not 
 remarkable even to the last. In such cases, the pain is some- 
 times (not alvv^ays) referred more to the back ; in other in- 
 stances, the quantity of urine may be greater than in health, 
 and the patient fears he labours under diabetes ; or that he is 
 impotent, &c. I have seen all these, and various other modi- 
 fications of the constitutional symptoms, attended by a con- 
 dition of the urine very similar to that above described ; and 
 ultimately, after a longer or shorter period, terminating unfa- 
 vourably. 
 
 This affection occurs in females as well as in males, but, 
 according to my observations, much less frequently. The symp- 
 toms in this case are somewhat modified, and are occasionally 
 accompanied by an increased vascularity and tumefaction about 
 the orifice of the urethra ; which, as well as the whole urethra, 
 are exquisitely irritable, and appear to the patient to be the chief 
 
396 
 
 DISEASES OF THE BLADDER, &C. 
 
 seat of her suffering. On examination of the urine, however, 
 it will be often that it coincides, in almost all respects, with 
 that above described — showing that the kidneys are deeply- 
 involved, and perhaps the primary seat of the affection. 
 
 We have stated, that a predisposition to this disease 
 usually exists in the form of a peculiar cachexia ; and with such 
 a predisposition, the exciting causes may be various, and 
 scarcely need recital. The pathological history of the affection 
 is obscure, and has not yet been so satisfactorily investigated 
 as it deserves to be. The following imperfect sketch is offered 
 as the result chiefly of my own observations on the subject. 
 
 Under common circumstances, and as far as the urinary organs 
 are concerned, the complaint most usually commences in the 
 kidneys ; and in some instances, I believe, it is either congenital, 
 or at least commences in very early life. The whole secreting 
 structure of the kidney seems to be more or less involved ; and 
 when the complaint is established, (perhaps before, or contempo- 
 raneously with its establishment,) the mucous membrane lining 
 the cavities of the kidney takes on a peculiar diseased action, 
 capable, in certain states of the system, of being propagated 
 to those parts of the membrane which are as yet healthy. 
 When the peculiar disease of the mucous membrane has 
 spread to all parts of the kidney, it at length extends down 
 the ureter to the bladder. In such cases, judging from what I 
 have once or twice noticed, the diseased action sometimes 
 (perhaps most frequently) commences in the bladder, about the 
 orifice of the ureter ; from which part it gradually spreads to 
 the neck of the bladder. At other times, the mucous mem- 
 brane about the neck of the bladder appears to be the part 
 first, or at least very early affected.'^' While the affection is 
 
 Several of the cases described by Mr. Coulson, under the denomina- 
 tion of Acute Inflammation of the Mucous Membrane of the bladder, 
 seem to me to be nearly allied to this form of disease. I have reason to 
 believe that the present disease often exists for years in a chronic form, 
 and confined chiefly to the kidney ; that when the degenerating process 
 reaches and attacks the bladder, it sometimes assumes, either sponta- 
 
IRRITABLE BLADDER FROM KIDNEY DISEASE, 397 
 
 confined to the kidney and fundus of the bladder, the degree 
 of irritability of this organ is generally not remarkable ; and 
 the patient may be perhaps called up once or twice only dur- 
 ing the night, &;c. But when the mucous membrane about 
 the neck of the bladder, and commencement of the urethra, 
 are involved, all the symptoms of what is called irritable 
 bladder, become fairly established in their most troublesome 
 form. With respect to the peculiar or intimate nature of 
 the affection of the mucous membrane, I can say but little. 
 In common language it may be called inflammation ; but this 
 does not by any means convey, to my mind at least, a just 
 notion of its characters. I should call it a species of degenera- 
 tion, rather than of inflammation ; that is, of perverted or dis- 
 eased, rather than of increased action. The mucus is not 
 increased in quantity, as in cystirrhoea or at least if it be, 
 its qualities are totally different from the mucus of cystirrhoea. 
 That is to say, it does not adhere together in ropy masses ; nor 
 does it appear to be capable of assuming a purulent form, like 
 the mucus of cystirrhoea. On the other hand, it partly consists 
 of imperceptible particles easily diffusible through the urine, 
 and with difficulty separated from it ; and partly of shred-like, 
 ill-defined visible particles apparently consisting of diseased 
 or altered epithelium. 
 
 This species of degeneration is not confined to the mucous 
 membrane. On the contrary, it seems to extend to other, or 
 analogous structures ; hence the organisation of the kidney, as 
 
 neously or from accidental circumstances, a more acute form, and termi- 
 nates fatally, like those described by Mr. C, with complete destruction 
 of the mucous membrane of the bladder, &c. It is remarkable, that in 
 all Mr. C.'s cases, one or both kidneys (generally the left) was found in 
 a state of disease ; and this circumstance, taken in conjunction with my 
 own observation, has induced me to form the present opinion, which, 
 however, 1 advance with diffidence. — See Coulson on Diseases of the 
 Bladder and Prostate, page 82, et seq. second edition. Also this volume, 
 page 378. 
 
 * Except, perhaps, in the acute form of the disease, when the mucous 
 membrane appears to be occasionally involved in the acute inflammation, 
 which sometimes precedes or accompanies the degenerating process. 
 
398 
 
 DISEASES OF THE BLADDER, kc. 
 
 well as its membranes, become involved, and more or less de- 
 stroyed ; and sometimes one or both kidneys contain oxalate of 
 lime or phosphatic concretions. Lastly, it may be observed, that 
 the general characters of this species of degeneration, in its 
 simplest and best defined forms, are destructive ; rarely cumu- 
 lative, or hypertrophic. The texture attacked, whether it be 
 mucous membrane or any other analogous texture, is gradually 
 destroyed, and disappears ; and when the affection exists in its 
 worst form, the restoration of healthy action in a part once in- 
 volved, seems to be impossible. Moreover, in the last stages of 
 the disease, the morbid cachexia appears to actively pervade the 
 system ; and not only the whole of the inner membrane of the 
 bladder, &:c., but the liver, spleen, intestines, and even the 
 lungs, are found in a state of organic change. 
 
 When the peculiar diathesis marking the above affection is 
 less decided, and when the strumous diathesis usually asso- 
 ciated with it, predominates,* the disease in earlier life some- 
 
 * Perhaps it may be worth while to mention^ that the peculiar affec- 
 tion alluded to seems to be more especially connected with deficient 
 and mal-assimilation of the gelatinous textures ; while struma in its sim- 
 plest form appears to be rather connected with deficient and mal-assi- 
 milation of the albuminous tissues. When gelatinous assimilation is 
 simply deficient, which is probably very rare, atrophy, i. e. diminished 
 product, results ; when gelatinous assimilation is deficient and unnatural, 
 as it is supposed to generally be in the form of the disease above de- 
 scribed, the result is degeneration, accompanied by a gradual loss of 
 substance in all the textures coimected with the gelatinous principle. 
 When albuminous assimilation is deficient, atrophy, both albuminous and 
 gelatinous, result as before, (for the gelatinous assimilation is only ano- 
 ther step in advance of albuminous assimilation, and therefore dependent 
 on it.) When albuminous assimilation is both deficient and unnatural, 
 diseased albuminous products (e. g. tuberculous matter, gouty chalk 
 stones, or lithate of soda) result. When albuminous (and gelatinous) 
 assimilation is simply excessive, hypertrophy is the result ; when exces- 
 sive and unnatural ; various morbid growths, from simple tubercle up to 
 the most highly organised tumour, may be supposed to result. If in 
 such organised tumours, &c., the gelatinous assimilation alone has been 
 deficient or imperfect, such morbid growths are apt to take on a malignant 
 nature ; if the albuminous (and of course the gelatinous) assimilation 
 has been imperfect, they degenerate into common strumous change or 
 ulceration. 
 
IRRITABLE BLADDER FROM KIDNEY DISEASE. 399 
 
 times shows itself in the form of tumours of various kinds. 
 These tumours occasionally partake of the character of nsevus ; 
 &:c., at other times they are associated with peculiar cutaneous 
 affections. Sometimes, among members of the same family 
 subject to these affections, we see one or more liable to excessive 
 irritability of the skin ; others, in early life, to a disposition to 
 phthisis ; or in middle life, to asthma ; or to affections of the 
 liver and spleen, particularly if they have been exposed to mala- 
 rious influence. The object of these remarks is to show, 
 that in a system thus predisposed, the kidneys and bladder, on 
 account of their intimate connexion with the sexual organs 
 and functions ; and on account of the innumerable diseases to 
 which these organs are exposed, are peculiarly liable to come in 
 for their share of the mischief. The affection of the kidneys 
 and bladder above described, therefore, may arise in some 
 instances spontaneously, and as a natural consequence of the 
 inherited tendency, as already stated ; but I need not say that 
 the disease is much more frequently excited by some abuse 
 or error in diet, &;c. ; or by local excitement or disease 
 established in the genital organs. When once established, 
 however, in a predisposed habit, be the exciting cause what it 
 may, the mischief proceeds more or less rapidly, and too fre- 
 quently without intermission, to its fatal termination."^ 
 
 I have mentioned, that when affections of the bladder ori- 
 ginate in renal disease, the orifice of the ureter on the side 
 affected, and the neck of the bladder, are the two parts of that 
 organ most liable to become diseased ; and that, according to 
 my observations, the orifice of the ureter is generally the first 
 
 * I have noticed that individuals inheriting this tendency are not only 
 more liable to, but suffer more from, epidemics, as fever, cholera, &c., 
 than the healthy. For the same reason, various exciting causes, such as 
 the use of ardent spirits for example, in a moderate degree only, will in 
 such individuals sometimes establish irremediable organic mischief in the 
 kidneys, liver, &c. Such individuals, therefore, should be more than 
 ordinarily cautious how they expose themselves to mischief. See the 
 section on serous urine. 
 
400 
 
 DISEASES OF THE BLADDEI?, kc. 
 
 point involved. This tendency to early affection probably re- 
 sults from the prior and constant contact of the diseased pro- 
 ducts with those particular portions of the bladder ; the mouth 
 of the ureter being first exposed to the unnatural mat- 
 ters constantly passing through it ; the neck of the bladder 
 to the constant contact of such matters, naturally gravitating 
 to it by the position of the body. For the same reason also, 
 the orifice of the urethra in females is apt to take on the dis- 
 eased action, as already stated. 
 
 Having thus described what may be considered as the fun- 
 damental characters of organic affections of the bladder origi- 
 nating in kidney disease, we may briefly notice some of those 
 rarer complications which occasionally occur in practice ; and 
 which, from the irritability they occasion in the bladder, are 
 liable to be confounded with calculus. Such are various ex- 
 crescences from the mucous membrane of the bladder. These 
 are not common, and when they occur, they usually occupy the 
 inferior and posterior portions of the bladder. If not compli- 
 cated with the above cachexia, they are usually harmless, and 
 only cause inconvenience by their mechanical effects. We 
 also read of polypous excrescences, elongations, kc, of the inner 
 membrane of of the bladder, and a variety of other rare 
 and non-malignant affections in systematic writers on the sub- 
 ject; to whose works the reader is referred for particulars. 
 The only affection of the kind we shall notice, is of a more 
 formidable character, viz. fungus hcematodes, a tumour ren- 
 dered malignant by being complicated with the above ca- 
 chexia ; and which, in its earlier stages, is often liable to be 
 mistaken for calculus in the bladder ; and indeed is with diffi- 
 culty distinguished from such affection. 
 
 The few cases I have seen of fungoid excrescences from the 
 bladder, have occurred in individuals who have either natu- 
 rally laboured under the peculiar cachexia above described, in 
 an exquisite degree ; or who from various exciting causes, as 
 for instance, residence in a malarious locality, &c., have had 
 such natural constitutional tendency much aggravated. In 
 
FUNGUS HiEMATODES. 
 
 401 
 
 a case, occurring in a peculiarly cachectic individual, in 
 whom one of the kidneys had been probably diseased from 
 early life, the affection seems to have existed for many years, 
 perhaps from birth, as an indolent tumour in the fundus of the 
 bladder, near the mouth of the ureter belonging to the dis- 
 eased kidney. This tumour (as was found to be the case after 
 death) contained a large quantity of phosphate of lime, and 
 seemed to have latterly increased in size, so as to have occasioned 
 a certain degree of irritability of the bladder ; on account of 
 which, under the apprehension that there might be stone in the 
 organ, the patient was induced to apply to a surgeon. The 
 sound was introduced, and apparently came in contact with 
 the tumour and wounded it ; as considerable pain and vesical 
 haemorrhage followed the operation. From this time, the 
 haemorrhage continued at intervals, and at length became 
 almost constant. The irritability of the bladder (though never 
 very urgent, and never accompanied by retention of urine) 
 became rapidly worse, and this, together with the loss of blood, 
 &c., visibly began to affect the general system. The nature of 
 the affection, which had been suspected from the beginning, 
 became at length too evident. The urine now constantly con- 
 tained large quantities of dark grumous highly offensive bloody 
 matter, mixed with clots ; and, in the latter stages, with frag- 
 ments of the medullary substance of the tumour. In a short 
 time afterwards, and a few months only after the operation of 
 sounding, the patient sank under the affection, quite worn out 
 and exhausted by his sufferings ; and on examining the blad- 
 der after death, a large fungoid mass, like a bunch of grapes, 
 was found attached to the tumour above described, in the fundus 
 of the bladder. The base of this tumour extended to the neigh- 
 bouring parts, and particularly involved the mouth of the con- 
 tiguous ureter ; which was much enlarged, and the kidney on 
 that side had evidently long been in a state of disease, as above 
 mentioned. 
 
 The preceding may be regarded as an extreme case ; the pro- 
 gress of the affection is sometimes much slower, and when the 
 
 D D 
 
402 
 
 DISEASES OF THE BLADDER, &C. 
 
 disease commences, as it sometimes does, in the kidney, and is 
 propagated downwards into the bladder, the patient occasion- 
 ally lives for years ; sometimes with intervals of comparative 
 freedom from inconvenience of any kind, and particularly from 
 haemorrhage, which is one of the most frequent symptoms. 
 Sooner or later, however, the complaint takes a decided turn ; 
 the haemorrhage becomes almost constant, and this, by further 
 debilitating the system, renders the patient still more liable 
 to the inroads of the disease, which progresses more rapidly 
 than ever, and speedily proves fatal. 
 
 In the case above described, the disease chiefly occupied the 
 fundus of the bladder ; but according to Sir B. Brodie, and 
 indeed according to my own experience, the affection most fre- 
 quently attacks the neck of the bladder or its neighbourhood. 
 In such cases, the sufferings of the patient are always very much 
 augmented by the mechanical impediment to the passing of 
 the urine, occasioned by the tumour. 
 
 Cancer of the urinary organs, and particularly of the blad- 
 der, is said to be a very rare disease. I have seen re- 
 peated instances, in which cancerous ulceration has extended 
 from the uterus, rectum, &c., to the bladder ; but I have seen 
 no case of cancer, which could be said to have commenced in 
 that organ, or in its appendages. 
 
 The above affections originate in the system in general, or 
 in the kidneys, and only secondarily involve the bladder. We 
 have now to briefly consider those affections connected with 
 the bladder itself, and its appendages ; and which not only 
 prove a source of irritable bladder, but are liable to be mistaken 
 for, or complicated with, calculus in that organ. 
 
 An irritable state of the bladder, occasioning frequent calls 
 for micturition, may be the chronic result of the thickening 
 or other disease of the coats of the bladder, or of the contracted 
 state of that organ, formerly described as the consequences of 
 inflammation. A similar train of symptoms may also arise 
 from an enlargement, or other disease, of the prostate ; which 
 may or may not accompany the above state of the bladder. 
 
GOUT, Sec, OF THE URETHRA. 
 
 403 
 
 Another fertile source of irritable bladder, and indeed of a 
 great deal of mischief, not only in that organ and its appen- 
 dages, but even in the kidneys themselves, is stricture of the 
 urethra. The management of this falls entirely within the 
 province of the surgeon ; and the subject is mentioned only 
 with the view of observing, that as long as the stricture re- 
 mains, nothing can be done towards alleviating the patient's 
 sufferings. The first object of the surgeon, therefore, will be 
 to remove all mechanical obstruction from this organ, and very 
 often, when this is accomplished, every symptom will vanish ; 
 that is to say, provided the bladder and kidneys have not, 
 from the long continuance or mismanagement of the case, 
 become organically affected ; which is too often the case, parti- 
 cularly in strumous and cachectic habits. 
 
 There are only two other affections which appear to belong 
 to our present subject, viz. Gouty and Rheumatic inflam- 
 mation of the urethra. I am unable to state whether 
 these two affections be distinct diseases, but I believe at 
 present that they are ; and that, like gout and rheumatism, they 
 sometimes exist in conjunction. Gouty irritation of the ure- 
 thra often assumes all the characters of gonorrhoea, and is not 
 only attended by a profuse discharge, but with great irritation 
 and scalding in passing water. The bladder and prostate often 
 participate in the affection, and become highly irritable ; so 
 that the calls to pass the urine are painfully urgent and fre- 
 quent. I have seen repeated instances of such attacks ; by 
 far the greater proportion of which have occurred in those 
 who have had a strong predisposition to gout, either inherited 
 or acquired, but who have never had gout openly. In the 
 greater number of these cases, I have not been able to trace 
 the affection to any distinct cause. In a few instances it seems 
 to have been produced by sexual excitement. 
 
 Rheumatic gouty irritation of the urethra sometimes attacks 
 those who labour under the affection in other parts of the 
 system ; of which I have seen instances. This is by far the 
 most troublesome form of the disease ; not so much from its 
 
 D D 2 
 
404 
 
 DISEASES OF THE BLADDER, kc. 
 
 severity, as from the obstinacy with which it resists the action 
 of remedies. A very troublesome species of rheumatism also, 
 nearly allied to rheumatic gout, sometimes attends or follows 
 common gonorrhoea. When I state that this species of rheu- 
 matism is nearly allied to common rheumatic gout, I mean as 
 regards the symptoms. Whether the two diseases be abso- 
 lutely identical, I do not pretend to determine. I believe the 
 two diseases, however, to be nearly allied in their nature, as 
 well as in their symptoms.^ 
 
 I do not think it necessary to enter into details respect- 
 ing any of the above affections, many of which indeed, as far 
 as it is my present purpose to notice them, have been already 
 described as the consequences of inflammation of the bladder 
 and prostate. I pass on, therefore, to the second general 
 division of affections connected with irritable bladder ; namely, 
 
 b. Irritable affections of the bladder connected with the nervous 
 system. " Irritability of the bladder," says Sir B. Brodie, " is 
 sometimes the result of mere nervousness ; of the same state of 
 the bladder, which in some other individuals occasions a constant 
 winking of the eyes, or twitches of the muscles of other parts. 
 The frequent expulsion of the urine, when once begun, is kept 
 up by habit ; the bladder becomes less capacious than it ought 
 to be, and it is not till after a lapse of time, nor without some 
 effort on the part of the patient, that it is restored to its natu- 
 ral condition."t It may be remarked, however, in addition, 
 that in such cases the functions of the kidney almost always 
 participate in the irritation ; and that on inquiry the urine is 
 not only increased in quantity, but becomes deranged in its 
 properties ; that is to say, the secretion has a specific gravity 
 below the healthy standard, often approaches to neutrality, 
 
 * This affection, which is frequently combined with ophthalmia, has 
 been described by various authors ; but the reader is more especially re- 
 ferred to a Clinical Lecture by Mr. Lawrence, in the Medical Gazette, 
 vol. xxxiii. page 506. 
 
 t On Diseases of the Urinary Organs, p. 75, second edition. 
 
NERVOUS AFFECTIONS AND SPASM OF THE BLADDER. 405 
 
 and deposits the phosphates on exposure to heat ; and is some- 
 times even slightly serous. 
 
 Sir B. Brodie also mentions another form of irritable blad- 
 der, which is occasionally a symptom of disease in, or 
 affecting, the nervous system. " An elderly man, for 
 example, complains of frequent attacks of giddiness. Some- 
 times, in walking, his head turns round, so that he is in 
 danger of falling; and this symptom probably arises from 
 altered structure of the arteries of the brain, causing an 
 imperfect state of the cerebral circulation. Not unfre- 
 quently this is attended with an irritable state of the bladder ; 
 and although the urine is of a healthy quality, and the bladder 
 itself is free from disease, the patient is tormented by a con- 
 stant micturition, voiding his urine without pdn, but at short 
 intervals and in small quantity at a time. Little can be done 
 for the patient's relief in such a case as this ; but it is important 
 that the real nature of the affection should be understood, that 
 if we cannot effect a cure, we may avoid tormenting him with 
 useless remedies."^ 
 
 I have seen cases resembling the above, and have generally 
 observed that sooner or later they have terminated in apoplexy 
 or paralysis. In no case of the kind, however, that I have 
 seen, has the urine been quite natural ; and it has been usually 
 of high specific gravity, and abounding in urea ; or sometimes 
 in the lithie acid. 
 
 Affections of the kidneys and bladder, connected with or- 
 ganic disease or injuries of the spine, have been already men- 
 tioned, and need not be here further noticed. We proceed, there- 
 fore, to make a few remarks on spasmodic and paralytic affec- 
 tions of the urinary organs, and particularly of the bladder. 
 
 Spasm of the bladder often accompanies the presence of a 
 stone in that organ, as well as many other affections before 
 described, to which the bladder and its appendages are liable. 
 It not unfrequently also accompanies diseases of the kidneys, 
 
 * Op. et loc. cit. 
 
406 
 
 DISEASES OF THE BLADDER, &C. 
 
 rectum, uterus, &c., and in some instances has been known to 
 recur periodically. There is also an idiopathic spasm of the 
 bladder mentioned by some authors, to which old men are 
 said to be particularly liable ; though the existence of such a 
 disease seems to be doubted altogether by others, who consider 
 it as merely symptomatic of some other disease. 
 
 In the particular affection alluded to, as well as in other 
 instances of spasmodic affection of the bladder, the patient 
 experiences an acute pain in the region of the organ, accom- 
 panied by a sense of constriction. This pain often extends 
 along the urethra, and sometimes gives occasion to the most 
 distressing erections. There is more or less of retention, and 
 occasionally of suppression, of urine, on account of this secretion 
 not being able to enter the bladder. In case of suppression the 
 urine accumulates in the ureters, &;c., which become distended 
 and painful ; and the pain is propagated to the kidneys, loins, 
 testicles, and even to the thighs ; and is often accompanied 
 by distressing nausea, or hiccough. The bladder is generally 
 contracted, and resembles a hard ball, which by pressing on 
 the rectum produces a frequent desire, without the power, of 
 going to stool, and sometimes causes protrusion of the rec- 
 tum. These symptoms are accompanied by great uneasiness, 
 agitation, and restlessness, with a cold clammy perspiration 
 extending more or less over the body ; and in those unfortu- 
 nate cases, in which the spasm continues, in spite of remedies, 
 for some hours, the extremities become cold, the patient falls 
 into a state of syncope or convulsions, and death soon succeeds. 
 In other instances, the patient dies with all the symptoms at- 
 tending suppression of urine. 
 
 Besides stone in the bladder, spasm of that organ may arise 
 from, or rather accompany, various other affections; such as from 
 the presence of acrid urine or pus from an abscess in the kid- 
 ney ; from ulceration or other organic disease of the bladder, 
 prostate, &c. ; from retention of urine; from gout; from excessive 
 venery, or the use of irritating diuretics, as cantharides ; from 
 various diseases of the intestinal canal, as worms, and espe- 
 
PARALYSIS OF THE BLADDER. 
 
 407 
 
 cially ascarides ; from hysteria, &;c. Slighter cases in young 
 subjects are in general not dangerous, and sometimes subside 
 spontaneously. The affection is most dangerous in old people, 
 and in proportion to its duration and intensity ; and when the 
 spasm depends on a cause that cannot be removed, it is very 
 apt to end in the affection to be next briefly noticed, viz. 
 
 Paralysis of the bladder. — Paralysis of the bladder may 
 either creep on imperceptibly as the result of age, and of 
 weakened powers in general, conjoined with an enlarged pros- 
 tate, or other affections of the urinary organs ; or it may take 
 place more suddenly, from some peculiar lesion or other affec- 
 tion of one of the great nervous centres, and particularly of 
 the spinal cord. The description of these forms of paralysis, 
 therefore, will consist in little more than a brief recapitulation 
 of the symptoms described, under various heads, in the fore- 
 going pages. The paralysis of old age is usually one of the 
 concomitants of an enlarged prostate. The enlarged prostate 
 presents an obstacle to the free passage of the urine, while the 
 muscular structure of the bladder, either from partaking in 
 the rigidity and thickening of the prostate, or from want of 
 power, ceases to exert the force requisite to expel the whole of 
 the urine from the bladder. The consequence is, that the 
 bladder constantly retains a certain portion of urine, to the 
 stimulus of which, from the diminished sensibility of the organ, 
 it becomes insensible. This quantity of retained urine gra- 
 dually increases as the disease proceeds, till from the greater 
 difficulty about the prostate, and the long-continued over dis- 
 tension of the organ, the bladder loses its power of contrac- 
 tion altogether. In such cases, the bladder sometimes 
 becomes enormously distended ; and the excess of urine subse- 
 quently descending from the kidneys, begins to flow off in- 
 voluntarily, without, however, diminishing the tension of the 
 bladder ; which at length, as well as the kidneys, become dis- 
 eased ; and the patient, if not previously cut off by the other 
 more urgent symptoms of the affection, dies from the local 
 disease set up in the kidneys and bladder. From the dimi- 
 
408 
 
 DISEASES OF THE BLADDER, kc. 
 
 nished sensibility of the bladder, in many cases of paralysis of 
 that organ, the patient is not conscious of its distended state, 
 and consequently suffers but little pain ; particularly if the 
 excess of urine flows off imperceptibly, in the manner above 
 mentioned. In other cases, the patient complains of a sense 
 of uneasiness, weight, and tension about the region of the 
 organ ; with numbness, and often severe cramps in the lower 
 extremities, and more or less of impediment or inconvenience 
 in the passage of the faeces, kc. The incontinence of urine 
 connected with paralysis of the bladder will be considered 
 more fully in a subsequent chapter. 
 
 It remains, in the last place, to make a few remarks on the 
 class of nervous affections of the kidneys and bladder, which, 
 for want of a better name, may be arranged under the general 
 denomination of hysteric affections. 
 
 The peculiar aberrations, mental and bodily, involuntary 
 and voluntary, connected with the female character and 
 functions, and generally known under the name of hys- 
 teria, are so numerous and varied, so unexpected and impro- 
 bable, that a volume might be occupied in describing them. 
 We shall confine our attention principally to those affections 
 of an hysteric character more especially involving the urinary 
 organs ; which, for reasons sufficiently obvious, are among 
 the most frequent as well as the most important. 
 
 Perhaps there is not a disease to which the urinary organs 
 are subject, that has not its counterpart or similar in hysteria. 
 Innumerable instances have occurred to me, for example, in 
 which calculi have been said to be passed from the kidneys 
 and bladder by hysteric females. Such calculi I have examined , 
 and found them to consist perhaps of a fragment of silex, or 
 even of brick, — in short, of anything but what is known to be 
 of uriuary origin. Moreover, in some of these cases, a train of 
 symptoms, resembling those accompanying nephritic attacks, 
 have been stated to accompany the descent and exit of the 
 calculus from the kidney and bladder ; and so accurately have 
 these symptoms been simulated and described, that neither 
 
HYSTERIC AFFECTIONS. 
 
 409 
 
 those who have witnessed thein, nor those who have heard 
 them described, have appeared to doubt the reality of the 
 attack, till the pretended calculus has made its appearance ; 
 when its chemical properties have at once dispelled the illu- 
 sion, and demonstrated the true nature of the affection. In 
 such cases, I have even known the properties of the urine 
 changed, (I know not by what means,) so as to correspond 
 with the symptoms described ; and there has been blood or 
 mucus, or other unnatural matters, present in the secretion, as 
 it were at the will of the patient.^ 
 
 One of the characteristic symptoms of hysteria, as is well 
 known, is diuresis ; and on occasions in which this symptom 
 occurs, the quantity of limpid urine, or of mere water that is 
 passed, is sometimes extraordinary. At other times, suppres- 
 sion of urine is a (pretended) symptom, and the patient de- 
 clares that for days together she does not void any water. 
 Retention of urine is another occurrence ; and the patient 
 
 * I may mention, by way of illustration, a striking- instance that oc- 
 curred to me many years ago. The patient was a remarkably sedate 
 individual, between thirty and forty years of age — in short, the last per- 
 son one would have suspected. She had for years, according to her own 
 account, suffered from nephritic attacks, the symptoms of which she 
 described in all their minutise, with the greatest accuracy. She had 
 never passed calculi ; but the attacks above mentioned were attended and 
 followed by large deposites of a white substance in the urine ; which was 
 generally alkalescent, and apparently much deranged. This white sub- 
 stance proved on examination to consist chiefly of carbonate of lime, with 
 some phosphate of lime, and triple phosphate of magnesia and ammonia. 
 At length, circumstances raised a suspicion in the mind of the gentleman 
 who usually attended her ; and on closely pressing her, and threatening 
 exposure, she confessed that the whole was a deception ; and that she had 
 been in the habit of mixing quick lime or chalk with the urine, and thus 
 of producing the appearances above mentioned. I learnt on inquiry that 
 some members of this lady's family were insane. Hysteric females are 
 subject, on certain rare occasions, to pass urine nearly black ; and I have 
 known this appearance kept up artificially for a long time together, by 
 the admixture of ink with the urine. I have also occasionally seen hys- 
 teric urine not only strongly serous, but otherwise deranged, so as to 
 cause alarm about the state of the kidneys and bladder ; yet the whole 
 has after a time disappeared, and the patient has become quite well. 
 
410 
 
 DISEASES OF THE BLADDER, &C. 
 
 either cannot, or, as some suppose, will not, empty the bladder 
 without mechanical assistance. All these affections, however, 
 are obvious in their nature, compared with those obscure affec- 
 tions of the spinal chord, or column ; of joints, &;c., which are 
 not unfrequently met with in females, and which appear in 
 many instances to belong to hysteria, or at least to be modified 
 by that affection. Such affections have been described by Sir 
 B. Brodie, and are well known to our most experienced sur- 
 geons. Formerly, however, the nature of these affections was 
 entirely overlooked ; and even still, perhaps, they have not 
 been so generally studied as they ought to be. The conse- 
 quence was, perhaps still is, that many a poor girl has been 
 confined upon her back for months, and even for years ; and 
 for the cure of an imaginary disease, her health and prospects 
 in life have been sacrificed in reality. 
 
 In investigating hysteric cases, we should constantly remem- 
 ber, that the utmost duplicity and cunning may be displayed, 
 where, from mere appearances, we should expectnothingbut the 
 most rigid truth — in short, that the whole energies of the patient's 
 mind are bent on deception ; and consequently that the decep- 
 tion is likely to be greater, and more difiicult of detection, in 
 proportion as the patient is more highly educated, or has been 
 more frequently seen and examined. Moreover, the sex, the 
 age, the apparent sufferings of the patient, all conspire to 
 interest us in her favour, to warp our judgment, and to unfit 
 us for an impartial inquiry into her case. One of the best 
 modes of proceeding, therefore, at the outset, is to make the 
 patient describe her own feelings, in her own words ; and if 
 possible in her own handwriting. At any rate, the principal 
 symptoms, as stated by herself, should be written down, before 
 a single question is asked. Indeed, leading questions in all 
 such cases should be most carefully shunned ; for though the 
 symptom inquired after may not be present at the time, yet 
 the hint will be carefully treasured up in the memory ; and the 
 symptom will not fail to appear at some future time. Hence, 
 as just observed, in hysteric affections the symptoms generally 
 
DIAGNOSIS AND PROGNOSIS. 
 
 411 
 
 become more numerous and urgent, in proportion as the pa- 
 tient becomes more knowing. I state this with pain and re- 
 luctance ; but when we consider that the character of the medical 
 man in attendance, no less than the well-being of the patient, 
 is at stake, it becomes our duty, for the sake of both parties, 
 to place the matter in a strong light. As to the motives of the 
 patient for such deception, that is another question. To become 
 an object of attention, — an interesting object, is an innate and 
 characteristic feeling of the female mind ; and if in early life 
 this feeling, in its natural and legitimate form, has been 
 thwarted or disappointed, it is almost sure to deviate into some 
 other channel ; and the ruling passion is displayed in attempt- 
 ing to excite pity and commiseration, where she cannot excite 
 erotic sentiment. This, however, may be said to be a question 
 of morals, rather than of medicine. I shall not, therefore, 
 pursue the subject further, but shall merely observe, that all 
 the worst cases of hysteric aberration that have fallen under 
 my notice, have appeared to be fairly referable to an exalted 
 or modified condition of the above-mentioned innate female 
 feeling ; tinctured perhaps, in some instances, by remote shades 
 of insanity. 
 
 We shall now take a brief recapitulatory review of the prin- 
 cipal subjects discussed in the present chapter, chiefly with 
 reference to diagnosis and prognosis. And it may not be 
 irrelevant to mention at the outset, that in most of the pre- 
 ceding diseases, the great object of our diagnosis, on which of 
 course the prognosis in no small degree depends, is to deter- 
 mine, in the first place, the presence or absence of stone in 
 the bladder, or of other mechanical disease ; that is to say, 
 whether the symptoms present depend on, or are in any way 
 connected with, vesical calculus ; or on stricture, or other me- 
 chanical obstruction about the neck of the bladder or urethra. 
 
 With regard to the presence of a stone in the bladder, though 
 it may be rendered probable, the fact cannot be positively 
 determined by the mere symptoms ; and the mechanical assist- 
 ance of the surgeon is necessary. In all cases of doubt and 
 
412 
 
 DISEASES OF THE BLADDER, &C. 
 
 difficulty, therefore, when the circumstances of the patient will 
 admit, the operation of sounding should be resorted to in the 
 first place. This operation falls entirely without my province ; 
 and I shall merely observe, that however dexterously the 
 sounding may be performed, a single negative result is in no 
 instance to be considered as decisive — indeed, I have known a 
 stone subsequently found in the bladder after repeated nega- 
 tive results. In such instances, blame is by no means neces- 
 sarily attributable to the surgeon. The stone might have been 
 encysted ; or lodged in a fold of the bladder ; or behind an en- 
 larged prostate, &c., — circumstances which though, at the time 
 of sounding, they sheltered the stone from the contact of the 
 instrument, may, from their temporary character, be subse- 
 quently removed, and the stone thus liberated. When a 
 stone of moderate size exists loosely in the bladder, it can 
 scarcely escape the tact of a dexterous surgeon. 
 
 Similar remarks may be made respecting the determination 
 and removal of mechanical obstructions about the neck of the 
 bladder or urethra ; the existence or absence of vfhich should 
 be determined at the very outset of the inquiry. This part of 
 the inquiry, however, like that of sounding, falls entirely 
 within the province of the surgeon ; and, by careful manage- 
 ment on his part, the mechanical impediments may be often 
 removed or relieved ; and when such removal or relief has 
 been timely accomplished, the whole train of bladder and 
 even of renal symptoms, (which, if the impediment had been 
 permitted to have remained, would have ended in destruction 
 of these organs,) sometimes entirely disappears. 
 
 When the surgeon has declared that neither stone exists in 
 the bladder, nor mechanical obstruction in the urethra, &c., 
 we must form our diagnosis in the best manner we are able 
 from among the symptoms. If the urine be acid, but abound- 
 ing in ropy mucus possessing alkaline properties ; if there be 
 a constant and urgent desire to void urine, which is attended 
 with difficulty, and more or less of smarting pain along the 
 whole urethra ; if there be a dull pain and sense of debility 
 
DIAGNOSIS AND PROGNOSIS. 
 
 413 
 
 about the back and loins, and more or less of low remitting 
 fever, we may infer that the mucous membrane of the bladder 
 is in a state of chronic but incipient inflammation ; if the 
 copious deposition of ropy mucus in the urine, which formerly 
 existed, has become diminished in quantity, and the secretion 
 has assumed a glairy, or an opake, or purulent appearance, and 
 is mixed with blood ; if the urine has become permanently alka- 
 line, and the desire to pass it more urgent and frequent than 
 ever ; if there be increased pain on pressure over the pubes ; if 
 the low feverish symptoms have assumed more of a hectic cha- 
 racter — we may presume that the chronic inflammation of the 
 bladder has reached that point at which the mucous membrane 
 has been more or less destroyed — in short, that the patient has 
 arrived at the last stage of the complaint, and will probably 
 sink under its effects. 
 
 When, after a surgical operation about the bladder, rectum, 
 &c., or after exposure to cold, or other exciting cause, a pa- 
 tient labouring under any urinary disease experiences the 
 following train of symptoms, we may conclude that general 
 inflammation (of the cellular substratum) of the bladder, &;c., 
 has taken place ; and that the affection will almost certainly 
 prove fatal. Rigor, followed by faint perspirations, malaise, 
 and disinclination to take food ; pain extending more or less, 
 especially on pressure, to all parts of the abdomen, back, and 
 rectum ; acceleration of pulse ; and a peculiar anxiety of ex- 
 pression ; — when to these symptoms, which rapidly increase, 
 there begin to be superadded intermission of the pulse ; a 
 brown and dry tongue ; occasional hiccough ; a tympanitic state 
 of the abdomen ; and great prostration of the vital powers — the 
 fatal event is near and inevitable. 
 
 A difficulty and frequent desire of passing the urine, parti- 
 cularly when it. occurs in a middle-aged or old individual, and 
 is accompanied by incontinence of urine during the night, is 
 almost a certain indication of chronic enlargement and irrita- 
 bility of the prostate gland ; and of a distended bladder from re- 
 tention of urine. If, in connexion with these or similar symp- 
 
414 
 
 DISEASES OF THE BLADDER, &:C. 
 
 toms, the patient occasionally voids small concretions com- 
 posed principally of the phosphate of lime ; the prostate is 
 probably both enlarged, and contains such concretions in its 
 ducts or cavities. When after the operation of sounding, 
 catheterism, exposure to cold, &;c., the patient experiences a 
 severe rigor, followed by a sense of throbbing pain about the 
 rectum, perinaeum, kc, increased by sitting, or evacuation from 
 the bowels ; with more or less of fever, and (after a time) com- 
 plete retention of urine ; acute inflammation of the prostate is 
 indicated. The same circumstance is indicated also, when in 
 gonorrhoea the discharge suddenly ceases, and a train of 
 symptoms, similar to those above recited, takes place. More- 
 over, in the last case, if frequent rigors and other symptoms of 
 hectic supervene, we may generally expect that an abscess is 
 forming ; which may finally discharge itself into the urethra, 
 or outwardly in the perinseum, Sec. 
 
 When, in cases of simple irritable bladder, there is no in- 
 creased discharge of mucus, and the urine when just voided is 
 transparent, it is probable that the irritability, which is usually 
 temporary only, depends on the mere unnatural quantity or 
 quality of the secretion : that is, the urine may be too dilute 
 or too concentrated ; too acid, or neutral, or alkaline ; or contain 
 some stimulating ingredient, &;c. On the other hand, when 
 cases of irritable bladder in young or middle-aged individuals 
 are accompanied by pale-greenish, whey-like, turbid, and serous 
 urine, of low specific gravity ; where there is no mechanical 
 impediment in passing the urine, but the frequent calls to void 
 this secretion are accompanied by a sense of burning uneasi- 
 ness, subsiding in general soon after the act of micturition, 
 and referred, in males more especially, to that part of the canal 
 lying in the perinaeum, and in females to the orifice of the 
 urethra ; when the general health of the patient, naturally 
 perhaps feeble, gradually declines, and he begins to complain 
 of a sense of weakness or uneasiness about the loins, accom- 
 panied by loss of appetite, kc, we may generally conclude 
 that the cause of the irritability lies in the kidneys ; that the 
 
DIAGNOSIS AND PROGNOSIS. 
 
 415 
 
 bladder, at first only secondarily affected, is likewise becoming 
 diseased ; and that the patient will ultimately sink under the 
 affection. When, with all the above symptoms, there is a 
 dark-coloured offensive bloody sanies in the urine, and more 
 or less of mechanical impediment in passing this secretion, 
 there is reason to suspect the presence of incurable fungus 
 haematodes in the bladder.^ 
 
 When, in affections of the bladder, particularly in aged in- 
 dividuals, there is an acute pain in the region of that organ, 
 extending in some cases to the urethra, at other times to the 
 loins, testicles, and down the thighs, with a sense of constric- 
 tion, conveying the feeling of a hard ball pressing on the rec- 
 tum. Sec. and preventing the egress of the faeces and urine ; 
 together with great restlessness, anxiety, cold perspirations, 
 and tendency to syncope, (fee, there is reason to suspect the 
 presence of spasm of the bladder. It is difficult to distinguish 
 spasm from inflammation in many instances, and sometimes 
 the two affections are united : the following contrast of the 
 symptoms, however, will generally assist us in our diagnosis. 
 Cystitis, or inflammation of the bladder, is accompanied by all 
 the symptoms of fever, while spasm is not. Pressure in- 
 creases the pain of cystitis, but not of spasm. The pain is 
 unceasing in inflammation, that of spasm comes on in pa- 
 roxysms. The pain in cystitis is burning, throbbing, or 
 lancinating; in spasm it is oppressive, dragging, and re- 
 sembling labour pains. The constitution of the patient also 
 should be taken into account. In the robust and sanguine^ 
 cystitis is the more probable disease ; in the weak and ner- 
 
 * The red particles of the blood discharged in the earlier stages of 
 fungoid disease have often a remarkable appearance, and appear to the 
 eye larger than natural ; so that after they have subsided to the bottom 
 of the urine^ they at first sight somewhat resemble grains of lithic acid 
 gravel, and, like that substance, when the vessel is inclined, may be dis- 
 tinctly seen to roll along the bottom. From this peculiar appearance of 
 the red particles of the blood, the presence of malignant disease may be 
 often suspected before the symptoms assume a decided character. 
 
416 
 
 DISEASES OF THE BLADDER, &C. 
 
 vous, spasm. These differences will rarely fail to direct us in 
 well-marked cases ; but when spasm and inflammation co-exist, 
 which is often, as above mentioned, the case, it is always 
 the safest plan to consider the affection as one of simple in- 
 flammation. 
 
 The symptoms of paralysis of the. bladder are so strongly 
 marked, that they can scarcely be mistaken. We pass on, 
 therefore, to hysteric affections of the urinary organs, a set of 
 diseases which tax our diagnostic skill to the utmost, and 
 sometimes defy it altogether. 
 
 As hysteria is often as much a moral as a physical disease, 
 to enable us to form a just estimate of many of the symptoms, 
 it is absolutely necessary to take into account the moral 
 history and character of the patient. These are delicate 
 points of inquiry, and we must leave their investigation to the 
 judgment and tact of the inquirer. Of the circumstances, 
 independently of those of a moral kind, to be particularly 
 attended to, the age of the patient is one of the most remark- 
 able. Hysteria, strictly speaking, is generally limited 
 to womanhood — to that interesting period of female existence, 
 in which all the characteristic traits of the sex exist in 
 their most susceptible and exalted state. We scarcely look 
 for hysteria before puberty, and rarely see it in advanced life ; 
 or if the tendency to hysteria does continue to advanced life, 
 we too often find that many of the derangements which in 
 early life were merely functional, have, from long continuance, 
 become confirmed diseases. Moreover, hysteria, in advanced 
 life, (or something called by this name,) is too often connected 
 with the abuse of cordial waters — in short, with the baneful 
 habit of dram-drinking and its consequences. 
 
 Other points to be kept in view are the rank in life ; and the 
 degree, and kind of education of the patient. A poor un- 
 sophisticated country girl may be disappointed or betrayed, 
 or otherwise cruelly treated, and her outraged feelings in 
 consequence may vent themselves in genuine hysteric at- 
 tacks ; but the case is very different with the indolent, pru- 
 
TREATMENT. 
 
 417 
 
 rient, and sentimental novel reader. Here, whatever may be 
 the cause of the derangement, hysteria seldom assumes its 
 vulgar form ; but the form of some extraordinary, calami- 
 tous, and interesting affection, calculated at once to excite 
 the wonder and the pity of the beholders. The patient 
 has suppression or retention of urine ; she may labour under 
 all the symptoms of renal or of vesical calculus ; the urine 
 itself may be red, black, white, serous, — in short, anything but 
 natural ; and, as before observed, the deception, if deception it 
 be, will be more complete and more difficult of detection, in 
 proportion to the reading of the patient. 
 
 However painful it may be to recur to these circumstances, it 
 is absolutely necessary to be well acquainted with them, to 
 enable us to form a correct diagnosis and prognosis in a great 
 many aifections connected with the urinary organs in females ; 
 and even with all our knowledge, and with the utmost care 
 and circumspection we can bestow on the subject, we shall 
 sometimes find ourselves outwitted. In females more ad- 
 vanced in years, as above stated, the diagnosis, as well as 
 prognosis, in affections of the urinary organs, are in general 
 more easy and certain ; for the imaginings of youth too often 
 become the sad realities of age.* 
 
 Treatment. — In discussing the treatment of the different 
 diseases considered in the present chapter, we shall follow 
 nearly the order in which they were described. According to 
 
 * In making these remarks, I am most anxious not to be misunder- 
 stood. Nothing can be further from my wishes and intention than the 
 design to convey an impression derogatory to the female character. In 
 hysteric cases, both the mind and body are really in a morbid state, 
 and the patient can scarcely be regarded in the light of an account- 
 able being. The striking peculiarity in such a state of the system con- 
 sists in that extraordinary relation between the mental and bodily powers 
 of the patient, which enables her, as it were by a mere act of volition, to 
 determine a certain degree of functional derangement into any part of the 
 body, or organ, her morbid fancy may intimate. 
 
 E E 
 
418 
 
 DISEASES OF THE BLADDER, &C. 
 
 this arrangement, we have, in the first place, to speak of in- 
 flammation of the bladder and its consequences. 
 
 In chronic inflammation of the mucous membrane of the 
 bladder, or catarrhus vesicce ; as well as in the chronic enlarge- 
 ment or degeneration of the prostate gland, very active measures 
 are seldom requisite or proper ; and indeed they often do more 
 harm than good. In the earlier stages of both these aff'ections, 
 when the urine is high-coloured and strongly acid, and when 
 there is obvious congestion about the hsemorrhoidal and abdo- 
 minal system in general, the abstraction of blood by the appli- 
 cation of leeches about the anus, or by cupping in the peri- 
 nseum. Sec, is often useful as a preliminary step. With these 
 remedies also may be conjoined active purgatives, of which 
 calomel should form one of the ingredients. Indeed, the occa- 
 sional use of gentle alteratives and purgatives will in general, 
 in all the earlier stages of the affection, be found to be service- 
 able, and even necessary. In the confirmed and passive stages 
 of these affections, the remedies mentioned, at least the ab- 
 straction of blood, are seldom required. Various counter- 
 stimuli, as issues, setons, blisters, &;c., to the perinaeum, loins, 
 thighs, &c., have been recommended in the chronic stages of 
 these affections ; but they are of little use. Nor in these 
 stages of the affection is much gained by purgatives, beyond 
 merely keeping open the bowels ; indeed, active purging, by 
 saline or by other injudicious remedies, seldom fails to aggra- 
 vate the chronic stages, both of catarrhus vesicae, as well as of 
 chronic enlargement of the prostate gland. 
 
 The diet in these affections should be light and easy of diges- 
 tion, and free from stimulating condiments ; and the patient 
 should either altogether abstain from, or very much diminish, 
 the quantity of fermented liquors. Moderate exercise will be 
 proper ; but exercise on horseback, or in a rough carriage, or, in 
 short, fatigue of any sort, should be avoided. During winter, 
 and in cold and damp weather, the patient should carefully pro- 
 tect himself, as much as possible, from their influence ; and if his 
 
TREATMENT. 
 
 419 
 
 circumstances admit, he may be even recommended to pass 
 the winter months in a warmer climate. After these general 
 remarks, we have to consider the remedies supposed to act 
 specifically on mucous membranes, and chronic hypertrophies. 
 
 The three great classes of remedies most generally bene- 
 ficial in chronic affections of the mucous membranes of the 
 urinary organs, are those of the balsamic, astringent, and seda- 
 tive kinds ; either of which may be given alone, or variously 
 associated with the others, according to the circumstances of 
 the case, or the judgment of the practitioner. Among reme- 
 dies of the balsamic class, the mildest, as well perhaps as one 
 of the most efficient, is the diosma. Next in order, follow 
 the tolu and Peruvian balsams ; the chian turpentine, copaiba, 
 cubebs, (fee. ; all of which, judiciously administered in small 
 doses, are often beneficial in chronic affections of the mucous 
 membrane of the urinary organs. Of remedies of a tonic and 
 astringent character, the pareira hrava, an old remedy lately 
 re-introduced by Sir B. Brodie, is undoubtedly one of the best 
 we possess in catarrhal affections of the bladder. Next to 
 this rank the uva ursi, and the lythrum salicaria. These 
 last, however, are more especially beneficial in those forms 
 and stages of the affection marked by irritative excitement, 
 rather than by vascular activity, or by organic disease. Hence 
 they are of very little use, when the irritation borders on in- 
 flammatory action on the one hand ; or when the urine is 
 decidedly alkaline, on the other ; and their beneficial effects 
 are chiefly confined to the intermediate stages of disease. Of 
 sedatives, it is difficult to speak in a decided manner, as so 
 much depends, respecting their use, on the idiosyncrasy of the 
 patient. The irritation of mucous membranes in general, and 
 particularly the irritation of the mucous membrane of the 
 bladder, &;c., seems to be less under the local and direct in- 
 fluence of sedatives, than pain or irritation in many other 
 parts. Hence we can seldom do much towards allaying the 
 irritation of the mucous membrane of the bladder, without 
 bringing the whole system under the influence of narcotics. 
 
420 
 
 DISEASES OF THE BLADDER, &C. 
 
 In the milder cases, henbane, conium, or lettuce, or various 
 combinations of these, may be resorted to ; the compound 
 tincture of camphor also, is an excellent preparation in many 
 of these affections. Vh en these fail, recourse must be had to 
 opium, or to some of its preparations. Of these, the Dover's 
 povrder is one of the mildest. IN'ext in order may be men- 
 tioned the vratery extract of opium, Battley's sedative solution, 
 tincture of opium, crude opium, &c. Then follow the prepa- 
 rations of morphia ; of which the most congenial and mildest 
 appears to be the meconiate of morphia ; and the most efficient 
 as well as the least injurious, with reference to its powers, the 
 muriate of morphia. The acetate of morphia I consider, in 
 general, not only more injurious to the nervous system, but far 
 inferior to the muriate, in point of sedative power. Yet there 
 are some individuals with whom the muriate of morphia dis- 
 agrees, but who can bear the acetate. I mention, once for all, 
 the different sedatives, and in the usual order of their powers ; 
 but I need not say, that owing to the idiosyncrasy of indivi- 
 duals, general rules respecting their use cannot be laid down 
 in a satisfactory manner ; and in fact, it is only by experience 
 that we can know what sedative agrees best with an individual ; 
 or whether he can tolerate any. Lastly, with respect to the 
 operation of narcotics, it may be stated, that different morbid 
 sensations are very differently controlled by them. Simple 
 pains, or aches, or smartings, or irritations, are in general, 
 cdBteris paribus, amenable to the operation of narcotics, nearly 
 in the order in which they are stated ; but there is one form 
 of sensation, or pain, or irritation, or whatever we may call' it, 
 connected with affections of the neck of the bladder, and par- 
 ticularly with certain conditions of the mucous membrane of 
 the organ, and which the patient describes as a sensation of 
 burning smarting heat, that is less under the control of seda- 
 tives than any other; and indeed can scarcely be subdued 
 without suspending or destroying the sensibility and conscious- 
 ness of the patient altogether. 
 
 After these separate remarks on the three great classes of 
 
TREATMENT. 
 
 421 
 
 medicinal agents most usually employed in chronic affections 
 of the mucous membrane of the bladder ; we may observe 
 that their good effects are often much increased by judicious 
 combination. It is impossible to lay down rules for all cases, 
 but the following hints may not be deemed irrelevant. The 
 effects of balsamic remedies are sometimes more decided when 
 conjoined with each other. Thus the infusion of disosma may 
 be often advantageously associated with small quantities of the 
 Chian turpentine, or cubebs, or even copaiba ; which may be 
 given in the form of pills, with the extract of henbane, conium, 
 hop, &c. If gouty irritation or hepatic congestion be present, 
 the acetous extract of colchicum, combined with some mild 
 mercurial, may be also administered at the same time with 
 the above. Balsamic and astringent remedies may be some- 
 times conjoined ; but as these two classes of remedies 
 seem to be indicated in different stages or modifications of 
 disease, their conjoint operation can be seldom required. Se- 
 datives are commonly necessary in every combination, in 
 some shape or other. In the earlier stages of the affection, 
 when the urine is acid, alkalies may be often employed in con- 
 junction with the other remedies ; while in the latter stages, 
 w^hen the urine is alkaline, the mineral acids often prove ser- 
 viceable. Finally, demulcent diluents, as barley or gum water, 
 linseed or marshmallow tea, rennet whey, &;c,, may be used 
 with advantage in moderation. 
 
 Acute inflammation of the bladder, of a phlogistic kind, in 
 young and plethoric subjects, requires prompt and decided 
 measures. Bloodletting from the arm, (some of the French 
 surgeons recommend bleeding from the foot in preference) to 
 be repeated according to circumstances, accompanied by local 
 bleeding by cupping or leeches, from the region of the pubes, 
 and especially from the perinseum, should be resorted to as 
 speedily as possible. These means may be followed by warm 
 fomentations, or the warm bath, the injection of emollient 
 fluids into the rectum, &;c. Internally, active doses of calomel, 
 conjoined with opium, may be exhibited ; and the bowels may 
 
422 
 
 DISEASES OF THE BLADDER, &C. 
 
 be relieved by laxative clysters. After the more urgent symp- 
 toms have been ^ubdued, various counter-stimuli may be ap- 
 plied to contiguous regions ; but if blisters be employed, they 
 should be vrithdrawn early, and such dressings be subsequently 
 applied as may tend to promote their effects. Retention of 
 urine, if present, of course must be obviated by the catheter ; 
 but, during the more acute symptoms, it will be proper to be 
 as sparing as possible in the use of instruments. The chronic 
 inflammation or irritation of the mucous membrane of the 
 bladder, too apt to follow acute attacks of that organ, must be 
 combated by the means recommended for that purpose in the 
 preceding paragraph. 
 
 General inflammation of the bladder, attacking more espe- 
 cially the cellular substratum of that organ and of its neigh- 
 bourhood, commonly bids defiance to our utmost skill. Here, 
 even from the outset, antiphlogistic remedies are almost en- 
 tirely out of the question ; and the utmost we can hope to 
 effect, is to mitigate, as well as we are able, the sufferings of 
 the patient ; and to support the fast ebbing powers of life by 
 nutritious diet and stimulating cordials. 
 
 The treatment of chronic degeneration and enlargement of 
 the prostate gland falls almost entirely within the province of 
 the surgeon. In the more passive conditions of the affection, 
 antiphlogistic means are neither indicated nor useful. The 
 use of sedatives is sometimes beneficial ; and in those cases in 
 which complete retention of urine occasionally takes place, 
 probably in some degree from spasm, a decided dose of opium 
 will sometimes promote the discharge of urine. When the 
 retention of urine is complete and permanent, relief can be 
 only obtained by the catheter. 
 
 The treatment of prostatal concretions, also, is for the most 
 part of a mechanical nature, and therefore belongs to the 
 surgeon ; there being no known medicinal means by which wo 
 may hope either to prevent their formation or increase. Mr. 
 Wilson observes, "If these calculi be not very troublesome, 
 our best plan will be to leave them alone, and not to irritate 
 
TREATMENT. 
 
 423 
 
 the gland by the introduction of the catheter more frequently 
 than may be necessary to prevent retention of the urine. 
 When very troublesome, and when they can be felt through 
 the rectum, they may be cut out by an incision, as in the old 
 method of cutting for the stone, or the gripe, as it was called ; 
 but what I should conceive to be the safer practice, they may 
 be extracted by an incision into the gland, from the peri- 
 neeum."* In some of these cases, they may be withdrawn by 
 Weiss's forceps — a method of removing them which I have 
 seen successfully practised by Sir B. Brodie in considerable 
 numbers. 
 
 Acute inflammation of the prostate must be treated much 
 the same as acute inflammation of the bladder. Cupping over 
 the loins, or in the perinaeum ; or the application of numerous 
 leeches about the perinaeum and anus, often affords relief, and 
 checks the more urgent symptoms. With these may be em- 
 ployed warm fomentations, or poultices to the perinseum, 
 the warm bath, &;c. The bowels should be kept open by mild 
 aperients or clysters ; and those purgatives likely to irritate 
 the rectum should be particularly avoided. In the earlier 
 stages of the disease, the use of instruments should be abstained 
 from as much as possible. When the more active symptoms 
 have subsided, relief is sometimes obtained by the judicious 
 use of sedatives ; which may be employed either internally, or 
 injected into the rectum ; and in this state of the affection, if 
 the catheter can be introduced without irritation, its use may 
 be beneficial. The management of abscesses and other 
 severe consequences of acute inflammation of the prostate, 
 belongs to the surgeon. 
 
 The treatment of the second great division of bladder and 
 prostate diseases, namely, those of an irritable kind, comes in 
 the next place to be considered. Cases of irritation of the 
 bladder, depending on mere derangements of the assimilating 
 functions, and on the unnatural properties of the urine result- 
 ing from indigestion, &c., are generally of a temporary charac- 
 * Lectures on the Urinary Organs, page 356. 
 
424 
 
 DISEASES OF THE BLADDER, &C. 
 
 ter, at least in tlieir earlier stages ; and are removable by adjust- 
 ing these functions. These points have been already so often 
 discussed, and are so well understood, that we need not dwell 
 on them here. We shall only, therefore, repeat the important 
 caution, namely, that dyspeptic individuals ought to be parti- 
 cularly observant with respect to diet, &c., lest they render 
 temporary affections permanent, and thus lay the foundation 
 of serious urinary disease. 
 
 The treatment of irritable bladder depending on renal affec- 
 tions is difficult, and too often unsuccessful. The simplest 
 form of the primary disease, which appears to constitute the 
 basis of all the more unmanageable varieties of this class of 
 affections, may be aggravated by injudicious remedies, but 
 scarcely seems capable of being much benefited by any. Great 
 care and attention will sometimes enable us to arrest 
 the affection for a while, perhaps for years ; but in every 
 instance, in which I have hitherto had an opportunity of 
 observing its progress during a lengthened period, I have 
 seen it terminate unfavourably in some form or other. 
 
 The first points to be attended to, are the strictest attention 
 to diet and regimen. The patient must consider himself an 
 invalid, and live carefully according to the rules laid down for 
 him. He should avoid all stimulating and indigestible articles 
 of food, and adopt a simple, light, and nutritious plan of diet. 
 Exercise must be taken, but it must be of a gentle kind ; and 
 long journeys in rough carriages ; and fatigue and exertion of 
 every kind are calculated to aggravate the affection, and must 
 be most carefully avoided. When practicable, sea voyages, 
 and residence in a warm climate during the winter, may be 
 recommended 
 
 The different forms and stages of these affections require 
 modes of treatment somewhat different ; and from idiosyncrasy 
 and other causes, the remedies which seem best adapted to the 
 
 * The reader is more especially referred to the chapter on serous urine, 
 for the detailed account of the treatment of anssmotrophic affections of the 
 kidney nearly allied to the present affections. See page 170, et seq. 
 
TREATMENT. 
 
 425 
 
 iifFection can often neither be borne at all, or be borne long- 
 enough to give the requisite chance of doing good. The 
 following is a brief sketch of the remedies and modes of treat- 
 ment I have found most beneficial in these affections. 
 
 In the early stages of the affection, if there be anything like 
 activity, a few ounces of blood may be abstracted by cupping 
 from the loins, or by leeches applied to the perinaeum. At 
 the same time, the citrate of ammonia may be given internally 
 in conjunction with mild but efficient purgatives. In general, 
 however, the abstraction of blood is seldom necessary, or at 
 least I have rarely seen patients who have required depletion. 
 In these stages of the affection when quiescent, the uva ursi, 
 the lythrum salicaria, the pareira brava, and even small doses 
 of chalybeates, as of the tinct. ferri muriatis, are sometimes 
 useful ; particularly if so directed or combined as to improve 
 the health in general, at the same time that they act on the 
 local affection. In the more advanced stages of the affection, 
 in which the urine has become decidedly serous, of low specific 
 gravity, and has a tendency to alkalescence, remedies of the 
 above character seldom do much good, and indeed, if adminis- 
 tered in a decided form, they appear sometimes to increase the 
 irritation. In these stages of the affection, if accompanied by 
 permanent excitement, the citrate of ammonia, either alone or 
 combined with the fluid extract of sarsaparilla, may be given ; 
 if quite passive, the infusum diosmcB, with the extract of sarsa- 
 parilla, or the dilute muriatic acid, are very excellent remedies ; 
 indeed, I have seen more benefit derived from these expedients, 
 and the judicious use of sedatives, than from any other means 
 whatever. Other remedies of the balsamic class in small doses 
 are sometimes beneficial, and their use may be associated or al- 
 ternated with the infus. diosmcs : such are the tinct henzoini 
 comp., the infusion of the wild carrot seed, or of sassafras, &:c. 
 All these, however, must be so administered as never to excite ; 
 and the weak state in which it is necessary to give them, must 
 be compensated for by the length of time during which they 
 are taken. In conjunction with these means, an issue or seton 
 
426 
 
 DISEASES OF THE BLADDER, kc. 
 
 may be instituted over the region of the kidneys ; but in ge- 
 neral, in diseases of the present description, the excitement 
 and worry produced by this class of remedies is hardly com- 
 pensated for by the little benefit they produce. In the last 
 stages of the disease, beyond general remedies, I know nothing 
 that can be directed to the local disease with any prospect of 
 advantage ; and the utmost we can hope to accomplish is to 
 alleviate the sufferings of the patient by sedatives ; of which, 
 perhaps, the muriate of morphia, with hyoscyamus or conium, 
 are among the most efficient. 
 
 When irritation from disease about the orifice of the ure- 
 thra exists in females, it must be obviated as far as possible by 
 local expedients — a point, in general, that can be only accom- 
 plished by the application of stimuli calculated to permanently 
 destroy the morbid sensibility of the part ; and when this has 
 been accomplished, the progress of the general affection seems 
 to be occasionally arrested, and the sufferings of the patient for 
 a time will be very much relieved. 
 
 With respect to the treatment of ulceration, polypous excres- 
 cences, elongations of the lining inemhrane of the Madder, enlarge- 
 ment of the prostate, and a variety of other similar chronic 
 affections giving occasion to irritable bladder, it is impossible 
 to lay down any specific plan of treatment ; but in the ma- 
 nagement of all of them the maxim should be borne in mind, 
 that it is much easier to do mischief than to do good. The 
 general principles of treatment likewise, stated in the preced- 
 ing paragraphs, should be kept in view ; and the remedies there 
 enumerated be so administered, on the one hand, as to mode- 
 rate activity ; and on the other, to mitigate the sufferings and 
 support the general health of the patient ; and these, joined 
 with such local assistance as an experienced surgeon knows 
 how to administer, will sometimes enable a patient to bear up 
 under his sufferings, and ultimately to arrive at comparative 
 comfort. At any rate, they constitute the whole that, in his 
 deplorable state, can be effected for him by human aid. Nearly 
 the me remarks may be made respecting the treatment of 
 
TREATMENT. 
 
 427 
 
 fungus hcBmatodes. Here, nothing can be done towards the 
 cure of the patient ; and all we can reasonably hope to effect 
 is, to allay in some degree his sufferings by sedatives ; and to 
 prolong his existence by checking and obviating the conse- 
 quences of that fearful haemorrhage which too often accom- 
 panies this affection, — a subject we shall briefly notice in the 
 next chapter, when we come to speak more particularly of 
 haemorrhage from the urinary organs in general. 
 
 The treatment of those cases of irritable bladder depending 
 on chronic thickening and contraction of the organ ; or on 
 enlargement of the prostate, stricture of the urethra or other 
 affections, of a mechanical nature, belongs almost exclusively 
 to the surgeon. As a remedy, the use of iodine, both in- 
 ternally and externally, has been strongly recommended when 
 the prostate has been enlarged and the bladder thickened, but 
 I know not with what result. I have repeatedly seen this 
 remedy tried in these affections, but cannot say that I have 
 been sensible of any improvement from its use. 
 
 Gouty irritation of the urethra usually resists the use of the 
 balsamic remedies, but readily yields to colchicum, and to the 
 general treatment adapted for gout in general. Rheumatic 
 gouty irritation of this canal is much more obstinate ; and in 
 short, like rheumatic gout in other parts, commonly defies for 
 a long time all our efforts to conquer it. Colchicum is of 
 very little use ; and the affection is best treated with Dover's 
 powder, or other preparations of a sedative kind, with the view 
 of allaying the irritation. I have sometimes seen benefit derived 
 from guaiacum ; but in other instances this remedy has failed ; 
 as has also the hydriodate of potash, which appears to be one of 
 the best remedies we possess for that peculiar affection appa- 
 rently nearly allied to rheumatic gout, which sometimes attends, 
 or follows, common gonorrhoea.^' 
 
 Cases of irritable bladder depending on affections of the 
 nervous system are manageable or otherwise according to the 
 nature of the nervous affection. If the nervous affection be 
 * See Mr. Lawrence's paper, before referred to, page 404. 
 
428 
 
 DISEASES OF THE BLADDER, (fec. 
 
 simply of the constitutional kind, the irritability may be merely 
 the result of habit; and in this case, a little well-directed 
 resolution on the part of the patient, aided by appropriate 
 medicines, will enable him to conquer the irritability ; or at 
 least to prevent it from becoming permanent. On the other 
 hand, if the cause be organic lesion of the brain, as is some- 
 times the case in aged individuals ; little, as Sir B. Brodie 
 justly observes, can be done towards the patient's relief, and the 
 cerebral disease will ultimately prove fatal. 
 
 The treatment of spasmodic affections of the bladder will 
 be considerably modified according to their cause. If the 
 spasm depends on the presence of stone, stricture, or any 
 other cause of a mechanical nature, this must be removed, or 
 the effects obviated as soon as possible. If inflammation be 
 present or threatened, cupping or leeches over the loins, or 
 about the anus or perinseum, followed by the warm bath or 
 fomentations, will be proper. With these remedies, opiates 
 either taken into the stomach combined with calomel, kc, or 
 applied locally in the form of suppository or injection, may be 
 administered with advantage. If the spasm be of a gouty 
 nature, mustard or other stimulating cataplasms may be ap- 
 plied to the feet ; or to any other part of the extremities the 
 gout may have recently left, or formerly been in the habit of 
 attacking. When spasm of the bladder causes retention of 
 urine, and inflammatory symptoms are absent, the muriated 
 tincture of iron, repeatedly given in small doses, as recom- 
 mended by the late Mr. Cline, will sometimes remove the 
 affection. In spasmodic affections of the bladder, of a purely 
 nervous or hysteric character, different tonics associated with 
 camphor, musk, valerian, and other remedies of a reputed 
 antispasmodic character, may be sometimes employed with 
 advantage. 
 
 The first point to be attended to in the treatment of para- 
 lysis of the bladder, is the prevention of an accumulation of 
 urine in that organ. This accident must be obviated, at any 
 rate, by the judicious use of the catheter ; while the rest of the 
 
TREATMENT. 
 
 429 
 
 treatment will very much depend upon the general nature and 
 cause of the affection. When the paralysis is connected with 
 spinal or other deep-seated disease, little for the most part can 
 be accomplished. Nevertheless, in some of the more favour- 
 able of these cases, the judicious use of stimuli, as electricity or 
 galvanism, the tincture of cantharides, &;c., may be worth a 
 careful trial. In the still milder forms of the affection, in 
 young and middle-aged individuals, depending on general 
 debility of the system, the cold bath and other invigorating 
 expedients and remedies offer a prospect of relief. When the 
 complaint is purely local and passive; in conjunction with the 
 above means, some of the continental writers have recom- 
 mended the injection of cold water into the bladder or rectum ; 
 and this expedient, as well as others calculated to ensure the 
 bracing effects of cold without its sedative operation, may be 
 resorted to. 
 
 It remains, in the last place, to make a few remarks on the 
 treatment of hysteric affections of the urinary organs. The 
 first great point to be attained in hysteric affections, is the 
 difficult one of an accurate diagnosis. We must make sure 
 that the affection we have to combat is hysteria, and notJdng 
 hut hysteria. For it should be always borne in mind, that 
 in irritable habits, and especially in females disposed to hys- 
 teria, a vei^y slight cause, such as a small stone in the bladder, 
 &c., will often produce very great suffering ; and that in such 
 cases, though the hysteric symptoms may predominate, and 
 render doubtful or conceal the original character of the excit- 
 ing cause, the affection is nevertheless of a mixed character ; 
 and that the hysteric part of the affection will probably cease, 
 when such exciting cause has been removed. Moreover, we 
 should bear in mind, that what was at first merely a func- 
 tional, may, by long continuance, become a real or organic, 
 disease. As an instance in illustration of this remark, we may 
 mention the retention of urine which sometimes occurs in 
 hysteric females. In the earlier stages of the affection, hys- 
 teric retention of urine is almost always a purely functional 
 
430 
 
 DISEASES OF THE BLADDER, &C. 
 
 disease, and the patient retains the power of emptying the 
 bladder, provided she be forced to exert the will. " As the 
 distension of the bladder increases," says Sir B. Brodie, " the 
 patient begins to get uneasy, and at last suffers actual pain ; 
 and as soon as this happens, the volition is exercised as usual, 
 and the bladder begins to expel its contents."^ Hence Sir B. 
 Brodie very properly goes on to observe, that if the bladder be 
 not relieved artificially by the introduction of the catheter, 
 the hysterical retention of urine is usually of short duration ; 
 but if the catheter be had recourse to, the natural cure is pre- 
 vented, and the existence of the disease may be prolonged for 
 an indefinite length of time — for weeks, or even for months. 
 The general rule, therefore, in such cases, is to interfere but 
 little. An active aperient may be given, or an assafoetida 
 enema, &;c., may be administered, but the use of the catheter 
 should not be resorted to. Yet, as observed by the same 
 author, cases of hysteric affection may arise, in which the 
 bladder by over-extension may have become paralysed and 
 unable to expel its contents, and in which consequently the 
 use of the catheter is absolutely necessary. The same remarks 
 are applicable to other affections, besides retention of urine. 
 Thus pains in the back, for instance, may come in time to 
 denote spinal or psoas disease ; the functional derangements 
 of the kidney may terminate in organic affection ; or in cal- 
 culus, &;c. In short, as we have elsewhere observed, we never 
 should make light of a case in which the symptoms have been 
 of a severe kind and of long duration ; how much soever it 
 may partake of the hysteric character. 
 
 * Lectures on the Urinary Organs, page 80, second edition. 
 
431 
 
 CHAPTER V. 
 
 OF HEMORRHAGE FROM THE URINARY ORGANS IN GENERAL. 
 
 The obvious nature of Hsematuria renders a description of 
 the affection unnecessary. The little, therefore, we have 
 to say on the different forms and circumstances under vrhich 
 blood appears in the urine, will be considered under the 
 heads of the causes, diagnosis, prognosis, and treatment of the 
 affection. 
 
 The general or predisposing causes, as well as the sources of 
 haemorrhage from the urinary organs, may be various, and 
 are often very obscure. In certain epidemics of the malignant 
 type, as for instance, in cholera in severe remittent or 
 typhoid fevers, arising from, or modified by malarious in- 
 fluence ; or in affections of the spleen and liver produced by 
 the same cause ; also in scurvy, &;c. ; the properties of the 
 
 * See page 23, where the tendency to haemorrhage from the urinary- 
 organs after this disease is noticed. The reader also will find haematuria 
 mentioned as a frequent symptom of many other diseases, both constitu- 
 tional and local, besides those mentioned m the text ; as_, for instance, of 
 chylous urine, haemorrhoidal congestion, suppression of the catamenia in 
 females, derangement of the bowels produced by the irritation of teething 
 in children, &c. We also read of haematuria as an epidemic affection both 
 in children and adults, in some countries and localities. In these in- 
 stances, the constitutional symptoms and tendencies may be very different, 
 and depend on very different causes ; but in the epidemic varieties the 
 cause is most probably of a general nature, and depends on unwholesome 
 diet, or on some modification of malarious influence. 
 
432 
 
 HEMATURIA. 
 
 blood and of the vital solids, appear to undergo certain changes 
 producing a tendency to haemorrhage from all the outlets of 
 the body, and from the kidneys and bladder in particular. In 
 such cases, although the hsematuria is to be regarded as a 
 mere symptom of a state of disease, the consideration of which 
 falls without our present design ; yet a thorough acquaintance 
 with the pathology of such affections is often of the greatest 
 importance in enabling us to form a correct diagnosis in 
 hgematuria ; as will appear from the following observations on 
 the subject. 
 
 The immediate or exciting cause of hsematuria may be of a 
 mechanical nature, that is, a calculous concretion ; or the cause 
 may consist in ulceration, healthy or malignant, of the kidney 
 and bladder, or of their appendages. The chief points of diag- 
 nosis, therefore, in hsematuria will be ; first, the causes, predis- 
 posing or exciting ; and secondly, the seat of the haemorrhage, 
 whether in the kidney, or in the bladder. On each of these 
 we shall offer a few remarks. 
 
 The nature of some of the predisposing causes of hsematuria 
 is so obvious from the history and symptoms, that their true 
 character can be hardly mistaken ; such, for instance, are 
 typhus, scurvy, &;c. The effects of malarious influence as a 
 predisposing cause are much more obscure ; and their nature 
 can, in many instances, be only made out by a minute and 
 careful investigation of the patient's history, and sometimes 
 not at all. This arises no less from the multiform degrees and 
 shapes assumed by this fearful scourge in different seasons and 
 climates ; than from the very different effects they produce on 
 different individuals, from idiosyncrasy, &;c. — circumstances 
 which, in conjunction with many others of a similar kind, 
 render it almost impossible to form a just estimate of how 
 much of the effect is due to the predisposing, and how much 
 to the exciting, cause of the haemorrhage. Moreover, the 
 difficulty is still further increased by the fact, that when 
 the predisposing causes are unusually active, either in vir- 
 tue of their own powers, or from the idiosyncrasy of the 
 
DIAGNOSIS, (fee. 
 
 433 
 
 patient ; a very trifling exciting cause that would not pro- 
 duce the least haemorrhage in a healthy individual, as for 
 instance, a very small renal concretion, may, in such a 
 strongly predisposed habit, give occasion to very severe haemor- 
 rhage. 
 
 When the haemorrhage cannot be traced to any of the con- 
 stitutional or predisposing causes above mentioned, we must 
 seek for its origin among those causes more immediately of a 
 local or exciting nature. These, as already stated, may be of 
 two kinds. The immediate exciting cause of the haemorrhage 
 may be a calculus, which, without causing ulceration strictly 
 so called, may have wounded some blood-vessel ; or the haemor- 
 rhage may result from ulceration, which may or may not be 
 produced or accompanied by a calculus, and may be either of 
 a healthy or of a malignant character. To state precisely on 
 which of these circumstances the haemorrhage depends, or with 
 which it is connected, is not always an easy task ; though the 
 following circumstances may enable us to form an opinion on 
 the subject. 
 
 If the haemorrhage occurs more particularly after exercise, 
 and if the blood be either florid or dark-coloured, and mixed 
 with lithic acid ; or if the urine abounds or has long abounded 
 in this principle, and the patient has occasionally passed lithic 
 acid gravel or concretions ; if there be more or less of pain 
 accompanying the haemorrhage ; if the patient be under the 
 age of puberty, or of middle or advanced age, the immediate 
 cause of the haemorrhage will almost certainly prove to be a 
 lithic acid concretion. On the other hand, when the haemor- 
 rhage, as before, particularly occurs after exercise, and the 
 blood is of a very dark colour, or like coffee grounds, and 
 unmixed with lithic acid ; when the urine is of a greenish citron 
 tint, and the patient has at no time of his life been subject to 
 urinary sediments (of lithate of ammonia) ; when he has occa- 
 sionally (or constantly) laboured^ under cutaneous eruptions, 
 particularly of the scaly kind, and presents the cachectic 
 aspect formerly described as peculiarly marking the oxalic 
 
 F F 
 
434 
 
 HEMATURIA. 
 
 acid diathesis, the probability is very great, that the haemor- 
 rhage is occasioned by a concretion of the mulberry variety ; 
 which may or may not be associated at the same time with 
 organic disease. Haemorrhage, at least to much extent, is 
 rarely produced by phosphatic concretions ; and when the 
 circumstance occurs, the properties of the urine and the his- 
 tory of the patient seldom fail to lead to a correct diagnosis on 
 the subject. 
 
 Ulceration in some portion of the urinary organs, is another 
 great source of hsematuria. Ulceration, as we have stated, 
 may proceed from very various causes, and be very different 
 in its character and consequences ; nor can we always sa- 
 tisfactorily determine either its cause or nature. The cha- 
 racters of the blood, and of the matters accompanying it, 
 usually afford us the surest means of diagnosis ; and in most 
 instances will enable us to approach the truth with tolerable 
 certainty. 
 
 When the patient labours under no constitutional disease 
 usually accompanied by haemorrhage, or has not suffered from 
 calculous affections of any description ; when he complains of 
 pain in the urinary organs and voids blood with the urine, 
 and the blood is mixed with mucus, and particularly with puru- 
 lent matter, a breach of surface must exist somewhere ; and 
 there is certainly either actual or incipient ulceration in some 
 portion of the urinary apparatus. If the blood, mucus, or 
 pus, present no remarkable appearance or offensive charac- 
 ter ; we have reason to hope that the ulceration is of a 
 common or favourable kind ; but if the blood be very dark 
 coloured, and associated with unnatural matters of a highly 
 offensive, and particularly of a putrid odour, the ulceration 
 very probably partakes of a malignant nature, and will prove 
 fatal. 
 
 Having ascertained, as far as we are able, the cause of the hae- 
 morrhage, the next point is to determine its seat — a circum- 
 stance often intimately connected with the cause, and sometimes 
 of equally great importance. 
 
DIAGNOSIS, (fee. 
 
 435 
 
 When urinary calculi have been known to descend from the 
 kidney, and there is a sense of heat, weight, and pain, in the 
 region of that organ ; when the pain darts to the end of the 
 urethra or testicles, and there is more or less of nausea and 
 vomiting, the haemorrhage, in general, may be reasonably sup- 
 posed to depend on the presence of a calculus in the kidney 
 or ureter. On the other hand, when the hsemorrhage comes 
 on after exercise, and there is occasional retention, or sudden 
 stoppage, of urine, accompanied by a sensation referred to the 
 end of the penis ; when a similar sensation is felt at the same 
 place, at the moment the bladder is emptied, there can be little 
 doubt that the bladder is the seat of the haemorrhage, and that 
 the cause is a stone in that organ. 
 
 When the symptoms accompanying the haemorrhage are 
 equivocal, and when those above mentioned in particular, are 
 wanting, which usually indicate the presence of stone in the kid- 
 ney or bladder ; our attention must be more immediately directed 
 to the character of the blood, and to the circumstances under 
 which it makes its appearance in the urine. When blood 
 enters the bladder from the kidney, it is generally more or less 
 equally diffused throughout the whole urine voided ; and if 
 the quantity of the blood has been considerable, coagulation 
 takes places in the ureters, producing suppression of urine, 
 and violent pain and vomiting, kc. When such symptoms are 
 present, and when some time afterwards we see in the urine 
 elongated masses of fibrin resembling worms, which had been 
 moulded in the ureters, the source of the blood is unequivo- 
 cally the kidneys. On the other hand, (supposing the patient 
 to have been previously quiescent,) when the first portions of 
 urine flow away nearly clear, and the great mass of the blood 
 comes away at the end of the process of micturition ; and when 
 all the symptoms usually accompanying renal irritation are 
 likewise absent ; there can be little doubt in general that the 
 source of the haemorrhage is in the bladder. 
 
 Further, the quantity of blood passed down from the kidney 
 is seldom so large as to fill the bladder, and by its coagulation 
 
 F F 2 
 
436 
 
 H.EMATURIA. 
 
 to cause retention of urine ; when, therefore, the bladder be- 
 comes distended with coagulated blood, and retention of urine 
 in consequence takes place, we may almost certainly conclude 
 that the haemorrhage has taken place in the bladder itself. 
 When the blood flows away yuttatim without the urine, it may 
 be supposed to come from some part of the urethra. In this 
 case, however, if the source of the haemorrhage be very near 
 the neck of the bladder, the blood occasionally makes its way 
 backwards into the bladder, and thus produces some uncer- 
 tainty as to its origin. Lastly, the phenomena presented by 
 the blood itself, sometimes throw light on the nature, as well 
 as the origin of the disease ; as for instance, in fungus haema- 
 todes.* 
 
 We have mentioned one of the formidable consequences 
 sometimes resulting from profuse haemorrhage into the blad- 
 der, namely, the coagulation of a large mass of blood in that 
 organ, and the consequent retention of urine occasioned by 
 the coagulum. Another unpleasant consequence of the pre- 
 sence of blood in any part of the urinary apparatus, to which 
 the urine has access, is the formation of a nucleus, around 
 which calculous matter may af some future time concrete. 
 Haemorrhage from the urinary organs, therefore, though not 
 caused by a calculus, may of itself prove a cause of calculus 
 hereafter. 
 
 After what has been stated, we need not dwell on the prog- 
 nosis in haematuria, which will be favourable or unfavourable, 
 according to its origin and degree ; and according as its cause 
 can be removed or otherwise. The loss of blood from the 
 urinary organs is seldom so large as to destroy life at once ; 
 yet when the cause is with difficulty removable, from the little 
 control we sometimes have over the affection, the daily loss 
 of blood is liable to produce serious inroads on the system ; 
 and once or twice I have seen it prove fatal.f 
 
 * See note, page 415. 
 
 t The circumstances attending- one of these cases were remarkable. 
 The patient had been long resident in a notoriously malarious situation. 
 
TREATMENT. 
 
 437 
 
 The treatment of hsematuria will depend on its cause, and on 
 its degree and seat. Hsematuria, when of a constitutional 
 character, and occurring in a young or plethoric subject, and 
 when it appears to be vicarious to hsemorrhoidal or catamenial 
 discharges ; when accompanied also by a full and strong pulse, 
 and more or less of inflammatory excitement, will sometimes 
 require general or local abstraction of blood, and the usual 
 antiphlogistic itreatment. Such cases, however, are rare ; at 
 least, they seldom come under the care of medical men in this 
 stage ; and the affection, constitutionally speaking, is usually 
 accompanied by some cachexia, or disease, of which debility is 
 a leading feature ; such as scurvy, typhus fever, &;c. Even 
 those affections of the liver and spleen, produced by malaria, 
 and accompanied by a hsemorrhagic tendency, often belong to 
 the same class ; at least they seldom bear or require general 
 depletion; 
 
 The treatment of fevers, scurvy, &;c., in which hsematuria is 
 rather to be viewed as a symptom, than as a disease, does not 
 fall to be considered in this place ; and the only affections of 
 a constitutional character to be noticed, are those obscure 
 forms of disease, most usually of malarious or gouty origin, in 
 which hsematuria apparently constitutes the chief affection to 
 be combated. In hsematuria decidedly connected with affec- 
 tions of malarious origin, the mineral acids, conjoined with 
 quinine, galls, the tinct.ferri muriatis, alum, and other reme- 
 
 At length he became subject to hsematuria, which, in spite of every re- 
 medy, continued more or less, if I remember rightly, for about two years. 
 I saw him a short time before his death, in a state of perfect anaemia, 
 and beyond a hope of recovery. After death, a mulberry calculus was 
 found in one of the kidneys, which was probably the immediate cause of 
 some portion of the haemorrhage. The greater part of the blood, how- 
 ever, appeared to have come from a spot about the size of a crown piece, 
 in the upper and posterior part of the bladder. The surface of the organ 
 was not apparently diseased in this spot; but the blood obviously transuded 
 through the mucous membrane, from a large plexus of veins distended 
 with dark-coloured blood, and situated immediately behind this portion 
 of the bladder. 
 
438 
 
 HEMATURIA. 
 
 dies of this class, are generally found to be tlie most efficient. 
 When the milder and safer remedies fail, we may resort to 
 those of a more powerful character, as arsenic, or lead ; and of 
 all other remedies, when the haemorrhage takes place from 
 the kidney, the acetate of lead is perhaps the most efficient. 
 In conjunction with the above remedies, when the liver, and 
 particularly the spleen, as is often the case, is congested and 
 tender, the occasional application of a few leeches to the part, 
 in conjunction with the preceding treatment, appears to be 
 beneficial ; at any rate, such application enables us to push our 
 tonic and astringent remedies with the greater confidence. 
 Some of these cases, however, resist for a long time every 
 means we can employ, and will at length cease spontaneously. 
 In other instances, they go on to a fatal termination. I have 
 seen one or two instances only, of the latter kind ; but during 
 the period just subsequent to that in which the cholera pre- 
 vailed in London, I saw a great many cases in which the 
 haemorrhage from the kidneys remained most profuse and 
 constant, in spite of every remedy, for many weeks together ; 
 but at length ceased of its own accord, and without leaving any 
 unfavourable result.* 
 
 When renal haematuria is connected with a gouty diathesis, 
 colchicum may be sometimes advantageously joined with the 
 appropriate styptic remedies. In such cases also, the carbonate 
 of soda may be often given with good effect after meals ; while 
 the mineral acids, &;c., are taken at other times of the day. 
 In ordinary cases of renal haemorrhage, when there are no 
 symptoms either of excitement or debility, and when the cause 
 appears to be of a mechanical nature, small doses of balsamic 
 and of terebinthine remedies, as copaiba, or turpentine, have 
 been much recommended by some writers. I have often re- 
 sorted to this class of remedies, but am sorry to say that I 
 
 * Except, perhaps, in a few instances, the formation of a nucleus around 
 which an oxalate of lime concretion was subsequently deposited. For, as 
 already observed, the oxalic acid diathesis prevailed in a remarkable 
 degree at this period. See page 22 et seq. 
 
TREATMENT. 
 
 439 
 
 have been generally disappointed in their effects.* If the 
 mechanical cause of the haemorrhage be small, we may en- 
 deavour to dislodge it from the kidney by the appropriate 
 means, and thus remove the affection permanently ; but if 
 from the symptoms and properties of the urine, there be 
 reason to fear that the concretion is too large to be removed, 
 all such attempts should be carefully avoided. 
 
 When the bladder is the source of the haematuria, the cause, 
 as before, may^be various. In plethoric individuals of middle 
 and advanced age, it is often connected with an hsemorrhoidal 
 tendency and enlarged prostate, and the haemorrhage is apt 
 to take place periodically. In such cases cupping over the 
 loins, or leeches to the peringeum and anus, will be useful. 
 Should the immediate cause of the haemorrhage be even a 
 stone in the bladder, before an attempt be made to remove 
 the calculus, the same means may be employed ; provided the 
 same state of congestion exists. In haemorrhage from the 
 bladder of a more passive character, and connected with 
 malarious influence, the constitutional remedies adapted for 
 such a state of the system, conjoined with the use of the 
 various styptic remedies above mentioned, may be resorted 
 to. 
 
 When the bladder becomes distended with blood, and com- 
 plete retention of urine in consequence takes place, recourse 
 must be had to a large-eyed catheter, and an exhausting syringe, 
 by the aid of which, and the occasional injection of cold water, 
 the coagula may be broken down and removed. If the haemor- 
 rhage be so profuse, that the bladder becomes again distended 
 with blood in a very sho^t time, the injection of cold water 
 into the rectum or bladder is sometimes of great use ; and 
 should these means fail, from twenty to forty grains of alum 
 
 * In some of these cases, the most efficient mode of exhibiting- this 
 class of remedies is to combine them (e. g. 3ii vel 3iii of the oil of tur- 
 pentine) with castor oil or other purgatives. This is an excellent remedy 
 in haemorrhagic tendencies connected with certain forms of splenetic de- 
 rangement arising from malarious tendency. 
 
440 
 
 HtEMATURIA. 
 
 may be dissolved in each pint of water injected into the 
 bladder, a remedy that seldom fails to check the bleeding, 
 even when the cause is malignant disease. I have never 
 known any unpleasant consequences follow the use of this 
 expedient ; and have seen it immediately arrest the most for- 
 midable hsemorrhage, when all other means had failed ; and 
 when the bladder had repeatedly become again distended with 
 blood, almost immediately after its removal. 
 
441 
 
 CHAPTER VI. 
 
 OF SUPPRESSION, RETENTION, AND INCONTINENCE OF URINE. 
 
 Suppression, retention, and incontinence of urine most usually 
 appear as symptoms of other diseases ; and in this character 
 they have been repeatedly noticed in the preceding pages. It 
 may not be amiss, however, for the sake of reviewing and con- 
 centrating what has been said on those subjects, to briefly con- 
 sider them as idiopathic affections . 
 
 In suppression of urine, or ischuria renalis, the functions of 
 the kidneys are more or less suspended or destroyed, and the 
 urine ceases to be separated. In retention of urine, or ischuria 
 vesicalis, the kidneys perform their office as usual, and the urine 
 makes its way into the bladder ; but from some cause the secre- 
 tion cannot be ejected from that organ. The symptoms attend- 
 ing these two affections are so different, that they can be hardly 
 mistaken ; and in all doubtful cases, the nature of the affection 
 can be readily determined by the introduction of a catheter 
 into the bladder. 
 
 Of suppression of Suppression of urine may be partial 
 
 or entire, and may depend on a variety of causes. The general 
 characters of the affection, also, may be considered as of three 
 kinds ; viz. inflammatory, spasmodic, and mechanical ; and 
 the symptoms will vary somewhat according to the general 
 character of the aff'ection.^ When suppression of urine is 
 
 * We hear and read of cases of suppression of urine taking- place sud- 
 denly in advanced life, in individuals apparently in perfect health. I have 
 
442 
 
 SUPPRESSION OF URINE. 
 
 accompanied by, or depends on inflammation of the kidneys, 
 tlie symptoms will partake more or less of the character of 
 those already described, as produced by that affection. When 
 the signs of inflammation are absent, and the patient has been 
 subject to gout ; or if a female, to hysteria ; the suppression 
 may be supposed to depend, in part at least, on spasm. The 
 presence of mechanical suppression may be suspected, when 
 the person has been subject to calculous affections, &;c. Gene- 
 rally, however, in this latter case, the effects cannot be ascribed 
 altogether to the simple operation of the mechanical cause, but 
 in part also to the inflammation or spasm, or both, to which the 
 mechanical impediment is liable to give occasion ; and the affec- 
 tion thus assumes a mixed character. When the suppression 
 of urine is complete, the following constitutional symptoms are 
 usually present : 
 
 The earlier and initiatory symptoms of suppression of urine, 
 may vary, as above stated, according to the general characters 
 of the affection ; but when the suppression becomes confirmed 
 and complete, all the minor distinctions are forgotten or over- 
 looked amidst the severe suffering and imminent danger of the 
 patient. The invasion of the affection is characterised by 
 anxiety, restlessness, and an indescribable sense of uneasiness 
 and distension, about the abdomen and loins. To these symp- 
 toms quickly succeed a peculiar expression of torpidity, and 
 disinclination to exertion of any sort, bodily or mental. The 
 stomach becomes more or less affected, and there is frequent 
 tendency to hiccough or nausea. The pulse in general is not 
 much accelerated, — on the contrary, is sometimes slower and 
 feebler than natural ; the patient scarcely complains, and gra- 
 dually lapses into a state of drowsiness, with incoherent rambling. 
 The drowsiness increases, and at length terminates in complete 
 
 seen no such instances; and in every case of suppression of urine that 
 has fallen under my own observation, there has been constitutional or 
 local disease present_, abundantly sufficient to account for the suppres- 
 sion. In such states of predisposition^ exposure to cold,, or gout, some- 
 times causes a rather sudden suppression of urine. 
 
SUPPRESSION OF URINE. 
 
 443 
 
 coma ; in which state, sometimes after repeated attacks of con- 
 vulsions, the patient expires. 
 
 Suppression of urine may take place at all ages, and in all 
 the forms above mentioned, from the action of the requisite 
 exciting causes. It most commonly occurs in children and in 
 old people. When it takes place during the period of adoles- 
 cence, particularly in females, it is almost always connected 
 with hysteria. In children, the irritation and derangement 
 arising from dentition, is perhaps the most frequent concomi- 
 tant or exciting circumstance of suppression of urine. In ad- 
 vanced age the affection is usually connected with gout, gravel, 
 or nephritic disease ; and the immediate exciting cause is most 
 usually exposure to cold. 
 
 Suppression of urine, when complete, and of an original 
 character, or supervening on any acute disease, for the most 
 part proves fatal. But there are many extraordinary cases on 
 record, in which, in suppression of urine, a vicarious discharge, 
 more or less resembling urine, has taken place by sweating, 
 vomiting, stool. Sec, and the patient under these circumstances 
 has sometimes survived for a long time, and even ultimately 
 recovered. Most of these cases have been said to occur in 
 females, and therefore have doubtless been of an hysteric cha- 
 racter — a circumstance which throws a strong suspicion over 
 their authenticity, and which renders it probable that the sup- 
 pression and vicarious discharges of urine, in some of these 
 instances, have been feigned. I have seen a few such cases, 
 in which the imposition, after having been practised for months, 
 has been at length detected ; and the display of ingenuity and 
 cunning, which has come to light on one or two of these occa- 
 sions, has been almost surpassing belief.^' 
 
 * When the suppression of urine is complete, coma almost invariably 
 becomes established before the end of the fifth day ; a complete suppres- 
 sion of urine, therefore, is obviously incompatible with life. It is surprising, 
 however, what relief appears to be aiforded to the system by the occa- 
 sional passage of a small quantity of urine, and it is probable that some 
 of the extraordinary cases of pretended suppression of urine on record. 
 
444 
 
 RETENTION OF URINE. 
 
 Suppression of urine, occurring as a symptom, has been 
 already referred to in many parts of this volume. I do not 
 think it necessary, therefore, to enter into details on the sub- 
 ject of its treatment ; but shall content myself with the follow- 
 ing general remarks on the subject. The treatment of sup- 
 pression of urine will depend chiefly on its causes, and on the 
 nature of the symptoms with which it is associated. When 
 combined with inflammation of the kidney, the active anti- 
 phlogistic means pointed out for the treatment of that affection 
 must be resorted to. When the suppression is of a spasmodic 
 character, the chief reliance will be placed on antispasmodic 
 remedies, conjoined, in chronic or partial forms of the affec- 
 tion, with diuretics or tonics ; or if associated with gout, sti- 
 mulating cataplasms may be applied to the feet, &:c. When 
 evidently connected with a mechanical cause, as calculus, (fee, 
 recourse must be had to the means recommended in such 
 affections ; and, at the same time, care must be taken to keep 
 down, as much as possible, the more active symptoms of inflam- 
 mation, &;c. 
 
 Of Retention of Urine. — In retention of urine, there is more 
 or less of pain and uneasiness in the region of the bladder, 
 accompanied for the most part, in the earlier stages at least, 
 by an urgent desire to pass off" the urine. The distended 
 bladder, also, forms in most instances a swelling above the 
 pubes, not only perceptible to the touch, but sometimes even 
 
 are referable to this principle. In other instances, the apparent absence 
 of urine may have been connected with some unusual termination of the 
 ureters or of the bladder ; as for instance, into the rectum,, &c. As for 
 the alleged vicarious discharges of urine by the stomach, nipples, ear, 
 &c., they are too marvellous to be true. I have seen repeated instances 
 of pretended vomiting of urine, and have examined the fluid, and found 
 it in some cases to closely resemble that secretion ; but in all such cases 
 the patient, on being narrowly watched, has been observed to practise 
 the deception of voiding and immediately swallowing the urine! In 
 other instances, the fluids brought to me as urinous discharges from the 
 stomach, have proved on examination to be altogether different from that 
 secretion. 
 
RETENTION OF URINE. 
 
 445 
 
 to tlie eye ; and the drawing off of the urine by the catheter, 
 if this can be effected, always gives great and immediate relief 
 to the patient's sufferings. 
 
 The different circumstances under which retention of urine 
 takes place, have been noticed in the preceding pages ; and 
 it only remains to remind the reader here, that the cause of 
 the retention may be inflammation, spasm, or mechanical 
 obstruction at the neck of the bladder, or in the urethra ; or a 
 combination of these causes. Retention of urine, also, is an 
 attendant or consequence of hysteria, of paralysis, or other 
 affections of the bladder, such as a preternatural thickening of 
 its coats, (fee. ; in short, there is hardly any affection liable to 
 be produced by such a variety of circumstances ; or that re- 
 quires more careful attention and study on the part of the 
 surgeon ; within whose province the treatment of this affection 
 usually depends. 
 
 Retention of urine when complete and permitted to continue 
 for some time, almost always ends fatally ; either by acting on 
 the kidneys and producing suppression of urine, and other 
 formidable consequences ; or by terminating in rupture, gan- 
 grene, (fee, of the bladder. Even when permitted to exist in 
 a slight degree for any length of time, it is very apt to ter- 
 minate in partial paralysis of the bladder, or other distressing 
 affections ; not only of that organ, but of the kidneys and sys- 
 tem in general. 
 
 As retention of urine depends on such a variety of causes, 
 many of them belonging exclusively to the surgeon, of course 
 the treatment must be various. Generally speaking, when 
 inflammatory symptoms are present, the usual well-known 
 means for removing such symptoms must be speedily had re- 
 course to. If the retention depends on a cause of a spasmodic 
 character, in conjunction with warm fomentations, (fee, seda- 
 tives, and particularly a full dose of opium, either internally 
 or by way of clyster, will be useful. In spasm of the neck of 
 the bladder, in particular, the tinct. ferri muriatis may be 
 repeatedly administered, till the desired effect is produced. 
 
446 
 
 INCONTINENCE OF URINE. 
 
 The plan of treatment to be adopted in hysteric retention of 
 urine has been already described.^ 
 
 When the above means fail, and when the retention depends 
 on a mechanical cause that cannot be removed, and the cathe- 
 ter cannot be introduced so as to draw off the urine, recourse 
 must be had, for immediate relief, to puncturing the bladder. 
 
 Incontinence of Urine, like suppression and retention, de- 
 pends on a variety of causes. In early life, it is often asso- 
 ciated with some tendency to urinary disease, and very fre- 
 quently with a disposition to gravel ; or sometimes, as in young 
 females, with constitutional weakness or irritability. In ad- 
 vanced life, as already stated in the preceding pages, inconti- 
 nence of urine is usually associated with disease of the neck 
 of the bladder or prostate, either of an organic or paralytic 
 character. Incontinence of urine in children takes place, for 
 the most part, in the night only, and while they are sleeping ; 
 and in some of these cases, if close inquiry be made, it will be 
 found, that the urine is passed off voluntarily, under the in- 
 fluence of a dream. In such cases, on examining the urine I 
 have generally noticed some unnatural property of that secre- 
 tion ; and most commonly a strong disposition to, or actual 
 deposite of, gravel. Hence I have been led to infer that in 
 this species of urinary incontinence, the acrid properties of the 
 urine are chiefly in fault ; and that these unnatural properties, 
 favoured perhaps by the position of the body, and probably 
 also by the morbid sensibility of the bladder, excite so vivid 
 an impression on the imagination during sleep, as actually to 
 lead to a voluntary discharge of the urine. This form of in- 
 continence of urine sometimes commences during the period 
 of dentition, and is afterwards kept up by mere habit, and parti- 
 cularly by the custom of lying on the back, which has consi- 
 derable effect in exciting the affection ; and in some individuals 
 in whom the original cause has been long removed, the incon- 
 tinence seems to occasionally recur from this circumstance. 
 
 On the other hand, we meet with cases of incontinence of 
 * See page 430. 
 
TREATMENT. 
 
 447 
 
 urine in young people, which may be considered as of an invo- 
 luntary or passive nature ; and in which the urine not only 
 flows oflP in the night, without the consciousness of the patient ; 
 but even by day the patient can scarcely control the desire, 
 and is obliged to empty the bladder more frequently than 
 natural. In some of these cases, the urine, as before, is unna- 
 tural, though in a very different way ; that is to say, the 
 secretion is copious, pale coloured, of low specific gravity, and 
 even serous — in short, there is actual diuresis. In others of 
 these instances, neither the quantity nor quality of the 
 urine appears to be in fault ; but there seems to be some pecu- 
 liar morbid condition of the urinary organs. Both these forms 
 of urinary incontinence in young people are exceedingly 
 difficult to be overcome, and sometimes remain till long after 
 puberty, and even till late in life, in spite of every remedy. 
 These forms of the affection, as well indeed as the form first 
 mentioned, sometimes run in families ; and I have known 
 almost all the children, and particularly the females, of a large 
 family, more or less subject to incontinence of urine. 
 
 Incontinence of urine in aged individuals is generally of a 
 very different character from the preceding form of the affec- 
 tion ; and may depend on a variety of causes, enumerated in 
 the preceding chapters ; such as chronic enlargement of the 
 prostate, kc. ; general paralysis ; partial paralysis, produced by 
 injuries of the spine, or over-distension of the bladder ; or by 
 some injury of the neck of the bladder or urethra, caused by 
 the passage of a calculus, &:c. 
 
 The treatment of incontinence of urine of course must vary 
 according to its cause and nature. In those children, in whom 
 incontinence is associated with gravel, it is of the utmost im- 
 portance that this point should be attended to, and the appro- 
 priate treatment employed in the first place ; for unless the 
 tendency to gravel be corrected, it is in vain to expect relief 
 from other remedies. For this purpose, great attention should 
 be paid to diet ; that is, sours and sweets, in the form of pastry 
 
448 
 
 INCONTINENCE OF URINE. 
 
 and other indigestible articles, should be prohibited ; and the 
 softest water only should be employed on all occasions. In 
 addition to these means, some contrivance should be adopted 
 to prevent the little patient from lying on his back ; and if 
 the affection appears to depend on habit, this habit should be 
 broken, if possible, by rousing the patient, and making him 
 empty the bladder, before the usual period arrives at which he 
 has been accustomed to wet the bed. When the tendency to 
 gravel has been removed, and the habit of incontinence broken, 
 the cure may be sometimes completed and rendered permanent, 
 by the employment of gentle tonics ; and particularly by the 
 use of sea-bathing, &:c. 
 
 The treatment of the more inveterate forms of urinary in- 
 continence, accompanied by diuresis, and occurring in suscep- 
 tible strumous individuals, is very difficult, and often resists all 
 the means we can employ. Something may be gained by 
 prohibiting altogether the use of fluids in the latter part of the 
 day, and by insisting on great attention to diet, &c. ; and, 
 indeed, without attention to these points, the other means 
 within our power are of little avail. In addition to these means, 
 a blister may be applied over the sacrum ; while the different 
 preparations of iron, and particularly the muriated tincture of 
 iron, may be given internally, either alone, or combined with 
 vegetable astringents or tonics; or, in some instances, with other 
 stimuli, as with the tincture of cantharides, (fee. In many 
 cases, however, the combination of gentle sedatives with the 
 tonics are preferable. The application of cold with a view to 
 its bracing effects, either in the form of local or general bath, 
 may be also useful in a few cases ; while in others, and per- 
 haps in the majority of instances, in which the skin is unusually 
 dry and torpid, the tepid sea-bath and cutaneous friction will 
 be preferable. 
 
 In these forms of incontinence of urine, depending on spinal 
 affections, we may resort to some of the above expedients ; 
 but the real amount of benefit we can ensure to the unfor- 
 
TREATMENT. 
 
 449 
 
 tunate patient, is in general very limited. The remedies 
 that offer the best chance of success are those of the counter- 
 stimulant class, such as repeated blistering, setons, issues, even 
 the actual cautery, according to some writers. With these 
 may be conjoined the application of electricity, galvanism, &;c. 
 When the incontinence depends on paralysis or insensibility, 
 or even on morbid irritability of the neck of the bladder and 
 urethra, particularly in females, much benefit is sometimes 
 derived from local applications, calculated to excite the natural 
 sensibility of the part on the one hand, or to destroy its mor- 
 bid susceptibility on the other ; such are the nitrate of silver, 
 and other well-known applications. 
 
 Incontinence of urine in the aged, depending on diseases 
 of the neck of the bladder, enlarged prostate, and their con- 
 sequences retention of urine, &c., is, for the most part, in- 
 curable. Something may be done towards mitigating the 
 sufferings of the patient, in a few instances, by limiting, as 
 much as possible, the quantity of fluids taken ; and by fre- 
 quently emptying the bladder by the catheter ; particularly 
 before retiring to rest. In addition to which expedients, such 
 of the, means, internal or external, above mentioned, as appear 
 suited to the particular case of the individual, may at the same 
 time be resorted to. 
 
 Lastly, when the incontinence resists all the means we can 
 employ, it becomes necessary to provide against the incon- 
 venience, by the adoption of some mechanical expedient, either 
 for preventing the flow of urine, or for receiving it as it flows. 
 For these purposes, a variety of means have been pro- 
 posed ; but none of them answer so completely as could be 
 desired. The jugum penis has been much recommended by 
 foreign writers ; but its use is open to very strong objections. 
 The best expedient founded on the principle of pressure is 
 an instrument so constructed as to act by means of 
 a spring on the urethra in the perinseum. Receptacles for 
 receiving the urine as it flows away, may be procured at the 
 instrument makers ; and some of them occasionally answer 
 
 O G 
 
450 
 
 INCONTINENCE OF URINE. 
 
 tolerably well for males.^ In females the difficulties are much 
 greater ; and perhaps a succession of clean sponges, enclosed 
 in an appropriate oilskin case, is as good an expedient as any 
 that can be adopted. To prevent the bed from becoming wet 
 also, the patient should sleep on a piece of waterproof cloth, 
 or leather covered with calico or thin flannel. 
 
 * The great objection to all receptacles for the urine is the very offen- 
 sive smell they soon acquire by use. Hence some prefer a common blad- 
 der, or one of the skins used for sausages, which, as being things of little 
 value, may not only be renewed daily, but sometimes answer much better 
 than more costly expedients. The bladder or skin may be enclosed in a 
 calico bag, furnished with strings, &c., for fixing it ; and to prevent the 
 regurgitation of the urine, the neck of the bladder or skin may be in- 
 verted inwards for two or three inches, so as to form a sort of valve. 
 
451 
 
 CHAPTEE VII. 
 
 OBSERVATIONS ON THE REMOVAL OF CALCULI FROM THE BLAD- 
 DER ; COMPRISING REMARKS ON THE EFFECTS OF SOLVENTS 
 FOR THE STONE, AND ON THE OPERATIONS OF LITHOTOMY 
 AND LITHOTRITY; with a REVIEW OF THE CIRCUMSTANCES 
 WHICH OUGHT TO DETERMINE THE CHOICE OF ONE OF THESE 
 MEANS IN PREFERENCE TO THE OTHER ; OR WHICH RENDER 
 ALL OF THEM DANGEROUS. 
 
 The cure of calculous diseases, is a problem that lias occupied 
 the attention of medical men from tlie infancy of the art. The 
 removal of the calculus from the bladder by a surgical opera- 
 tion was early, and still continues to be practised ; and this 
 formidable alternative of cutting, not only first led to the 
 attempts to get rid of the concretion by some more gentle and 
 safe expedient ; but still urges on both doctor and patient to 
 the attainment of the same desirable object. I am sorry, 
 however, to be obliged to confess at the outset, that in 
 spite of all the boasted light of modern science, the pro- 
 blem remains unsolved ; and that we cannot by any known 
 medicinal means, (or at least by any known method of directing 
 these means,) get rid of a large calculus in the bladder, by 
 other than by mechanical expedients. When I make this 
 avowal, I must request not to be misunderstood. I do not 
 mean to assert, that the removal of calculi from the bladder 
 without surgical operation is impossible ; neither do I mean to 
 
 G G 2 
 
452 
 
 SOLVENTS FOR THE STONE. 
 
 assert that nothing has been done towards accomplishing so 
 desirable an object. On the contrary, I not only believe, or 
 rather hope, that the object will be attained ; but willingly 
 admit, that considerable progress has been already made 
 in certain favourable instances, towards the attainment of 
 such object. Within the last few years, however, and sub- 
 sequently to the publication of the second edition of this 
 volume, the operation of Lithotrity, or of crushing the stone 
 in the bladder, has been introduced ; and this important im- 
 provement has so changed the relations between the medical 
 and surgical methods, that they almost cease to be contrasted, 
 and consequently have lost a good deal of their interest. We 
 shall take a short review of the above subjects under the fol- 
 lowing heads : First, with reference to the removal of concre- 
 tions from the bladder, by natural or medicinal expedients : 
 Secondly, with reference to the removal of concretions from 
 the bladder by surgical expedients ; and to the circumstances 
 which should determine our choice between lithotomy and litho- 
 trity : and Thirdly, with reference to the question — what are 
 the conditions of the kidney, Sec, which in the present state of 
 our knowledge and experience, should deter us from attempt- 
 ing the removal of the stone by any expedients? 
 
 1. Of natural arid medicinal expedients for removing concre- 
 tions from the bladder. — We have seen that healthy urine 
 is so constituted, as never to be in a state of complete 
 saturation even when cold. At the temperature of the human 
 body, therefore, its point of saturation may be supposed to be 
 still further raised ; and we may consequently infer, that a per- 
 fectly healthy condition of the urine is not only one of the most 
 natural, but probably, also, one of the most powerful solvents 
 for all the ingredients likely to exist in urinary calculi, that we 
 can hope to possess. So satisfied am I of the general truth of 
 this remark, that my belief is, that there is scarcely any form 
 of stone, that would long bear the continued action of healthy 
 urine, without becoming more or less dissolved or disinte- 
 grated. This view is founded on the sj^ontaneous changes 
 
SOLVENTS FOR THE STONE. 
 
 453 
 
 which calculi sometimes undergo in the bladder itself; and on 
 the length of time calculi occasionally remain in that organ, 
 during which they not only do not become larger, but in some 
 instances, there is reason to believe, actually become less. A 
 few striking examples are sufficient to illustrate my meaning ; 
 but were I to detail all the minor examples of similar occurrence 
 that have fallen under my notice, they would occupy a large 
 space. 
 
 Some years ago I was requested to see an old gentleman 
 labouring under all the symptoms of a lithic acid calculus in 
 the bladder, from which he suffered considerable inconvenience ; 
 but not so much as to materially injure his health, or to affect 
 the properties of the urine. He was very obstinate, and would 
 neither be sounded, nor persevere in the medicines recom- 
 mended to him. He went on for a year or two, suffering 
 occasional pain and irritation, but without having recourse to 
 medicines of any kind ; at least medicines directed to the blad- 
 der affection. At this time, he began to pass away from the 
 bladder, with more or less of irritation, fragments of lithic 
 acid, which had evidently formed portions of different calculi ; 
 some of them of considerable size. He continued to pass these 
 fragments occasionally for a year or two ; at the end of which 
 time he had passed as many as filled a small box ; which had 
 all the appearance of fragments voided by individuals who have 
 undergone the operation of lithotrity. He is still alive, and 
 upwards of ninety years of age ; but as he resides in the coun- 
 try, I am unable to state whether he labours under the symp- 
 toms of other concretions in the bladder ; or whether he still 
 continues to pass the fragments above mentioned. The ques- 
 tion here is, what caused the disintegration of these calculi ? I 
 confess I am unable to answer this question, except on the 
 principle above mentioned. The effect could not be ascribed 
 to medicine, for none was taken ; neither could it have de- 
 pended on mechanical means, for no instrument had been 
 introduced into the bladder. The properties of the urine 
 alone, therefore, remain, to which we can refer the pheno- 
 
454 
 
 SOLVENTS FOR THE STONE. 
 
 inenon ; but of these I can give little account, further than 
 that, on inquiry, the urine was stated to scarcely differ to the eye 
 from the normal condition. There was occasionally a little 
 blood and some mucus in the urine, but never enough to war- 
 rant the conclusion, that the urine had become alkaline, or the 
 bladder diseased ; in which case it is probable he would not 
 now have been alive and in good health. It is remarkable, 
 that the edges of some of the fragments voided, were sharp and 
 angular, as if the fracture had been recent ; while the edges of 
 others were blunt and rounded, as if they had been some time 
 in the bladder, and subjected to a solvent process. I have 
 seen many cases analogous to, or similar to the above, but in 
 some of them, alkaline medicines had been given, which ob- 
 tained the credit of the cure. In another case of a patient far 
 advanced in life, who, as he had not been suspected of having 
 stone, had not taken alkalies, I once saw a great many 
 fragments of a large calculus passed from the bladder. These 
 fragments, moreover, did not consist of lithic acid ; but of an 
 unusual compound, of which the oxalate of lime formed a 
 principal ingredient. This gentleman did not afterwards, ap- 
 parently, suffer more from bladder irritation, than many indi- 
 viduals of his age who have no stone in that organ ; and he at 
 length died from another disease. He was never sounded, 
 and I am unable to state whether a concretion remained in 
 the bladder or not. 
 
 I ha,ve already mentioned that calculi often remain in the 
 kidney and bladder for very long periods, without apparently 
 increasing in size or giving much uneasiness. I have many 
 times had opportunities of watching such cases, and have found 
 the urine at times, either from temporary derangements of the 
 health, or from other causes, become alkaline, and deposit the 
 phosphates for a few days. By a little rest and attention, 
 however, all this has disappeared, and the urine has resumed 
 its former acid conditions. On such occasions, we can scarcely 
 doubt that a slight deposition of the phosphates sometimes 
 takes place on the calculus in the bladder ; and that when 
 
SOLVENTS FOR THE STONE. 
 
 455 
 
 the urine again becomes acid, such phosphatic deposite is 
 redissolved. Of course these inferences cannot be grounded on 
 ocular proof; yet by close attention we may occasionally ob- 
 tain such evidence, as to leave little doubt of their correct- 
 ness. Thus, long after the urine has recovered its acidity 
 and ceased to deposite the phosphates, there may be not 
 unfrequently seen in such cases, large grains (and sometimes 
 scales or thin laminae) of the mixed phosphates, which present 
 every appearance of having been detached from the lithic acid 
 nucleus. Those thin layers of the phosphates, also, which we 
 often see interposed between the different laminae of lithic acid 
 in large concretions, show that during the formation of the 
 calculus, such temporary changes as those above mentioned 
 have at different periods taken place ; while the partial ab- 
 straction and peculiar appearance of these laminae unequivo- 
 cally prove that they have, in some instances, undergone mate- 
 rial changes since their original deposition.^ 
 
 For the following remarkable instance of the effects of a 
 perfect state of health, and of a natural condition of the urine, 
 both in preventing the enlargement of a calculus, as well as 
 of obviating its painful effects, I am indebted to Mr. Richard 
 Smith, of Bristol : 
 
 " In 1804, I sounded a man in the (Bristol) Infirmary, and 
 would have cut him then ; but he was frightened and left the 
 house. He became a common sailor — fought in several 
 actions on board a man-of-war, and was discharged at the 
 peace, never having been inconvenienced in the slightest manner. 
 In 1831 he came to us again, told me who he was, and his 
 history ; and as the calculus was now troublesome, was cut and 
 did well."t During the above long period of twenty-seven 
 
 * Many of the thin white films between the laminae of lithic acid cal- 
 culi do not depend on the phosphates ; but consist, in some instances^ of 
 a little lithate of soda, or, in others, of bleached and water-worn lithic 
 acid. 
 
 t Extract from a letter, dated March 31st, 1838. Mr. Copland Hutchi- 
 
456 
 
 SOLVENTS FOR THE STONE. 
 
 years, we can hardly suppose that the stone remained sta- 
 tionary ; and as it was constantly placed in a fluid capable of 
 acting as a solvent, and could, therefore, scarcely have increased 
 in size, the supposition is not unreasonable, that on the whole it 
 actually became less. Yet as the entire stone was not removed, 
 when the general health became deranged and the urine un- 
 natural, the portion left was sufficient to operate as a nucleus, 
 around which deposites subsequently took place. 
 
 As stated at the commencement^ I could readily multiply 
 proofs and arguments in favour of the opinion I have ad- 
 vanced, viz. that the urine itself, when in a perfectly natural 
 condition, is one of the most universal as well as powerful 
 solvents we possess, for its own diseased deposites. This, 
 however, I do not think necessary ; for even those who doubt 
 or deny this opinion, will scarcely call in question the prac- 
 tical inference to which it leads, viz. that in all cases of 
 urinary concretion, one of the first points to be attended to, 
 is to restore the healthy condition of the urine, by improving, 
 as far as we are able, the general health, and the local con- 
 dition of the urinary organs. 
 
 Medicinal solvents for the stone have been employed in two 
 ways, viz. by the mouth, and by injection into the bladder; 
 but before we take a short review of the employment of sol- 
 vents in these two modes, it may not be amiss to make a few 
 remarks on the subject of solvents in general. 
 
 The two great classes of solvents for the stone may be 
 divided into the alkaline and the acid. Now the composition 
 
 son would probably have considered this case favourable to the fact he 
 attempted to establish, that a seafaring life was unfavourable to calculous 
 affections. Without admitting or denying this fact, we can understand 
 how. during a long state of activity and health, the urine remained in a 
 natural condition^ and therefore unfavourable to the calculus accretion j 
 and how during a state of inactivity, and probably, therefore, of deranged 
 health, the urine again became deranged, and the calculus, in conse- 
 quence, troublesome. 
 
SOLVENTS FOR THE STONE. 
 
 457 
 
 of the urine and of urinary calculi is such, that some of the 
 ingredients of which they consist are soluble in alkalies, and 
 some in acids. Moreover, except in positive diseases of the 
 kidney, the urine is never devoid of both these classes of prin- 
 ciples. When, therefore, we introduce an alkali or an acid 
 into the bladder in excess, with the view of acting as a 
 solvent, we not only infringe the important maxim above in- 
 culcated, and render the urine unnatural ; but as a necessary 
 consequence, we run the risk, while we dissolve one ingredient, 
 of precipitating another. Hence, alkalies and acids, even if we 
 could introduce them into the bladder in their free state, would 
 be at least doubtful remedies ; and in the majority of cases per- 
 haps would be positively mischievous.^ Fortunately, however, 
 alkalies and acids cannot be introduced into the bladder 
 through the system, without undergoing material changes ; 
 for the vital powers, when they retain anything like their 
 natural energies, exert themselves either to neutralise or to 
 destroy their effects. 
 
 When, therefore, we consider that in healthy urine there 
 is no free and uncombined alkaline, or acid ingredient ; 
 when also experience teaches us that vital agency, without ex- 
 treme violation of its laws, will not permit the introduc- 
 tion of any free or positive agent into the bladder ; how can 
 we arrive at any other conclusion, than that uncombined 
 agents of the alkaline or acid kind are ill calculated to act 
 as solvents for calculi ; and that solvents are to be sought for 
 among a class of harmless and unirritating compounds, the 
 elements of which are so associated as to act at the same time 
 
 * The use of caustic alkalies not only impairs the digestive functions 
 much more than the use of the carbonated alkalies, but while they are 
 less efficient as solvents, they have much more tendency to precipitate 
 the phosphates ; and in some habits, if not in all, they certainly give oc- 
 casion to the formation of oxalic acid. For these and for the other 
 reasons mentioned in the text, I have long abstained, (except under pe- 
 culiar circumstances^) from the use of the caustic alkalies in calculous 
 affections. 
 
458 
 
 SOLVENTS FOR THE STONE. 
 
 with respect to calculous ingredients, both as alkalies and 
 acids ? At present, no such class of compounds of a decided 
 character are known, or appear likely to be discovered ; yet, 
 as no chemical fact can be stated a priori, we know not what 
 remains in store among the arcana of nature. 
 
 The nearest approach to a solvent possessing the properties 
 above mentioned that we are perhaps acquainted with, are those 
 forms of the alkaline carbonates, in which the carbonic acid is in 
 great excess — in short, such compounds as exist in a great many 
 natural mineral waters, and particularly in those of Vichy. 
 In some of these waters, the other saline compounds may con- 
 tribute to the effect in a way at present unknown ; but in the 
 greater number, their solvent and disintegrating powers seem 
 to depend, partly on the supercarbonated alkalies they contain ; 
 and partly on the quantity of fluid in which such supercar- 
 bonated alkalies are taken. Moreover, the improvements in 
 the general health arising from the change of air, diet, &:c., aided 
 by the steady perseverance for a long time in their use, all con- 
 spire to favour the effects of the waters, and to secure their ut- 
 most influence. That waters of the above description, when 
 thus perseveringly employed, are capable of acting both on 
 lithic acid as well as on phosphatic calculi, is generally ad- 
 mitted ; nor perhaps is their modus operandi very unintelligi- 
 ble ; for such waters, from the quantity in which they are 
 usually taken, and from the hurried operation of the kid- 
 neys, actually make their way to the bladder but little changed ; 
 where the alkalies they contain may be supposed to exert their 
 feeble powers by dissolving the lithic acid; and the car- 
 bonic acid, by dissolving, or at least by retaining in solution, 
 the phosphates — two objects, which, when aided by plenty 
 of water, are by no means incompatible within certain 
 limits. Nor is the operation of such highly carbo- 
 nated waters confined to their mere solvent effects ; they 
 undoubtedly possess disintegrating powers ; that is, powers of 
 disturbing the attraction, both cohesive and adhesive, by which 
 
SOLVENTS FOR THE STONE. 
 
 459 
 
 the molecules of calculi are held together, so as to render 
 them brittle and easily broken into fragments.^ 
 
 It need not be stated, that our soda and potash waters are 
 artificial compounds originally intended to represent the mineral 
 waters ; and that when duly prepared and adjusted to particular 
 cases, they are often, medicinally speaking, equally efficient ; 
 and if in reality they fail to be beneficial in the same degree, 
 the difference probably arises more from the absence of the 
 circumstances above alluded to, namely, the change of air, of 
 scene, &c., which always accompany the use of mineral waters 
 at their source, and which doubtless add very much to their 
 powers, than from any want of action in the remedies. 
 
 Artificial soda and potash waters should, as just stated, to en- 
 sure their utmost benefit, be varied and adapted to particular 
 cases. As solvents, the potash waters are preferable ; and when 
 the calculus is of the lithic acid variety, and the diathesis decided, 
 from 3SS. to ji. of the carbonated alkali, and as much of the 
 tartarized soda, may be dissolved in each bottle, which may be 
 taken twice a day with an equal quantity of warm distilled water. 
 On the other hand, when the concretions consist of the phos- 
 phates, and the urine is decidedly alkaline, the alkali may be 
 omitted altogether, and the compound may either consist of 
 distilled water impregnated with carbonic acid gas ; or occa- 
 sionally some acid, as the nitric, may be substituted for the 
 alkali. By adjusting the remedy to the particular circum- 
 stances of the case, between these two extremes ; by large 
 dilution ; by attention to diet and exercise, and by 'perseverance ; 
 it is probable that an impression may be made on the calculi 
 in the kidney and bladder in some instances ; at least as much 
 impression as is made by any known mineral water. The worst 
 of this class of remedies however is, that though in many in- 
 stances they act tuto etjucundl^ they cannot be said to possess 
 the third great requisite of acting citb. Nor are they only 
 long and tedious, but they are uncertain in their operation ; 
 
 * See the recent works of M. Petit on these subjects ; and particularly 
 on the Vichy waters. Paris, 1834 and 1837. 
 
460 
 
 SOLVENTS FOR THE STONE. 
 
 and though the concretion may be dissolved or disintegrated, 
 and large quantities be brought away, yet an accidental frag- 
 ment may be left, sufficient to form a nucleus for renewed 
 accretion ; and thus to embitter the future existence of the 
 patient. Moreover, from the length of time required for the 
 use of such solvents, they are only calculated for the idle and 
 wealthy ; and those who are actively engaged in the business 
 of life, can neither bestow the requisite time nor attention to 
 their application. There are many individuals, also, who can- 
 not persist in remedies of this class without great detriment 
 to their assimilating powers and nervous system, however 
 carefully they may be adjusted to the case and circumstances ; 
 and such individuals, when unfortunately afflicted with calcu- 
 lous affections, are obliged to resort to other expedients. For 
 these and other reasons that might be adduced, I fear that the 
 hopes of relief which can be fairly and honestly held out to 
 patients afflicted with stone, from all solvents at present 
 known, are not such, except in a very few instances, as ought 
 to induce them to delay having recourse to more efficient 
 remedies. 
 
 The above observations apply more especially to lithic acid 
 and phosphatic calculi. The oxalate of lime calculi, not only 
 from their state of aggregation, but from their chemical pro- 
 perties, are still more refractory ; nor are there at present, I 
 believe, any means known, which can be reasonably expected 
 to act as solvents or disintegrants of this variety of calculus. 
 
 The application of solvents for the stone by injecting them 
 into the bladder, is another mode recommended for the em- 
 ployment of this class of remedies ; and there are some forms 
 of the affection in which this mode of applying them may be 
 beneficial. On the whole, however, this mode of applying 
 solvents is open to still greater objections than the taking 
 them internally. They cannot be employed in an active form ; 
 and the length of time in consequence during which it becomes 
 necessary to keep the bladder, &;c., in a state of excitement by 
 the introduction of the necessary instruments, constitutes an 
 
LITHOTOMY AND LITHOTRITY, 
 
 461 
 
 almost insurmountable objection to their general use. Tbe 
 only form of disease to which they seem in any way adapted, 
 are certain conditions of the mucous membrane of the bladder, 
 accompanied by a deposition of the phosphates. In such cases, 
 I have seen the injection of a weak acid decidedly beneficial, 
 not only to the mucous membrane of the bladder, but in disin- 
 tegrating phosphatic concretions.* 
 
 2. We have now to make a few observations on the mechanical 
 methods of removing calculi from the bladder, viz. lithotomy and 
 lithotrity — operations with which, viewed as mere matters of 
 surgery, we have nothing to do. Our remarks will be con- 
 lined solely to the effects and consequences of lithotomy and 
 lithotrity considered as therapeutic means. The subject may 
 be viewed under the two following heads, viz. the compara- 
 tive safety, and the comparative practicability, of lithotomy and 
 lithotrity. 
 
 If we view the safety of an operation as bearing a certain 
 relation to its severity, which generally speaking, perhaps, we 
 are justified in doing, there can be little hesitation in deciding 
 generally, that the safety lies on the side of lithotrity. In 
 lithotrity there is not, or ought not to be, any breach even of 
 surface ; while lithotomy not only necessarily requires an ex- 
 tensive breach of surface, but of substance ; and, in short, 
 however dexterously performed, may be considered, from the 
 very nature of the organs concerned, as one of the most 
 formidable operations of surgery. Such is the general result 
 of the comparison, everything being considered as equal and 
 favourable ; but such a consideration is rather hypothetical 
 than real ; and we have to view matters as they are, rather 
 than as they ought to be. 
 
 The best test of the safety of an operation is derived from sta- 
 tistical details. On the side of lithotomy this point has been ex- 
 tensively investigated, and the general result is, that of the whole 
 number of individuals lithotomised, one in seven or eight dies. 
 
 * See Sir B. Brodie's Lectures on Diseases of the Urinary Organs^ page 
 257 et seq., second edition. 
 
462 
 
 LITHOTOMY AND LITHOTRITY. 
 
 On the side of lithotrity, from its recent origin, and its pro- 
 gressive, and perhaps still imperfect, character, we have no data 
 fairly comparable with the above ; nor indeed any very satis- 
 factory data for the additional reason, that lithotomy, when 
 it proves fatal, destroys life in a few days at the utmost ; whereas 
 lithotrity, though it may become a cause of death, seldom does 
 so at once ; for a patient may linger for weeks or months, and 
 apparently die from some other disease, though the remote 
 cause of death might have been lithotrity ; of which I have 
 seen instances. I am doubtful, therefore, if everything be taken 
 into account, whether the mortality has not been as great from 
 lithotrity, as hitherto practised, as from lithotomy. 
 
 Let us now view the matter with reference to the pain and 
 suffering arising from the two operations. Lithotomy, even 
 at the best, is a most painful and severe operation ; lithotrity, 
 when dexterously performed under favourable circumstances, on 
 the contrary, gives comparatively very little pain. Here, as 
 before, the adva,ntage, generally and abstractedly speaking, is 
 all on the side of lithotrity ; but how do matters stand in 
 reality ? The pain in lithotomy is concentrated into a few 
 minutes, and afterwards, comparatively speaking, the suffering 
 is usually trifling. The pain of lithotrity, on the contrary, 
 (which may be, and often is, very severe,) is frequently distri- 
 buted by repetition over weeks and even months ; so that the 
 amount of suffering from lithotrity may be even greater than 
 from lithotomy. Again, by the operation of lithotomy, the 
 stone is at once entirely removed, and there is no chance of 
 a nucleus being left for future accretion ; on the other hand, 
 there is no absolute certainty in lithotrity that all the stone is 
 removed ; and fragments may be left, which may serve as 
 nuclei for future formations. Moreover, independently of acci- 
 dents of this kind, the operation of lithotrity seems to often 
 leave a greater tendency in the system to form future depo- 
 sites, than the operation of lithotomy. The shock produced 
 on the constitution by the formidable process of cutting ; and 
 the salutary effects induced on the health by the renovating 
 
LITHOTOMY AND LITHOTRITY. 
 
 463 
 
 processes necessarily following the operation, aided perhaps by 
 the severe discipline he otherwise undergoes, sometimes seem 
 to produce such a total change in the habit of the patient, 
 that a tendency to form gravel, &c., does not recur for a long 
 time after the operation. On the contrary, from the little 
 suffering produced by lithotritic operations in some instances, 
 and the severe derangements of the mucous membrane of the 
 bladder sometimes following in others, the disposition to form 
 lithic acid gravel on the one hand, remains much the same 
 after, as before the operation ; while the disposition to form 
 phosphatic calculi is too often increased. For these and many 
 other reasons which might be mentioned, we are obliged to 
 confess, that the balance which, at first sight, seems to be so 
 much in favour of lithotrity as compared with lithotomy, is in 
 reality, as it has been (perhaps as it still is) practised, very 
 much diminished. We may hope, however, that the ingenuity, 
 skill, and perseverance, displayed by the inventors and culti- 
 vators of the art, will still lead to its further improvement. 
 
 We have, in the next place, to consider the practicabi- 
 lity of lithotrity, as compared with lithotomy. The practi- 
 cability of the operation of lithotrity as compared with that of 
 lithotomy, other things being equal, depends on the size of the 
 stone ; on the capacity of the urethra (and therefore the age) 
 of the patient ; on the composition, in some respects, of the 
 stone ; and on the idiosyncrasy of the patient. The magnitude 
 of the stone increases the difficulty of extracting it both by 
 lithotomy and lithotrity ; but the ratio of the difficulty, and 
 consequently the practicability of removing the stone by litho- 
 trity, increases so rapidly with the size of the stone, that the 
 operation becomes impracticable long before the operation of 
 lithotomy. When the stone, therefore, is of a large size, and 
 the operation of lithotomy in consequence becomes proportion- 
 ably more difficult and dangerous, lithotrity in its present 
 state fails us altogether, and the patient has no alternative but 
 to be cut in the old way. This is undoubtedly much to be 
 lamented ; for though very large stones are by no means of 
 
464 
 
 LITHOTOMY AND LITHOTRTTY. 
 
 common occurrence, and will probably hereafter be still more 
 rare, yet they sometimes occur, and it becomes a painful task 
 to inform the patient or his friends, that there is no other 
 means of relief than that of a seyere operation, rendered un- 
 usually difficult and dangerous by the circumstances of his 
 case. Lithotrity, therefore, is only fairly comparable with 
 lithotomy, when the stone is of moderate or of small size ; and 
 in such cases, undoubtedly, the balance is yery much in fayour 
 of lithotrity. A small or moderately sized calculus can now, 
 in the great majority of instances, be crushed and remoyed, 
 without much pain or risk to the patient ; and without much 
 chance of fragments being left in the bladder. Or should 
 fragments be left, and future calculi be formed, they in .their 
 turn can be remoyed with equal facility. In short, from the 
 present time, yery few if any need suffer from a large stone in 
 the bladder, proyided they apply for adyice as soon as the 
 symptoms are perceiyed ; to which early application, the faci- 
 lity, safety, and certainty, from the operation of lithotrity, as 
 compared with the same operation when the stone is larger, 
 or with the operation of lithotomy, hold out eyery induce- 
 ment. 
 
 Other circumstances, particularly affecting the operation 
 of lithotrity, are mechanical impediments about the neck of 
 the bladder or urethra, as enlarged prostate, stricture, &c., 
 which render the introduction of the necessary instruments 
 impracticable. Similar remarks apply to early age, when 
 the narrowness of the urethra, and the natural irrita- 
 bility of the constitution at this time of life, offer great 
 impediments to lithotrity. In some of these cases, on the 
 other hand, lithotomy is practicable with less hazard than 
 ordinary ; as, for instance, in young children, in whom, as 
 it appears from statistical inyestigations, the risk is, coBteris 
 paribus, decidedly less than in adults. Eyen simple enlarge- 
 ment of the prostate, according to Sir B. Brodie, is not 
 to be regarded as adding to the danger of the operation of 
 lithotomy, though it may add to its difficulty. Hence, as he 
 
LITHOTOMY AND LITHOTRITY. 
 
 465 
 
 observes, old men between seventy and eighty, sometimes 
 stand a better chance than those who are ten or twenty years 
 younger.^ 
 
 Other things being equal, the quality of the stone may, com- 
 paratively speaking, have a certain influence as regards litho- 
 tomy and lithotrity. Calculi of the oxalate of lime, and even 
 sometimes of the lithic acid species, are occasionally so hard 
 that they are crushed with great difficulty, and not without 
 risk of bending or breaking the instruments ; and when 
 such calculi are broken, the sharp and angular fragments are 
 apt to cause great irritation in the bladder ; whereas, hardness 
 of the stone, instead of being a disadvantage, is rather an ad- 
 vantage in lithotomy ; the great object in lithotomy being, in 
 all instances, to remove the stone at once and entire. For 
 similar reasons a soft stone is favourable in lithotrity, but un- 
 favourable in lithotomy ; for in withdrawing the stone from 
 the bladder, it is almost sure to be broken — an accident that 
 not only complicates the operation, but may, by leaving a 
 fragment in the bladder, give occasion to the formation of 
 another calculus. On the other hand, there are circumstances 
 connected with the hardness and softness of calculi which 
 sometimes modify the above observations. Hard stones, like 
 those of the mulberry and lithic acid varieties above mentioned, 
 are usually connected with a sound and quiescent state of the 
 bladder; whereas soft stones, which usually consist of the 
 phosphates, are often connected with an irritable or diseased 
 condition of the mucous membrane of that organ. 
 
 A sound state of the bladder is favourable for both species 
 of operation. An unsound and irritable state of the bladder, 
 like an enlarged prostate, though it may sometimes render 
 lithotrity very difficult or impossible, does not always prevent 
 lithotomy. Idiosyncrasy often materially influences the prac- 
 ticability or success of an operation. There are some indi- 
 
 * Lectures on Diseases of the Urinary Organs, page 302. Second 
 edition. 
 
 H H 
 
466 
 
 LITHOTOMY AND LITHOTRITY. 
 
 viduals in whom the urethra and bladder are comparatively 
 so insensible, and who feel so little inconvenience, not only 
 from the immediate, but from the constitutional effects of 
 instruments, that they can almost tolerate anything ; whereas, 
 we meet with others, who suffer the greatest irritation, both 
 local and constitutional, from the mere introduction of instru- 
 ments, and in whom consequently, even the attempt at lithotrity 
 is almost impossible ; such individuals, therefore, if relieved at 
 all, can be only relieved by lithotomy. These differences may 
 in some degree depend on the degree of moral courage of the 
 patient ; but I have seen instances in which they could not be 
 referred to this cause. 
 
 3. Finally, we have to make a few observations on the cir- 
 cumstances which forhid altogether the attempt at removing cal- 
 culi from the bladder; at least by mechanical expedients. 
 Whenever the kidneys are decidedly diseased, all operations, 
 but particularly operations about the urinary organs, are dan- 
 gerous, on account of the facility with which inflammatory ac- 
 tion is apt to be induced on the diseased structure, and to prove 
 fatal. The different forms of diseased kidney, however, are, 
 cceteris paribus, attended with different degrees of risk. Thus 
 most of the affections of the kidney connected with ansemo- 
 trophy, and occurring in early age, so enfeeble the vital ener- 
 gies, and particularly the vital powers of renovation and re- 
 sistance to disease — in short, so impair the tenure of life, that 
 the slightest shock, whether from epidemic disease, or from a 
 surgical operation, is almost sure to destroy life. Whenever, 
 therefore, disease of the kidney of this kind is distinctly ascer- 
 tained to be present, all operations, and particularly the opera- 
 tions of lithotomy and lithotrity, are quite out of the question; 
 as they will very probably only abridge the existence of the 
 patient, without giving him a chance of recovery. On the 
 other hand, affections of the kidney of the haemotrophic kind, 
 though with due preparation, they may bear surgical opera- 
 tions much better ; are not always free from risk. Indeed 
 
LITHOTOMY AND LITHOTRITY. 
 
 467 
 
 without preparation, the risk is fully as great as in affections of 
 the anaemotrophic character ; for the inflammatory action liable 
 to be superinduced in the kidney is sometimes so acute, and so 
 rapidly assumes the adynamic form, that it becomes perfectly 
 unmanageable. In all cases of serous urine, therefore, in mid- 
 dle-aged plethoric individuals, particularly if the urine be of 
 high specific gravity and deposites the lithate of ammonia, 
 before any operation be attempted, the system should be pre- 
 pared by cupping and active aperients ; by which expedients, 
 the danger from the operation, in a great many instances, is 
 very much diminished. 
 
 Nearly the same observations apply to organic diseases of the 
 bladder, the existence of which are unfavourable for the opera- 
 tions of lithotrity, as well as of lithotomy. Indeed, chronic 
 inflammation of the mucous membrane of the bladder is, as 
 before observed, more unfavourable for lithotrity than for 
 lithotomy ; for sometimes when the stone is removed by litho- 
 tomy, the state of the bladder becomes improved to an extent 
 that would scarcely be expected ; whereas the inflammatory 
 excitement is sure to be increased by lithotrity, and its conse- 
 quences. 
 
 In the preceding observations, I have endeavoured to take 
 a brief but impartial review of the operations of lithotrity and 
 of lithotomy, and of the cases to which they are respectively 
 applicable or inapplicable; and it only remains, in conclu- 
 sion, to reiterate the important truth, that the operation of 
 lithotrity has now so much reduced the risk, the pain, and the 
 consequences of the presence of a small stone in the bladder in 
 a healthy individual, that very few cases occur in which we 
 are justified, under such circumstances, in recommending or 
 allowing the stone to remain in that organ ; and consequently 
 that every one with symptoms of calculus ought to apply as 
 early as possible for advice, and, if deemed practicable sto submit 
 at once to the operation, and get it removed. 
 
 H H 2 
 
APPENDIX. 
 
 CONTAINING TABLES, ILLUSTRATING THE NUMBER OF FATAL 
 CASES FROM DIABETES AND CALCULUS, IN DIFFERENT DISTRICTS OF 
 
 ENGLAND AND WALES; 
 
 THE COMPARATIVE PREVALENCE, 
 AND LAWS OF FORMATION AND ALTERNATION OF 
 DIFFERENT CALCULOUS DEPOSITES ; 
 THE COMPARATIVE PREVALENCE OF CALCULOUS AFFECTIONS AT 
 DIFFERENT AGES, AND IN THE DIFFERENT SEXES; 
 
 AND THE 
 
 RATE OF MORTALITY FROM THE OPERATION OF LITHOTOMY. 
 
TABLE I. 
 
 Fatal cases of Diabetes and of Calculus, occurring in England and Wales, from the 1st 
 July to the 31st December, 1837, both inclusive. — From the first Annual Report of the 
 Registrar General of Births, Death, and Marriages, in England, page 120, et seq. 
 
 District. 
 
 Metropolis ; including parts of the 
 counties of Middlesex, Surrey, and 
 Kent 
 
 Manchester and Salford. Part of 
 the county of Lancaster 
 
 Liverpool and West Derby. Part of 
 the county of Lancaster 
 
 Leeds. Part of the county of York,. , 
 
 Birmingham. Part of the county of 
 Warwick 
 
 Middlesex, (part of,) Hertfordshire, 
 Buckinghamshire, and Bedfordshire. 
 
 Kentjj^Surrey, (part of,) Sussex, Hamp- 
 shire, and Berkshire , . . 
 
 8. Dorsetshire and Wiltshire, 
 
 9. Devonshire 
 
 Essex, 
 
 10. Cornwall 
 
 11. Somersetshire 
 12. 
 
 13. Norfolk and Suffolk 
 
 14. Cambridgeshire, Huntingdonshire, and 
 
 southern parts of Lincolnshire 
 
 15. Lincolnshire, (northern parts of,) Rut- 
 
 landshire, Derbyshire, Nottingham- 
 shire, Leicestershire, and Northamp- 
 tonshire.. . , 
 
 Oxfordshire, Gloucestershire, Worces- 
 tershire, (except Dudley,) and War- 
 wickshire, (except Birmingham) 
 
 Mining parts of Staffordshire, Shrop- 
 shire, and Worcestershire 
 
 Cheshire, Shropshire, and Stafford- 
 shire, (except Mining Disticts)., .. 
 Lancashire,(except Liverpool and Man- 
 chester,) south of Morecombe Bay . . 
 West Riding of Yorkshire, (except the 
 northern part thereof, and Leeds),, 
 City and Ainsty of the City, and the 
 East Riding of the county of York. 
 Durham, and North Riding of York- 
 shire, with such parts of the West 
 Riding as are not included in district 
 
 20, (except the mining part) 
 
 The mining parts of Nortumberland 
 
 and Durham 
 
 Cumberland and Westmoreland, and 
 such parts of the counties of Lancas- 
 ter and Northumberland as are not 
 included respectively in districts 19 
 
 and 23 
 
 Wales, Monmouthshire, and Hereford- 
 shire 
 
 16. 
 
 17. 
 18. 
 19. 
 20. 
 21. 
 
 25. 
 
 Totals in England and Wales* . 
 
 Population 
 in 1831. 
 
 1,594,890 
 
 236,935 
 218,233 
 135,581 
 110,914 
 515,893 
 1,351,236 
 373,797 
 503,118 
 304,785 
 415,252 
 304,315 
 682,788 
 
 311,714 
 1,045,133 
 
 977,108 
 
 223,457 
 721,555 
 905,501 
 773,254 
 199,515 
 
 319,042 
 
 318,941 
 
 338,273 
 
 1,016,219 
 
 13,897,187 
 
 Disease. 
 
 f Diabetes. 
 "I Calculus. 
 
 ^ Diabetes. 
 I Calculus. 
 K Diabetes. 
 1^ Calculus. 
 ^ Diabetes. 
 I Calculus. 
 i Diabetes. 
 I Calculus, 
 f Diabetes. 
 ( ('alculus. 
 i Diabetes. 
 I Calculus. 
 ^ Diabetes. 
 I Calculus. 
 I Diabetes. 
 "I Calculus. 
 ^ Diabetes. 
 I Calculus. 
 
 Diabetes. 
 
 Calculus. 
 S Diabetes. 
 I Calculus. 
 S Diabetes. 
 ^ Calculus. 
 
 i Diabetes. 
 I Calculus. 
 
 S Diabetes. 
 \ Calculus. 
 
 f Diabetes. 
 ( Calculus. 
 
 i Diabetes. 
 ( Calculus. 
 S Diabetes. 
 
 Calculus, 
 f Diabetes. 
 ( Calculus. 
 S Diabetes. 
 I Calculus. 
 ^ Diabetes. 
 1^ Calculus. 
 
 J Diabetes. 
 \ Calculus. 
 
 J Diabetes. 
 \ Calculus. 
 
 ^ Diabetes. 
 ^ Calculus. 
 
 i Diabetes 
 I Calculus 
 
 5 Diabetes. 68 
 ( Calculus. 161 
 
 Male. male. Total 
 
 * There is a discrepancy hetween the general account and the details for which I 
 am unable to account. Instead of 13,897,1 87, the details give the whole population 
 13,897,449. This trilling error does not affect the results. 
 
472 
 
 APPENDIX. 
 
 Observations on Table I. 
 
 Diabetes and calculus have been selected, from their well-defined 
 characters. The table probably presents a near estimate of the num- 
 ber of diabetic cases, on account of its generally fatal termination ; but 
 by no means a near estimate of the number of calculous cases, since 
 the large majority of such cases recover. This explains the apparent 
 anomaly presented by the table, as regards Norfolk, and other districts 
 where calculous affections are notoriously abundant. Many important 
 facts, however, may be deduced from the tables, respecting the pre- 
 valence of the two diseases, even imperfect as the data are. Thus 
 there are seven or eight times more cases of diabetes occurring in 
 Cheshire and Lancashire, (supposing the population to be equal,) than 
 in the metropolis. The table also clearly shows the greater preva- 
 lence of stone cases (and probably of other urinary affections) in large 
 towns, than in the rural districts, as noticed by Dr. Yellowly. Accord- 
 ing to the table, diabetes is about 2| times, and stone 8 J times, more 
 frequent in males than in females. 
 
 The period comprised by the annexed table is too limited to enable 
 us to draw any other than the most general conclusions ; a defect 
 which, no doubt, future reports will remove. Perhaps, however, the 
 following remarks of the Registrar are not very wide of the truth. 
 
 Diseases of the urinary organs destroy five times as many males as 
 females — the rate of mortality under this head having been '199 and 
 •037 per 1,000. This disparity has been ascribed to mechanical 
 causes ; but will a mechanical explanation account for the fact, that 
 sixty-eight males, and only twenty-eight females, died of diabetes ? 
 Dr. Yellowly, in a paper pubhshed in the Philos. Trans. 1829, esti- 
 mated that one in one hundred and eight thousand persons was cut 
 annually for stone in England and Wales. It appears from the table, 
 that forty-seven in one million males, and five in one million females, 
 die of stone and gravel. The latter, it must be admitted, is a vague 
 term in popular language ; but the mortality from stone is certainly 
 one in one hundred thousand annually." — Report, page 105. 
 
APPENDIX. 
 
 473 
 
 TABLE II. 
 
 Exhibiting a general view of the relative prevalence of the different forms of urinary calculi in 
 England, (namely, in two of the principal hospitals, Bartholomew's and Guy's, in London, and 
 in tlje hospitals of Norwich, Manchester, and Bristol ;) and in Swabia, Germany ;* and in 
 Copenhagen, Denmark. 
 
 General character 
 of calculi. 
 
 1. Lithic acid. 
 Lithate of 
 ammonia. 
 
 2. Oxalate of lime. 
 
 3. Cystic oxide. 
 
 4. Phosphates. 
 
 Carbonate of lime. 
 Silex. 
 
 5. a. Alternating 
 calculi com- 
 posed of two 
 layers. 
 
 Particular species of calculi. 
 
 Lithic acid, nearly pure 
 
 Lithate of ammonia, nearly pure 
 
 Lithate of ammonia, mixed with vari- 
 able proportions of the lithate and 
 oxalate of lime, and phosphates.. . . 
 
 Oxalate of lime, nearly pure 
 
 Cystic oxide, nearly pure 
 
 Phosphate of lime, nearly pure 
 
 Triple phosphate, nearly pure. ..... 
 
 Mixed phosphates 
 
 t(Phosphate of lime, with carbonate of 
 
 lime) 
 
 -mixed with a little lithic acid. 
 
 deposited on foreign bodies , . 
 
 (Carbonate of lime and silex) 
 
 Siliceous 
 
 Lithic acid, and lithate of ammonia. . . 
 
 — and oxalate of lime 
 
 and phosphate of lime. . . 
 
 and mixed phosphates. .. 
 
 C Lithic acid, lithate of ammonia,) 
 and (lithate of magnesia and mixed 
 phosphates) 
 (Lithic acid and lithate of lime) and 
 
 mixed phosphates. 
 (Lithic acid, lithate and oxalate of 
 
 lime,) and lithic acid 
 (Lithic acid, lithate of ammonia and 
 oxalate of lime,) and mixed phos- 
 phates 
 
 Lithate of ammonia and lithic acid. .. 
 
 and oxalate of lime. . . 
 
 and phosphate of lime. 
 
 and mixed phosphates. 
 
 Lithate of soda and lithic acid 
 Lithate of lime, and (lithate and oxalate 
 
 of lime and lithate of ammonia) 
 (Lithate and oxalate of lime,) and 
 
 oxalate of lime 
 
 (Lithate of ammonia and of lime,) and 
 lithate of ammonia and lime, alter- 
 nately - 
 
 Oxalate of lime and lithic acid 
 
 and lithate of ammonia 
 
 and phosphate of lime 
 
 and mixed phosphates 
 
 and (lithic acid and mixed 
 
 phosphates) 
 
 and silex. . . 
 
 Mixed phosphates and oxalate of lime 
 and phosphate of lime.. . 
 
 Phosphate of lime and mixed phos- 
 phates 
 
 and oxalate of lime 
 
 England. 
 
 Conti- 
 nent. 
 
 5 S g 
 
 11 
 
 13 
 
 16 
 
 164 
 
 55 
 
 15 
 
 22 
 
 SB 
 
 I, 
 
 18 
 
 11 
 
 74 
 
 33 
 
 12 
 
 16 32 
 
 53 
 
 S s 
 
 13 
 
 27 
 
 230 
 59 
 145 
 
 14 
 98 
 5 
 13 
 12 
 106 
 
 27 
 
 448 
 
 5 
 13 
 12 
 106 
 
 2 
 18 
 5 
 
 566 
 
474 
 
 APPENDIX. 
 
 TABLE II.— Continued. 
 
 General character i 
 of calculi. i 
 
 Particular species of calculi. 
 
 England. 
 
 Conti- 
 nent. 
 
 h. yl/fe?-/iaZ/7io- Lithic acid, oxalate of lime, and phos- 
 
 calculicom- " \ p^ate of lime... , 
 
 posed of three > oxalate of lime, and litbate ot 
 
 layers. i ammonia 
 
 oxalate of lime, and lithic acid 
 lithate of ammonia, and oxa- 
 
 late of lime 
 ' , lithate of ammonia, and lithic 
 
 phates. 
 
 -, lithate of ammonia, and phos- 
 
 , oxalate of lime, and phosphates 
 (Lithic acid and lithate of lime,) oxa- 
 late of lime, and mixed phosphates. 
 (Lithic acid, lithate and oxalate of lime) 
 lithic acid, and mixed phosphates., 
 Lithate of ammonia, oxalate of lime 
 
 and mixed phosphates 
 
 oxalate of lime, and phosphate 
 
 of lime 
 
 , oxalate of lime, and lithic acid 
 
 , oxalate of lime, and lithate of 
 
 ammonia 
 
 , phosphate of lime, and lithate 
 
 of ammonia 
 
 , phosphate of lime, and lithic 
 
 acid 
 
 , phosphate of lime, and oxalate 
 
 of lime 
 
 phosphate of lime, and mixed 
 
 phosphates 
 
 , lithic acid, and phosphates. 
 
 , lithic acid, and lithate of am- 
 
 monia 
 
 , lithic acid, and phosphate of 
 
 lime 
 
 , lithic acid, and oxalate of lime 
 
 (Lithate and oxalate of hme,) oxalate 
 
 of lime, and mixed phosphates.. 
 (Lithate and oxalate of lime,) (do. al- 
 ternately,) and phosphates , 
 
 Oxalate of lime, lithic acid and lithate 
 
 of ammonia. 
 
 , lithic acid and oxalate of lime 
 
 , lithic acid, and phosphate of 
 
 lime 
 
 lithic acid, and mixed phos- 
 
 phates. 
 
 -, lithate of ammonia, and phoS' 
 
 phate of lime 
 , lithate of ammonia, and oxalate 
 
 of lime 
 
 Mixed phosphates, phosphate of lime, 
 and mixed phosphates 
 
 13 
 
 13 
 
APPENDIX. 
 
 TABLE II.— Continued. 
 
 475 
 
 General character 
 of calculi. 
 
 c. Alternating 
 calculi com- 
 posed of four 
 layers. 
 
 d. Alternating 
 calculi com- 
 posed of several 
 layers. 
 6. Mixed or com- 
 pound calculi 
 
 Particular species of calculi. 
 
 Lithic acid, lithate of ammonia, litliic 
 
 acid, and lithate of ammonia 
 
 oxalate of lime, lithate of am- 
 
 monia, and phosphate of lime 
 
 oxalate of lime, lithic acid 
 
 and oxalate of lime. 
 
 -, oxalate of lime, lithic acid, 
 
 and lithate of ammonia. . . 
 Lithate of ammonia, oxalate of lime 
 lithate of ammonia and phosphates 
 , oxalate of lime, lithate of am- 
 
 monia, and oxalate of lime 
 
 , oxalate of lime, phosphates 
 
 and oxalate of lime 
 
 oxalate of lime, lithic acid, 
 
 England. 
 
 and lithate of ammonia. 
 
 , oxalate of lime, phosphate of 
 
 lime, and phosphates 
 
 , oxalate of lime, lithic acid, 
 
 and phosphates 
 
 , oxalate of lime, lithic acid, 
 
 and oxalate of lime 
 
 oxalate of lime, lithate of 
 
 ammonia, and lithic acid 
 
 -, phosphate of lime, oxalate of 
 
 ime, and lithate of ammonia. . . 
 Oxalate of lime, lithic acid, lithate of 
 ammonia, and lithic acid 
 
 lithic acid, oxalate of lime. 
 
 and phosphate of lime. » . . 
 
 lithic acid, oxalate of lime 
 
 and phosphates 
 
 lithic acid, lithate of ammo- 
 
 nia, and phosphates... 
 Composition not mentioned. 
 
 Mixture not mentioned 
 
 Fibrous matter and phosphates. 
 
 Conti- 
 nent. 
 
 10 
 
 129 87 663 187:^18 81 155 ..1520 
 
 24 
 
 24 
 
 * I do not know whether the term Suevia, in the original, is intended to represent the whole 
 district of Germany formerly known as Swabia ; or whether it is understood to comprehend that 
 part of Swabia only, now included in the kingdom of Wurtemburgh. 
 
 f The ingredients of particular species of calculi in the preceding table, included between 
 parentheses, are to be understood as existing in a mixed state. 
 
476 
 
 APPENDIX. 
 
 Table II. — Observations. 
 
 In this table the urinary calculi contained in the museums of Bar- 
 tholomew^'s* and Guy's Hospitals-j- in London, and of the provincial 
 hospitals of Norwich,! Manchester,§ and Bristol, || are contrasted with 
 the calculi existing in Swabia in Germany,^ and in Copenhagen** in 
 Denmark. The data here collected are too limited to throw much 
 light on the relative prevalence of calculous aflPections in different 
 parts of England, much less in England as compared with the diflPerent 
 countries of Europe ; yet in other points of view, and particularly in 
 demonstrating the relative prevalence of the different species of cal- 
 culi, and the order of the succession of the different layers of which 
 calculi are composed, &c., they are highly interesting and important. 
 
 In this table, the whole of the data comprising the analyses of 1520 
 calculi, are collected into one point of view, under the general heads 
 
 * The calculi in the museum of Bartholomew's Hospital have been recently and 
 carefully examined by Mr. Taylor, who has published an account of his analyses in 
 the Medical Gazette, vol. xxii. p. 189, from which these data are taken. 
 
 f The analyses here given are by the late Dr. Marcet. (See his work on Calcu- 
 lous Disorders, page 107, first edition.) At the time he examined them, many of 
 the calculi do not seem to have been divided ; so that the analyses are less satisfac- 
 tory than could be desired. This collection, which has been doubtless much in- 
 creased since Dr. ^I.'s time, deserves to be carefully re-examined. 
 
 X The analyses of the Norwich calculi were made by Dr. Yellowly, and are most 
 elaborate and complete. See Philos. Transactions, 1829 — 30, pages 55 and 415. 
 
 ^ The analyses of the Manchester calculi were made by the late Dr. Henry. 
 Med. Chirurg. Trans, vol. x. p. 127. 
 
 II The Bristol collection was analysed by jNIr. R. Smith. Med. Chirurg. Trans, 
 vol, xi. 
 
 % The analyses here given were made by Rapp. See W. Rapp iiber Harnsteine 
 in Naturwissenchaftliche Abhandlungen. Tiibingen, 1826, I. 1. page 133, et seq. 
 I have not seen this work, but have copied the analyses from an Essay or Thesis 
 De Lithogenesi praesertim Urinaria; auct. Eduard. Arnold. Martin. Jenas, 1833. 
 
 ** From a Thesis De Chemicis Calculorum Vesicariorum Rationibus, auct. 
 Eduard. Aug. Scarling, Haunige, 1839. See British and Foreign Medical Review, 
 vol. ix.p. 360. This is a very excellent essay on the subject. 
 
 The analyses of a portion of the calculi in the Hunterian Museum, by Mr. Brande, 
 formerly given, have been omitted, as the whole of that splendid collection has 
 been now examined by 'Mr. Taylor. Mr. T.'s results are not yet published. 
 
APPENDIX. 
 
 477 
 
 of 1. Lithic acid, 2. Mulberry/, 3. Cystic oxide, 4. Phosphatic, 5. Alter- 
 nating, and 6. Compound Calculi. 
 
 On each of these heads we shall make a few remarks. 
 
 1. Of lithic acid calculi. — The proportions pure lithic acid C2^c\^\\ 
 to the whole numbers contained in the different museums, are as fol- 
 low :— In Bartholomew's Hospital? as 1 : llfi ; in Guy's Hospital, 
 as 1 : 5-f ; in the Norwich Hospital, as 1 '. 4+ ; in Swabia, as 1 : 11^ ; 
 in Copenhagen as 1 ; 5— . The relative proportions of pure lithic acid 
 calculi in the Manchester and Bristol Museums are not mentioned ; 
 hence, abstracting the Manchester and Bristol, the general proportion 
 of pure lithic acid calculi is as 1 : 6i, nearly. 
 
 The relative proportions of calculi in the different museums, com- 
 posed essentially of lithic acid, (i. e. consisting of pure lithic acid, lithate 
 of ammonia, and the latter ingredient mixed with minute quantities 
 of the lithate and oxalate of lime, and the phosphates,) are, in Bar- 
 tholomew's Hospital, as 1 : 7 — ; in Guy^s Hospital, as 1 4— ; in the 
 Norwich Hospital, as 1 : 3+ ; in the Manchester Hospital, as 1 .* 21+ ; 
 in the Bristol Hospital, as 1:3—; in Swabia, as 1 .* 10+ ; and in 
 Copenhagen, as 1 : 4|— . The general proportion in all the collections 
 is as 1 : 32—. 
 
 If we take into account all the calculi of which the lithic acid or its 
 compounds form the nucleus, the proportions of calculi originating with 
 this principle (and which probably would otherwise have not been form- 
 ed) is very much greater. Thus in Bartholomew's Hospital the propor- 
 tion of caculi containing the lithic acid or some of its compounds as a 
 nucleus, is to the whole number of calculi as 1 .* Ij — ; in Guy's Hos- 
 pital, as 1 : 4—, (not fairly comparable, as the calculi do not appear 
 to be divided ;) in the Norwich Hospital, as 1 .* 1J+ ; in the Man- 
 chester Hospital, as I : Ij— ; in the Bristol, as 1 I 2^+; in Swabia, 
 as 1 : 1^+ ; and in Copenhagen, as 1 .* IJ. The relative proportions 
 of all the calculi originating in some form or combination of lithic acid, 
 in all the different collections, is nearly as 1 .' \l, which is equal to say- 
 ing, that if a lithic acid nucleus had not been formed and detained in 
 the bladder, two persons at least out of three who suffer from calculus 
 would have never been troubled with that affection. 
 
 2. Of mulberry or oxalate of lime calculi. — The proportions of 
 mulberry calculi in the different hospitals are nearly as follow : in 
 
478 
 
 APPENDIX. 
 
 Bartholomew's Hospital, as 1 : 16-}-: in Guy's Hospital, as 1:4—; 
 in the Norwich Hospital, as I SU— ; in the Manchester Hospital, 
 as 1 : 17 ; in the Bristol Hospital, as 1 : 6f — ; in Swabia, as 1 : 27 ; 
 in Copenhagen there does not appear to be any calculus composed 
 throughout of oxalate of lime ; but if we take the nearest approach 
 to such composition, in which calculi are composed principally of this 
 salt with a mixed nucleus, likewise containing oxalate of lime, the 
 proportions will be as 1 : 19i— ; the general proportions in all the 
 museums are as 1 I 14J. 
 
 If we take into account all the calculi of which the oxalate of lime 
 constitutes more or less of the nucleus, the proportions in the different 
 museums will be — in Bartholomew's, 1 .* 4J-r ; in Guy's, 1 ." 4— ; in 
 Norwich, 1 : 7^+ ; in Manchester, 1 .* 4J+ ; in Bristol, 1 ^ SJ — ; in 
 Swabia, 1 : 27 ; and in Copenhagen, 1 .* '2-to +• The general proportion 
 of calculi, into the nucleus of which oxalate of lime largely enters, 
 in all the museums, is as 1 ; 4J-f ; which is equivalent to saying, that 
 if a mulberry stone had not been formed and detained in the bladder, 
 two persons out of about nine who suffer from calculus would not 
 have been troubled with that affection. 
 
 3. Of cystic oxide calculi. — Of this rare form of urinary calculus, 
 four out of the seven museums contain no specimen. Calculi of this 
 substance exist in the museums of Bartholomew's, Guy's, and the 
 Manchester Hospitals, amounting altogether to five only. Hence 
 the general proportion to the whole number of cystic oxide calculi 
 examined, is only as 1 .* 304. 
 
 4. Of phosphatic calculi. — Calculi composed throughout of the 
 phosphates are comparatively of uncommon occurrence ; while calculi 
 consisting externally of the phosphates, as will be presently shown, 
 are the most frequent of all others. At present we have to do with 
 calculi composed essentially of the phosphates. 
 
 The proportion of calculi composed of the phosphate of lime, in 
 Bartholomew's Hospital, is as 1 .* 32 J ; in Guy's Hospital, as 1 ; 29 ; 
 in the Norwich Hospital, as 1 .' 132|^; in the Bristol, as 1 .* 155. The 
 other museums contain no specimen. The general proportion of 
 phosphate of lime calculi, to the whole number, is as 1 117—. 
 
 The proportion of calculi composed of the pure triple phosphate is 
 still less ; thus in Bartholomew's Hospital the proportion is as 1 ' 129; 
 
APPENDIX. 
 
 479 
 
 in Guy's, as 1 ; 43i ; in the Bristol, as 1 : 218 ; in Copenhagen, as 
 1 - 19i— . The other museums contain no specimen. The general 
 relation of the triple phosphate in all the collections, is as 1 ; 126f . 
 
 On the other hand, the proportion of calculi composed of the mixed 
 phosphates is very considerable ; thus, in Bartholomew's Hospital, the 
 proportion is as 1 .* 12^ ; in Guy's, as 1 ; 3i+ ; in the Norwich, as 
 1 : 19— ; in the Manchester, (including those containing a little lithic 
 acid,) as 1 ; 8i ; in the Bristol, as 1 : 12-|- ; in Swabia, as 1 ; II5+ ; 
 in Copenhagen, as 1 .* 19^—. The relative proportion of the mixed 
 phosphates in all the collections is as 1 .* 12J+. 
 
 Under the head of the phosphates are included a few rare specimens 
 of other calculi, e. g. carbonate of lime and siliceous calculi. Of these 
 two varieties, there is only one of each reported to exist in the Copen- 
 hagen collection ; and one containing silex in the Norwich collection. 
 
 The general proportion of all the calculi arranged under the heads 
 of the phosphates, in the different museums, is as 1 • 10—. 
 
 5. Of alternating calculi. — Calculi composed of different layers 
 constitute by far the most frequent results of urinary diseases ; of the 
 successive forms assumed by which, they may be said to constitute 
 the index. We shall first consider the relative proportions of the 
 calculi composed of two, three, and four deposites ; and afterwards of 
 the whole conjointly. 
 
 The proportion of alternating calculi composed of two deposites is, 
 in Bartholomew's Hospital, as 1 : 2~— ; in Guy's, none are reported, 
 probably on account of the calculi not having been divided ; in Nor- 
 wich, the proportion of alternating calculi composed of two layers is 
 stated to be as 1 : 2|— ; in Manchester, as 1 : 2|; in the Bristol, as 
 1 .' 3— ; in Swabia, as 1 ; 1 J+ ; and in Copenhagen, as 1 .* 21—. The 
 proportion of alternating calculi composed of two layers, in the con- 
 joint collections, is as 1 : 2§+. 
 
 The proportion of alternating calculi composed of three deposites, 
 is, in Bartholomew's Hospital, as 1:6—; in Guy's Hospital, none is 
 reported ; in the Norwich Hospital, the proportion is as 1 : 6+ ; in 
 the Manchester, as 1 : 26^ ; in the Bristol and Swabia collections, none 
 is reported ; in Copenhagen, the proportion is stated to be as 1 : 4|— . 
 The proportion in all the collections, is as 1 : 8| — 
 
 Alternating calculi composed of four deposites are only reported 
 
480 
 
 APPENDIX. 
 
 to exist in the Norwich Hospital, and the proportion stated is as 
 1 : 26i-j-. In the different collections there are twenty-four alter- 
 nating calculi, the composition of which is not stated. The proportion 
 of all the varieties of alternating calculi in the different collections, is 
 somewhat more than one-half; that is, as 1 : 2—. 
 
 6. Of mixed or compound calculi. — In one sense of the term, all 
 calculi may be said to be mixed or compound, as there are perhaps 
 none absolutely pure, i. e. formed of a single ingredient. But in the 
 sense in which the term is here applied, namely, as expressive of 
 calculi composed of different ingredients mixed together in large or 
 nearly equal proportions, compound calculi may be said to be rare. 
 The most usual mixtures consist of the lithate of ammonia and of 
 lime ; of the oxalate, carbonate, and phosphate of lime ; of the lithate 
 of ammonia, and the mixed phosphates, &c. ; and such mixtures are 
 usually confined to small calculi or calculous nuclei. Calculi com- 
 posed of pure lithic acid, or of any other pure ingredient, with the 
 phosphates or other compounds, do not appear to exist ; at least I 
 have met with no such mixtures. 
 
 Lastly, it remains to make a few remarks on the order of calculous 
 deposites ; an inquiry that throws considerable light on the laws of 
 their formation and general pathology. 
 
 On reference to the table it will be found, that in the different 
 alternating calculi, the ratio in which the oxalate of lime succeeds to 
 lithic acid, is as I ; 15-|+ ; on the contrary, that the ratio in which 
 lithic acid succeeds to oxalic acid, is as 1 : 13^^. Hence the alternation 
 of the two ingredients may be considered as nearly equal. It will 
 be found, however, that the oxalate of lime succeeds to the lithate of 
 ammonia, &c., more frequently than to lithic acid ; thus the ratio in 
 which the oxalate of lime succeeds to the lithate of ammonia was 
 1 .* 9|^— . On the contrary, the ratio in which the lithate of ammonia 
 succeeds to the oxalate of lime, is only as 1 : 38 ; a very striking 
 distinction. The ratio in which the phosphates succeed to lithic 
 acid, is as 1 .* 9^— ; in which the phosphates succeed to the lithate of 
 ammonia, is as 1 ; 122— ; and in which the phosphates succeed to 
 the oxalate of lime, is as 1 : 75+. On the contrary, three instances 
 only occm' in which the lithic acid or lithate of ammonia succeeds to 
 a phosphate ; and the proportion in which the oxalate of lime succeeds 
 to the phosphates is as 1 253^ only. The general proportion in 
 
APPENDIX. 
 
 481 
 
 which the phosphates succeed to the other ingredients in all the 
 collections, is as 1 : 4t^+. Hence the generality of the important law 
 alluded to in various parts of this volume, that in urinary calculi a 
 decided deposition of the mixed phosphates is not followed by other de- 
 positions. 
 
 TABLE III. 
 
 Illustrating the frequency of calculous affections at different ages^ and 
 in the different sexes. 
 
 The following table represents the numbers of calculi occurring at 
 decennial periods at the Bristol, Leeds, and Norwich Hospitals. 
 The two first are from Mr. Smith's valuable paper, published in the 
 eleventh volume of the Med. Chirurg. Transactions. The last from " A 
 Treatise on the Formation, Constituents, and Extraction of Urinary 
 Calculus. By John Green Crosse, Esq., Surgeon to the Norfolk and 
 Norwich Hospital. London, 1835." 
 
 Under 10 years of age 
 Between 10 and 20 
 20 and 30 
 SO and 40 
 40 and 50 
 50 and 60 
 60 and 70 
 70 and 80 
 
 Brietol. 
 
 Leeds. 
 
 Norwich. 
 
 Total ill the 
 three hos- 
 pitais. 
 
 *136 
 
 83 
 
 281 
 
 500 
 
 65 
 
 21 
 
 106 
 
 192 
 
 35 
 
 21 
 
 48 
 
 104 
 
 34 
 
 12 
 
 48 
 
 94 
 
 37 
 
 28 
 
 47 
 
 112 
 
 28 
 
 21 
 
 96 
 
 145 
 
 18 
 
 9 
 
 70 
 
 97 
 
 2 
 
 2 
 
 8 
 
 12 
 
 355 
 
 197 
 
 704 
 
 1256 
 
 1 f 
 
 . . Males, 1205, 
 1 Females, 51. 
 
 From this table it appears, first, that nearly one half of the whole 
 number of stone cases occurs before the age of puberty ; and that there 
 is an evident increase in the number of cases about the age of forty 
 years. Secondly, that the proportion of females to males afflicted 
 with calculous affections, is only about 1 : 23. An estimate that 
 agrees very well with Sir B. Brodie's observations before alluded to.f 
 
 * In one of these cases no operation was performed. f See page 369. 
 
 I I 
 
482 
 
 APPENDIX. 
 
 TABLE IV. 
 
 Illustrating the ratio of mortality from the operation of lithotomy at 
 different ages."^ 
 
 
 Bristol. 
 
 Leeds, t 
 
 Norwich. 
 
 General 
 Ratio. 
 
 Cured. 
 
 Died. 
 
 Ratio. 
 
 Cured. 
 
 Died. 
 
 Ratio. 
 
 Cured. 
 
 Died. 
 
 Ratio. 
 
 Under 1 0 years of age 
 
 106 
 
 29 
 
 1 
 
 * 4^ 
 
 
 
 
 262 
 
 19 
 
 1- 
 
 •14f- 
 
 
 Between 10 and 20 
 
 52 
 
 13 
 
 1 
 
 :5 
 
 
 
 
 97 
 
 9 
 
 1 
 
 ll| 
 
 
 20 and 30 
 
 30 
 
 5 
 
 1 
 
 :7 
 
 
 
 
 43 
 
 5 
 
 1 
 
 
 
 30 and 40 
 
 27 
 
 7 
 
 1 
 
 '5- 
 
 
 
 
 45 
 
 3 
 
 1 
 
 16 
 
 
 40 and 50 
 
 26 
 
 11 
 
 I 
 
 
 
 
 
 37 
 
 10 
 
 1 
 
 4^ 
 
 
 50 and 60 
 
 22 
 
 6 
 
 1 
 
 
 
 
 
 71 
 
 25 
 
 1 
 
 •3i 
 
 
 60 and 70 
 
 11 
 
 7 
 
 1 
 
 :24 
 
 
 
 
 50 
 
 20 
 
 1 
 
 'H 
 
 
 70 and 80 
 
 1 
 
 1 
 
 1 
 
 . 1- 
 
 
 
 
 6 
 
 2 
 
 1 
 
 :4 
 
 
 
 275 
 
 79 
 
 1 
 
 • 438 
 
 104 
 
 28 
 
 1 144 
 
 611 
 
 93 
 
 1 
 
 :7M 
 
 i] : 5rii 
 
 From these data it appears, that the mortality from lithotomy has 
 been much less in the Norfolk Hospital than in either of the others. 
 It also appears from the Norfolk table, that the general risk from the 
 lithotomy is less in children than in adults ; but on the other hand, 
 from the Bristol table, the chances seem to be nearly equal. These 
 differences are inexplicable ; but from the greater number of cases in 
 the Norfolk Hospital, and from other circumstances, the data fur- 
 nished by that hospital present the most accurate estimate of the 
 relative mortality, before and after puberty, from the operation of 
 lithotomy, as at present practised. If we take the Norfolk table as 
 our standard, we may conclude that the general mortality from litho- 
 tomy, as it has hitherto been practised, is about 1 : 7i. 
 
 * From the same authorities as the preceding table. 
 
 t Of the one hundred and ninety-seven cases of calculi in the Leeds Infirmary, 
 alluded to in the preceding table, sixty-five declined undergoing the operation. 
 Hence there are only one hundred and thirty-two operations mentioned in this 
 total. 
 
 I 
 
APPENDIX. 
 
 483 
 
 TABLE V. 
 
 lUmlmtiny the ratio of mortality from the operation of lithotomy as 
 influenced by the magnitude of the calculus."^ 
 
 Weight of the calculus. 
 
 Number of 
 operations. 
 
 Ratio. 
 
 Cured. 
 
 Died. 
 
 1 ounce and under 
 
 1 to 2 ounces 
 
 2 to 8 ounces 
 
 3 to 4 ounces 
 
 4 to 5 ounces 
 
 5 to 6 ounces 
 
 6 to 7 ounces 
 
 7 to 8 ounces 
 
 482 
 101 
 19 
 4 
 2 
 2 
 0 
 tl 
 
 47 
 18 
 16 
 7 
 S 
 0 
 2 
 0 
 
 1 :e>\\ 
 i:2j+ 
 1 : 14 
 l:if 
 
 TABLE VL 
 
 In this table the five hundred and twenty-nine calculi, weighing 
 one ounce and under, are arranged according to their weight in 
 drams ; with the result as to the cure or death of the patient. 
 
 
 
 
 
 
 Number of 
 
 
 Weight of the calculus. 
 
 operations. 
 
 Ratio. 
 
 
 Cured. 
 
 Died, 
 
 
 1 dram and under 
 
 122 
 
 12 
 
 1 : Hi 
 
 1 to 2 drams 
 
 101 
 
 10 
 
 1 : Ut'o 
 
 2 to 3 drams 
 
 90 
 
 5 
 
 1 : 19 
 
 3 to 4 drams 
 
 60 
 
 8 
 
 i:8i 
 
 4 to 5 drams 
 
 28 
 
 1 
 
 1 :29 
 
 5 to 6 drams 
 
 35 
 
 3 
 
 1 : 12f 
 
 6 to 7 drams 
 
 21 
 
 3 
 
 1 :8 
 
 7 to 8 drams 
 
 25 
 
 5 
 
 1 :6 
 
 I'hese tables strikingly illustrate the effects of magnitude in increas- 
 ing the risk from the operation of lithotomy. 
 
 * From Mr. Crosse's work above quoted. The cases occurred in the Norwich 
 Hospital. 
 
 t This stone was supposed by Mr. Cross to have been taken from the scrotum. 
 
LONDON : 
 
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 ON THE NATURE AND TREATMENT OE STOMACH 
 
 AND URINARY DISEASES ; being an Inquiry into the Connexion of 
 Diabetes, Calculus, and other Affections of the Kidney and Bladder with 
 Indigestion. By William Prout, M.D., F.R.S. The Third Edition, with 
 Six Engravings. 8vo, cloth, 20s. 
 \* This Edition has been re-written, and contains a considerable addition of 
 new and important matter. The Author, in presenting to the public the results 
 of nearly thirty years' observation and experience, has still kept in view, as 
 much as possible, the practical character of his treatise. 
 
 THE PATHOLOGY AND DIAGNOSIS OE DISEASES OF 
 
 THE CHEST ; illustrated chiefly by a Rational Exposition of their Physical 
 Signs. By Charles J. B. Williams, M.D., F.R.S., Professor of the 
 Practice of Medicine, University College, London. 
 The 4th Edition, with much important new matter. Plates. 8vo, cloth, 10s. 6d. 
 
 THE ANATOMIST'S YADE-MECUM ; A SYSTEM OE 
 
 HUMAN ANATOMY. By W. J. Erasmus Wilson, Lecturer on 
 Anatomy and Physiology at the Middlesex Hospital Medical School. 
 Foolscap 8vo, cloth, 12s. 6d. 
 The design of the " Anatomist's Vade-Mecum" is to present to the profession, 
 and particularly to the student, a systematic work, to which he may refer with 
 confidence for a complete digest of the present state of the science of Anatomy, 
 and which shall record the newest researches and discoveries. In the present 
 work, the fulfilment of these objects is insured in the name and reputation of the 
 Author, and no expense has been spared in wood-cut illustrations to render it 
 the MOST BEAUTIFUL AND PERFECT VOLUME THAT HAS 
 EVER BEEN PLACED IN THE HANDS OF THE STUDENT. In 
 the arrangements of subjects great care has been observed to avoid complexity 
 of description, and to adopt so clear and concise a style as shall impress the facts 
 forcibly on the mind, and facilitate their conception and acquirement. 
 
 \_For Specimens of the Illustrations see opposite page.^ 
 
4 WORKS ON ANATOMY, SURGERY, MIDWIFERY, ETC. 
 
 PRACTICAL REMARKS ON THE DISCRIMINATION 
 
 AND APPEARANCES OF SURGICAL DISEASES. By John 
 HowsHiP, Esq., Surgeon to the Charing Cross, Hospital. 8vo, cloth, 10s. 6d. 
 
 PATHOLOGICAL OBSERYATIONS ON THE DISEASES 
 
 OF THE UTERUS. By Robert. Lee, M.D., F.R.S., Lecturer on Mid- 
 wifery at St. George's Hospital. Part I. Imperial 4to, with Four highly 
 finished Coloured Drawings by Mr. Perry. Price 14s. 
 This work will illustrate, by cases and coloured plates, the nature, symptoms, 
 and treatment of 
 
 I. Malignant diseases of the Uterus. 
 
 II. Fibrous, Calcareous, and other Tumours of the Uterus, which do not 
 assume a malignant form. 
 
 HI. Infiammation, and the various morbid conditions of the Uterus, by which 
 its functions are disturbed, but which seldom produce any permanent 
 alteration of the structure of its component parts. 
 
 IV. Diseases of the Ovaria, Fallopian Tubes, and External Uterine ap- 
 pendages. 
 
 V. Diseases of the Gravid Uterus and its contents. 
 
 " This work will prove a magnificent contribution to medical science. Four plates, 
 executed in the first style of art, are given in illustration."— Medical Gazette. 
 
 MEDICAL AND PHYSIOLOGICAL COMMENTARIES. 
 
 By Martyn Paine, A.M., M.D., Professor of the Theory and Practice of 
 Medicine in the University of New York. Two volumes 8vo, comprising 
 1530 pages, price £1. 16s. 
 The subjects examined relate to obscure and controverted questions in Patho- 
 logy, and embrace a critical review of some of the most important doctrines in 
 Physiology and Medicine. 
 
 A PRACTICAL TREATISE ON THE BILIOUS REMIT- 
 
 TENT FEVER ; its History, Causes, Effects, and Treatment, with Experi- 
 ments on the temperature of the system in health, and when labouring under 
 the disease in its diJfferent stages, and in the paroxysms of the Tertian or 
 Intermittent Fever ; together with remarks on the connexion of diseases 
 with the changes of the atmosphere upon Epidemics ; Medical Topography, 
 illustrated by Diagrams ; and Statistics of the Naval Squadron on the West 
 India Station. By William Arnold, M.D., Fellow of the Royal College 
 of Physicians, Edinburgh ; Member of the Wernerian and other learned 
 Societies, &c. &c. 8vo, cloth, 10s. 
 
 PRACTICAL OR OPERATIVE SURGERY. 
 
 By Robert Ltston, Esq., Surgeon to the North London Hospital. The 
 Third Edition, 8vo, cloth, 22s. 
 
 This edition has been carefully revised throughout by the Author, is illus- 
 trated with additional wood-cuts, and contains much important new matter. 
 
 [For Specimens of the Illustrations see opposite page.'] 
 
6 
 
 WORKS OX AXAT03IY, SURGERY, XIDWIFERY, ETC. 
 
 ' 0^^ THE AXATOMI, PHYSIOLOGY, XSD PATHOLOGY 
 
 OF THE EAR ; he'mg the Prize Essay in the University of Edinburgh. 
 ' By Joseph Williaais, M.D., Member of the Royal College of Surgeons. 
 One Sto volume, ^th plates, price 10s. 6d. 
 " We are glad that this neglected branch of Surgery is in a fair way of attracting the atten- 
 tion which on every account it merits. We can recommend Dr. Williams's work as con- 
 taining much interesting and useful informa^tion." — Dublix Medical Press. 
 
 TRA]N'SACTIOXS OF THE PROYIiN^CIAL MEDICAL 
 
 AXD SURGICAL ASSOCLITIOX ; Volume VIII. 8vo, cloth, price 
 £1. lis. 6d., containing : — 
 
 L The Report of the Section appointed to inquire into the present state of 
 Vaccination, as read at the Anniversary Meeting of the Provincial Medical and 
 Surgical Association, held at Liverpool, July 25, 1839. 
 
 IL The Retrospective Address delivered at the Seventh Anniversary Meet- 
 ing of the Provincial Medical and Surgical Association, held at Liverpool, July 
 24th and 25th, 1S39. By John Addington Stmoxds, M.D., Senior Physician 
 to the Bristol General Hospital, Lecturer on the Practice of Medicine, &c. &c. 
 
 IIL Retrospective Address in Surgery, from July, 1836, to July 1839, deli- 
 vered at Liverpool, July 24th, 1839. By J. H. James, Esq., Surgeon to the 
 Devon and Exeter Hospital. 
 
 IV. Observations on the Variolse Vaccinae, as they occasionally appear in the 
 Vale of Aylesbury, with an aocount of some recent Experiments in the Vacci- 
 nation, Retro -vaccination, and Variolation of Cows. By Robert Ceelt, Esq., 
 Surgeon to the Buckinghamshire Infirmary. (Illustrated by 35 Coloured 
 Engi'avings from Original Drawings.) 
 
 " The eighth volume of the Transactions of the Association has just made its appearance : 
 but, we regret to say, at so late a period of the quarter, as to preclude our giving any detailed 
 account of its contents. We cannot, however, let the opportunity pass of calling the atten- 
 tion of the profession, in this and other countries to the most valuable memoir of Mr. Ceeley 
 contained in it, entitled ' Observations on the Variolce Vacciuae as they occasionally appear 
 in the Vale of Aylesbury, with an account of some recent experiments on the Vaccination, 
 Retro-vaccination, and Variolation of Cows.' This memoir extends to 150 pages, and is 
 illustrated by thirty-five beautifully coloured plates. We entirely concur in the following 
 judgment pronounced on this paper by the council in the preface to the volume : ' Several 
 questions of the utmost interest to the welfare of the community generally, as well as the 
 medical science, will be found to be most ably investigated. The variolation of the cow has 
 been satisfactorily accomphshed, with the effect of thereby generating the vaccioe : the cha- 
 racters of the vaccine in the cow, with several of its irregularities, are carefully described and 
 figured, and some of the most nearly allied spurious forms pointed out, by attention to which 
 many of the difficulties attendant upon a recurrence to the cow for renewed supphes of the 
 vaccine may be obviated. Considerable light has also been thrown upon the value of the 
 practice of retro-vaccination as a means of renewing and restoring the properties of h-mph 
 presumed to be deteriorated or otherwise altered by repeated transmissions through the 
 human body while the paper altogether must form a standard of reference for those who 
 are engaged in the endeavour to extend and perfect the vaccine as a means of protecting 
 millions from the fatal ravages of the smallpox." — British axd Foreigx Medical Review, 
 July, 1S40. 
 
 To be had separately, 
 REPORT OF THE VACCIXATIOX SECTION of the ASSOCIATION. 
 
 Price 2s. 
 
 OBSERVATIONS on the VARIOLA VACCINA, (iUustrated by Coloured 
 Engra^-ings.) By R. CEELY, Esq. Price 21s. 
 
PUBLISHED BY MR. CHURCHILL. 
 
 7 
 
 A COMPENDIUM OF MATERIA MEDICA & PHARMACY; 
 
 Adapted to the London Pharmacopoeia, embodying all the New French, 
 American, and Indian Medicines, and also comprising a Summary of Practical 
 Toxicology. By J. Hunter Lane, M.D. F.L.S. F.S.S.A. One neat pocket 
 volume, 5 s. cloth. 
 
 " Dr. Lane's volume is on the same general plan as Dr. Thompson's long known Con- 
 spectus ; but it is much fuller in its details, more especially in the chemical department. It 
 seems carefuUy compiled, is well suited for its purpose, and cannot fail to be useful." — 
 British and Foreign Medical Review. 
 
 " This work contains a concise but comprehensive account of all the simple and com- 
 pound medicines in use; it contains a greater amount of chemical information than we 
 often meet with in a small work on Pharmacy. The work is worthy of recommendation." — 
 Lancet. 
 
 APHORISMS ON THE TREATMENT & MANAGEMENT 
 
 OF THE INSANE ; with Considerations on Public and Private Lunatic 
 Asylums, pointing out the errors in the present system. By J. G. Millingen, 
 M.D., late Resident Physician of the Middlesex Pauper Lunatic Asylum at 
 Hanwell, and formerly Superintendent of the Army Lunatic Asylum at 
 Chatham. 18mo, cloth, 4s. 6d. 
 " Dr. Millingen, in one small pocket volume, has compressed more real solid matter 
 than could be gleaned oat of any dozen of octavos on the same subject. We recommend 
 this vade mecum as the best thing of the kind we ever perused." — Dr. Johnson's Review. 
 
 A TREATISE ON AEFECTIONS AND DISEASES OF THE 
 
 VERTEBRAL COLUMN, CONTRACTIONS of the CHEST, PRO- 
 JECTIONS OF THE SHOULDER, HIP, &c. This work will contain a 
 new and successful Plan of Treatment, without confining the Patient con- 
 stantly to the recumbent position. It will also be illustrated by Plates 
 and numerous cases. By E. W. Tuson, F.R.S., F.L.S., Surgeon to the 
 Middlesex Hospital, (nearly ready.) 
 
 BRITISH AND FOREIGN MEDICAL REVIEW. 
 
 Edited by John Forbes, M.D. F.R.S. 
 
 " We have now, for the first time, a Medical Review from the British press, deserving of 
 comparison with the most celebrated of the Journals devoted to literature and general science. 
 The articles do not consist simply of an analysis of the work subject to examination ; but of 
 a critical digest of all the information therein contained, and of all that can be gathered from 
 other sources unnoticed by the author. The most profound research, extensive experience, 
 and critical acumen, are brought to bear upon the subjects discussed ; and the consequence 
 is, a more satisfactory epitome of the state of medical science at the present time than we 
 have met with in any other work which has come under our observation. The execution of 
 the mechanical part is fully equal to the literary ; and we have no hesitation in pronouncing 
 The British and Foreign Medical Review the first medical periodical in the world." — 
 The American Medical Library and Intelligencer. 
 
 " The British and Foreign Medical Review is certainly the ablest periodical now published 
 in England." — Journal of the Calcutta Medical and Physical Society, Dec. 1837. 
 
 THE BRITISH AND FOREIGN MEDICAL REVIEW is pubHshed 
 Quarterly, price Six Shillings. The first ten volumes may be had, elegantly done 
 up in Cloth Boards, with Gold Letters, at the same price as the single Numbers. 
 
 No. XXI. was published on the 1st of January, 1841. 
 
8 WORKS ON ANATOMY, SURGERY, MIDWIFERY, ETC. 
 
 AN ATLAS OP PLATES, ILLUSTRATIVE OF THE 
 
 PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND 
 SURGERY ; with descriptive letter-press. No. XII. just published, price 
 Is. 6d., containing Six Engravings, and three sheets of letter-press. To be 
 completed in Fourteen numbers. By Francis H. Ramsbotham, M.D., 
 Physician to the Royal Maternity' Charity, and Lecturer on Obstetric Medi- 
 cine at the London Hospital, &c. The Plates are Engraved by Mr. Henry 
 Adlard, from Drawings made expressly for this Work by Mr. Bagg. 
 
 " There is so much in the practice of Midwifery which cannot be understood without pic- 
 torial illustrations, that they become almost essential to the student ; but hitherto the expense 
 has proved an impediment to their being employed so much as desirable. The work before 
 us is decidedly the cheapest of the kind which has ever fallen under our notice. Six really 
 good engravings and several wood cuts, vdth two sheets of excellent letter-press, for 
 eighteen-pence. The work has only to be known to make the demand for it very extensive." 
 — Medical Gazette. 
 
 " We strongly recommend this work j it is a useful contribution to medical literature, and 
 decidedly the cheapest work which has ever issued from the medical press of this country." 
 — Lancet. 
 
 "We can speak very favourably both of the letter-press and of the plates, and as a large 
 sale can only remunerate the Publisher, we wish him that large sale which he deserves." — 
 Dr. Johnson's Review. 
 
 " We strongly recommend the work of Dr. Ramsbotham to all our obstetrical readers, 
 especially to those who are entering upon practice ; it is not only one of the cheapest, 
 but one of the most beautiful works m Midwifery."— British and Foreign Medical 
 Review. 
 
 " We feel much pleasure in recommending to the notice of the profession, one of the 
 cheapest and most elegant productions of the medical press of the present day. Each number 
 contains six well- executed and accurate engravings on steel, several very beautiful wood- cuts, 
 for eighteen-pence. The text is written in a clear, concise, and simple style. We oifer our 
 most sincere wishes that the undertaking may enjoy all the success which it so well merits." — 
 Dublin Medical Press. 
 
 The unanimous testimony of the medical press to the unprecedented cheap ■ 
 ness and merits of this work, has promoted that extensive sale upon which the 
 Publisher calculated for the return of the great outlay necessary to its produc- 
 tion. The regular appearance of the work, and the increased expense incurred 
 for the engravings, may be taken as a guarantee that it will be completed in 
 the style with which it was commenced : an extra sheet of letter-press is also 
 given in each number. 
 
 A COMPANION TO THE MEDICINE CHEST, 
 
 AND COMPENDIUM OF DOMESTIC MEDICINE ; comprising plain 
 directions for the employment of medicines, with their properties and doses ; 
 and brief descriptions of the symptoms and treatment of diseases, and of the 
 disorders incidental to infants and children : with a selection of the most 
 efficacious prescriptions. Intended as a source of easy reference for Clergy- 
 men, and for families residing at a distance from professional assistance. 
 By John Savory, Member of the Society of Apothecaries, and Fellow of the 
 Medico-Botanical Society of London. Second Edit., 12mo, cloth, price 5s. 
 
 "This little work, divested as much as possible of technical and scientific phraseology, is 
 intended for the use of travellers, and those humane characters who, residing at a distance 
 from a duly qualified medical practitioner, devote a portion of their time to the relief and 
 mitigation of the complicated misfortunes of disease and poverty among their poor neighbours. 
 It is, howevei", earnestly recommended not to place too much confidence on books of domestic 
 medicine, especially in such cases as are of a serious nature, but always to have recourse to 
 the advice of an able physician as early as it can be obtained."— Extract from Preface. 
 
PUBLISHED BY MR. CHURCHILL. 
 
 9 
 
 A PRACTICAL ¥ORK ON THE DISEASES OF THE EYE 
 
 AND THEIR TREATMENT, MEDICALLY, TOPICALLY, AND 
 BY OPERATION. By Frederick Tyrrell, Senior Surgeon to the 
 Royal London Ophthalmic Hospital, Surgeon to St. Thomas's Hospital, 
 Professor of Anatomy and Surgery at the Royal College of Surgeons in 
 London, &c. &c. 2 vols. 8vo, with coloured Plates, £1. 16s. 
 
 " This work is written in a perspicuous style, and abounds in practical information ; we 
 add our earnest recommendation to our readers, to procure and read through the two volumes, 
 assuring them that they will be richly repaid for their trouble. A series of plates, illustrative 
 of the various diseases, are given." — Dublin Journal of Medical Science. 
 
 A DISCOURSE ON THE PHENOMENA OF SENSATION, 
 
 AS CONNECTED WITH THE MENTAL, PHYSICAL AND IN- 
 STINCTIVE FACULTIES OF MAN. By James Johnstone, M.D,, 
 Physician to the General Hospital, and Lecturer on Materia Medica and 
 Therapeutics at the Royal School of Medicine, Birmingham. One 8vo vol. 
 
 A PRACTICAL TREATISE ON THE FUNCTION AND 
 
 DISEASES OF the UNIMPREGNATED WOMB ; with a chapter on 
 Leucorrhoea, Fluor Albus, or Weakness. By Charles Waller, M.D., 
 Consulting Physician- Accoucheur to the London Midwifery Institution, 
 Lecturer on Midwifery and Diseases of Women and Children, at the Medical 
 School, Aldersgate Street. 1 vol. 8vo, cloth, illustrated by Plates, price 9s. 
 
 THE TREATMENT OF SOME AFFECTIONS OF THE 
 
 PROSTATE GLAND. By R. A. Stafford, Surgeon to the St. Mary- 
 lebone Infirmary. 8vo, with plate, price 5s. 
 
 " We have read Mr. Stafford's work with considerable interest : the great frequency of 
 such diseases, their difficulty of management, their extreme inconvenience, render every 
 attempt to improve their treatment worthy of encouragement, and entitle the practitioner 
 who, with a view to such improvement, ventures out of the beaten road of practice, to our 
 liberal consideration, our cordial thanks, and sincere gratulations on his success."— 
 Medical Gazette. 
 
 ANATOMICAL, PATHOLOGICAL AND THERAPEUTIC 
 
 RESEARCHES ON THE YELLOW FEVER. By P. Ch. A. Louis, 
 Physician to the Hotel Dieu. From observations taken by himself and 
 M. Trousseau, as Members of the French Commission at Gibraltar. Trans- 
 lated by G. C. Shattuck, M.D., Member of the Society for Medical Ob- 
 servation at Paris. 8vo, cloth, 10s. 
 
 CHURCHILL^S CATALOGUE OF MODERN MEDICAL 
 
 WORKS, comprising Anatomy, Medicine, Surgery, Midwifery, Materia 
 Medica, Pharmacy, Chemistry, Medical Jurisprudence, Botany, Veterinary 
 Surgery, &c. &c. With their prices and dates, 12mo, Is. 
 
10 
 
 WORKS ON ANATOOT, SURGERY, ^HDWIFERY, ETC. 
 
 WORKS LATELY PUBLISHED. 
 
 RESEARCHES OX THE DEYELOPMEXT, STRTJCTTJRE, 
 
 AND DISEASES OF THE TEETH. Br Alexander Nasmtth, F.L.S., 
 F.G.S., and Fello^v of the Royal 3Iedical and Chirurgical Society. 8yo, clotL, 
 plates, price 10s. 6d. 
 
 " Such interesting and important discoveries have lately been made on the structure of 
 the teeth, and so important have these organs become as guides to the anatomist in the 
 classification of the different members of the animal kingdom, that a new work on the subject 
 was imperatively caUed for, and the demand could not have been more efficiently responded 
 to than it is by Mr. Xasmtth in the work before us." — Laxcet. 
 
 " Here we terminate our notice of this interesting and important volume, strongly recom- 
 mending it to the attention of aU who are interested in the scientific investigation connected 
 with oar profession." — Medical Gazette. 
 
 " The work of Mr. Nasmyth contains an entire translation of the papers of Retzics, 
 illustrated by many beautiful and original plates : also, a complete view of the researches of 
 those whose names we have introduced in the present article : and, lastly, a comprehensive 
 historical survey of all works on odontology."— British axd Foreign Medical Review. 
 
 " We shall but try to convey such an idea of the value of Mr. Nasmyth's work as may 
 excite the desire to study it vnth. the attention it deserves. It is illustrated by seven most 
 beautifully executed steel engravings." — Dublix Medical Press. 
 
 THE MODER>' TREATMENT OE SYPHILITIC DISEASES 
 
 both Primary and Secondary ; comprehending an Account of improved 
 Modes of Practice adopted in the British and Foreign Hospitals, with 
 numerous Formulae for the Administration of many new remedies. By 
 Langstox Parker, Professor of Anatomy and Physiology in the Bir- 
 mingham Royal School of Medicine. 12mo, cloth, price 5s. 
 " An excellent little work ; it gives a clear and sufficiently fuU account of the opinions and 
 practice of M. Ricord, Desrulles, Cullerier, WaUace, &c. Such a digest cannot fail to be 
 highly useful and valuable to the pracritioner."— Dublix Medical Press. 
 
 " This httle work is a useful compendium of the practice of the French surgeons. The 
 book is judicious and weU timed, and will save many practitioners from the erroneous dulness 
 of routine." — Medical Gazette. 
 
 " This manual, we doubt not, wHl be extensively read : we recommend our readers to 
 procure the book, it is not a large one, and a perusal wiH afford much information."— 
 DcBLix Medical Jourx'al. 
 
 PEBTIPLES OF GENERAL AT^D COMPARATIVE PHT- 
 
 SIOLOGY, intended as an Introduction to the Study of Human Physiology, 
 and as a Guide to the philosophical pursuit of Xatural History. By "NYm. 
 B. Carpenter. M.D. 8vo, with 240 figm'es on Copper and Wood, price 15s. 
 
 No treatise on physiology which has hitherto appeared in our language exceeds the 
 present, either in the comprehensiveness of its principles, or in the value and abundance of 
 its facts. We recommend it to aU our readers, and to men of science of every description.'' — 
 British axd Foreigx Medical Review. 
 
 " In Dr. Carpenter's work lately published, wiH be found the best exposition we possess 
 of aU that is furnished by comparative anatomy to our knowledge of the nervous system, as 
 weU as to the more general principles of Life and organization." — Dr. Hollaxd's Medical 
 Notes. 
 
 " This is an admirable work, and will give Dr. Carpenter a high rank among the cultivators 
 of natural philosophy. We strongly recommend it to aU who have leisure for the dehghtf ul 
 subject of which it treats." — Medical Gazette. 
 
 m 
 
PUBLISHED BY MR. CHURCHILL. 
 
 A TREATISE ON THE NATURE AND TREATMENT OF 
 
 HOOPING-COUGH, and its COMPLICATIONS ; iUustrated by Cases, 
 with an Appendix, containing Hints on the Management of Children, with 
 a view to render them less susceptible of this and other Diseases of Child- 
 hood, in an aggravated Form. By George Hamilton Roe, M. D., Fellow 
 of the Royal College of Physicians, and Physician to the Westminster 
 Hospital. Octavo, cloth, price 8 s. 
 
 A MANUAL OE BRITISH BOTANY; in which the Orders and 
 Genera are arranged and described according to the Natural System of De- 
 Candolle ; with a Series of Analytical Tables for the assistance of the 
 Student in the Examination of the Plants indigenous to, or commonly culti- 
 vated in, Great Britain. By D. C. Macreight, M. D., Lecturer on Materia 
 Medica and Therapeutics at the Middlesex Hospital. Small 8vo, cloth, 7s. 6d. 
 
 " There is a prodigious mass of elementary matter and useful information in this Pocket 
 Volume." — Medico-Chirurgical Review, July, 1838. 
 
 "This very elegant little volume is a most useful accession to Botanical Literature." — 
 Literary Gazette. 
 
 A TREATISE ON DISEASES OE THE SKIN. By p. rayer, 
 
 D.M.P. Translated from the French, by William B. Dickenson, Esq., 
 M.R.C.S. Svo, price 12s. 
 " We can recommend the present translation of Rayer's Treatise as an excellent companion 
 at the bedside of the patient."— Lancet. 
 
 " The translation of Rayer has conferred a great obligation on the science of medicine in 
 England."— Medical and Surgical Journal. 
 
 THE FIRST LINES OE THE PRACTICE OE SURGERY; 
 
 designed as an Introduction for Students, and a concise Book of Reference 
 for Practitioners. By Samuel Cooper, Professor of Surgery in the Univer- 
 sity of London. Sixth Edition, carefully corrected, and considerably 
 improved. Svo, price IBs. 
 
 By the same Author. 
 
 A DICTIONARY OE PRACTICAL SURGERY ; comprehending 
 
 all the most interesting improvements, from the earliest times down to the 
 present period, &c. &c. Seventh Edition. One very thick Svo. vol. ^1. 10s. 
 
 THE MODERN PRACTICE OE PHYSIC ; exhibiting the 
 
 Characters, Causes, Symptoms, Prognostics, Morbid Appearances, and im- 
 proved Method of treating the Diseases of all Climates. By Robert Thomas, 
 M.D. Tenth Edition. Svo, 18s. 
 
 A SUPPLEMENT TO THE PHARMACOPOEIA; being a 
 
 Treatise on Pharmacology in general : including not only the Drugs and 
 Compounds which are used by Practitioners in Medicine, but also most of 
 those which are used in the Chemical Arts, or which undergo Chemical Pre- 
 parations. Sixth Edition. Svo, 14s. 
 
12 
 
 WORKS ON ANATOMY, SURGERY, MIDWIFERY, ETC. 
 
 A SYNOPSIS OF THE VARIOUS KINDS OF DimCULT 
 
 PARTURITION, with Practical Remarks on the Management of Labours. 
 By Samuel Merriman, M.D., F.L.S. Fifth Edition, with additions, 8vo, 
 Plates, price 12 s. 
 
 " The merits of this work are already too well-known, and too highly appreciated by the 
 profession, to require that we should express, at any great length, the high opinion we 
 entertain of what is imiversaUy regarded as one of the very best practical books of reference 
 in our language." — Dublin Medical Journal. 
 
 THE EYE : a Treatise on the Art of Preserving this Organ in a Healthy 
 Condition, and of Improving the Sight ; to which is prefixed, A VIEW OF 
 THE ANATOMY AND PHYSIOLOGY OF THE EYE. By J. C. 
 August Franz, M.D. With Plates, post 8vo, price 7s. 6d. 
 
 TOIL MEDXCAIi AXD SUXtGZCAIi EXAIMEZSTil.TIOia'. 
 
 BY JOHN STEGGALL, M.D., 
 
 LICENTIATE OF THE ROYAL COLLEGE OF PHYSICIANS. 
 
 A MANUAL rOR THE USE OF STUDENTS PREPARING 
 
 FOR EXAMINATION AT APOTHECARIES' HALL. Ninth Edition. 
 12mo cloth, 8s. 6d. 
 
 II. 
 
 A MANUAL EOR THE COLLEGE OF STJUGEONS; 
 
 intended for the use of Candidates for Examination, and Practitioners. By 
 John Steggall, M.D., and M. W. HrLi,ES, Surgeon. One thick volume, 
 12mo cloth, price 12s. 6d. 
 
 m. 
 
 GREGORrS CONSPECTUS MEDICINiE THEORETICS. 
 
 The First Part, containing the Original Text, with an Ordo Verborum and 
 Literal Translation. Price 10s. 
 
 IV. 
 
 THE EIRST EOUR BOOKS OE CELSUS. Containing the 
 Text, Ordo Verborum, and Translation. Price 8s. 
 The above two works comprise the entire Latin Classics required for Exami- 
 nation at Apothecaries' Hall. 
 
 V. 
 
 A new, correct, and complete edition of 
 
 CELSUS DE RE MEDICA, E RECENSIONE LEONARDI 
 
 TARG^. Price 7s. 
 
 VI. 
 
 THE DECOMPOSITIONS OE THE NEW LONDON 
 
 PHARMACOPCEIA ; with Observations on the most active preparations. 
 Price 3s. 
 
 vn. 
 
 THE ELEMENTS OE BOTANY. Designed for the Use of 
 Medical Students. With Nine Coloured Plates. Price 6s. 
 
PUBLISHED BY MR. CHURCHILL. 
 
 13 
 
 THE PHYSICIAN^S YADE MECUM; OR, MANUAL OF 
 
 THE PRINCIPLES AND PRACTICE OF PHYSIC ; containing the 
 Symptoms, Causes, Diagnosis, Prognosis, and Treatment of Diseases, &c. 
 New Edition, considerably enlarged, edited by Dr. Ryan. 7s. 6d. boards. 
 
 A TREATISE ON THE DISEASES OF CHILDREN: 
 
 With Directions for the Management of Infants from the Birth. By the 
 late Michael Underwood, M.D. Ninth Edition, revised by Samuel 
 Merriman, M.D., F.L.S., and Marshall Hall, M.D., F.R.S. 8vo, 
 boards, 15s. 
 
 BILLARD'S TREATISE ON THE DISEASES OF 
 
 INFANTS ; founded on recent Clinical Observations and Investigations in 
 Pathological Anatomy, made at the " Hospice des Enfans Trouves," at 
 Paris, under the superintendence of M. Baron, with a Medico-Legal Disser- 
 tation on the Viability of the Child. With Notes, by Dr. Ollivier of 
 Angers. Translated from the Third French Edition, with Notes, by James 
 Stewart, M.D,, Late Physician to the New York Orphan Asylum, and 
 one of the Consulting Physicians of the Northern Dispensary of the City of 
 New York. In one large 8vo volume, price 14s. cloth. 
 
 This translation of Dr. Billard's work wiU supply a want felt to exist in our medical 
 literature. The author has enjoyed opportunities of pursuing pathological investigations to 
 an almost unlimited extent, and, as the result, he has presented to the world a book 
 remarkable for the variety and importance of the facts it contains. Of the manner in which 
 Dr. Stewart has executed his task, we can speak in the highest terms." — Dr. Johnson's 
 Review, April, 1840. 
 
 The Author's opportunity for pursuing the necessary investigation of the 
 various subjects treated of in this work may be learned from the circumstance 
 of his occupying a station in the " Hospice des Enfans Trouves," which enabled 
 him, in one year alone, to examine the condition of 5300 infants, and to extend 
 his anatomical researches to nearly 700. 
 
 ELEMENTS OF NATURAL PHILOSOPHY; being an Expe- 
 
 rimental Introduction to the Study of the Physical Sciences. Illustrated 
 with Two Hundred and Thirty Wood-cuts. 8vo, price 12s. cloth. By 
 GoLDiNG Bird, M.D., F.L.S., F.G.S., Lecturer on Natural Philosophy at 
 Guy's Hospital. 
 
 " By the appearance of Dr. Bird's work, the student has now all that he can desire, in one 
 neat, concise, and well-digested volume. The elements of natural philosophy are explained 
 in very simple language, and iUustrated by numerous woodcuts."— Medical Gazette. 
 
 " This work teaches us the elements of the entire circle of natural philosophy in the 
 clearest and most perspicuous manner. -Light, Magnetism, Dynamics, Meteorology, Elec- 
 tricity, &c., are set before us in such simple forms, and so forcible a way, that we cannot 
 help understanding their laws, their operation, and the reraai'kable phenomena by which 
 they are accompanied or signified. As a volume of useful and beautiful instruction for the 
 young, and as a work of general value to both sexes, we cordially recommend it."— Literary 
 Gazette, 
 
 " This work marks an advance which has long been wanting in our system of instruction. 
 Dr. Bird has succeeded in producing an elementary work of great merit, which may be pro- 
 fitably used, not only by the medical, but by the general student."— Athenaeum. 
 
14 WORKS ON ANATOMY, SURGERY, MIDWIFERY, ETC. 
 
 A TREATISE ON THE DISEASES OE THE HEART 
 
 AND GREAT VESSELS, and on the Affections wMch may be mistaken 
 for them. By J. Hope, M.D., F.R.S., Physician to St. George's Hospital. 
 Third Edition. One thick 8vo volume, with plates, price 18s. 
 
 " The addition of one-third of new matter to the present volume, and the care with which 
 the whole has heen revised and corrected, will, I trust, sufficiently prove my respect for the 
 favoiirable opinion of my professional brethren, as evinced, not in this coTxatry only, but also 
 on the European and American continents, by the sale of no less than six or seven editions 
 and translations in as many years." — Extract from Preface. 
 
 OUTLINES OF HUMAN PHYSIOLOGY. 
 
 Fourth Edition, with Numerous Engravings on Wood. By Herbert Mayo, 
 F.R.S., Surgeon to the Middlesex Hospital. Svo, cloth, IBs. 
 
 THE SURGEON^S VADE MECUM; A HANDBOOK OF 
 
 THE PRINCIPLES AND PRACTICE OF SURGERY; iUustrated 
 with numerous Wood Engravings. By Robert Druitt, M.R.C.S. Fcap. 
 Svo, cloth, price 8s. 6d. 
 
 INTERMARRIAGE ; or, the Mode in which, and the Causes why, 
 Beauty, Health, and Intellect, result from certain Unions, and Deformity, 
 Disease, and Insanity from others ; demonstrated by Delineations of the 
 Structure and Forms, and Descriptions of the Functions and Capacities, 
 which each Parent, in every Pair, bestows on Children, in conformity with 
 certain Natural Laws, and by an account of Corresponding Effects in the 
 Breeding of Animals. Illustrated by Drawings of Parents and Progeny. 
 By Alexander Walker. Octavo with Plates, price 14s. cloth. 
 
 A CLINICAL TREATISE ON THE ENDEMIC FEYERS 
 
 OF THE WEST INDIES, intended as a Guide for the Young Practitioner 
 in those Countries. By W. J. Evans, M.D. Octavo, cloth, price 9s. 
 
 " We strongly recommend this work to every medical man who leaves the shores of England 
 for the West India Islands. It is fuU of instruction for that class of the profession, and io deed 
 contains a great mass of materials that are interesting to the pathologist and practitioner of 
 this country." — Medico-Chirurgical Review. 
 
 A MANUAL OF PRACTICAL MIDWIFERY, containing a 
 
 Description of Natural and Difficult Labours, with their Management. In- 
 tended chiefly as a book of reference for Students and Medical Practitioners. 
 By James Reid, M.D., Lecturer on Midwifery at the W^ebb Street Medical 
 School. 5s. 6d. With Engravings. 
 
 "The relative diameters of the pelvis and the foetal head, and the different presentations 
 of the child, are aU usefuHy represented by wood engravings among the letter-press, 
 and the book is thus particularly well calculated to effect the objects of such a work."— 
 Lancet. 
 
PUBLISHED BY MR. CHURCHILL. 
 
 15 
 
 ELEMENTS OF THE THEORY AND PRACTICE OF 
 
 MEDICINE ; designed for the use of Students. By George Gregory, 
 M.D., Physician to the Fever Hospital. Fifth Edition, cloth, price 16s. 
 
 THE MORBID ANATOMY OF THE HUMAN EYE. 
 
 By James Wardrop, Esq., Surgeon to his late Majesty George IV. Second 
 Edition, illustrated with Eighteen coloured Plates. 2 vols, royal 8vo. 
 Price 30s. 
 
 " The republication of a work which no subsequent production on ophthalmology has 
 equalled, and which the whole existent range of works cannot supplant." — Lancet. 
 
 The price has been considerably reduced from the former Edition, but the 
 same regard has been paid to the fidelity and beauty of the colouring of the 
 Plates. 
 
 MEDICAL BIBLIOGRAPHY. BY JAMES ATKINSON, 
 
 Senior Surgeon to the York County Hospital, and late Vice-President of the 
 Yorkshire Philosophical Society. Vol. I. royal 8vo. 16s. 
 " We have never encountered so singular and remarkable a book. It unites the German 
 research of a Plouquet with the ravings of Rabelais, — the humour of Sterne with the satire 
 of Democritus,— the learning of Burton with the wit of Pindar." — Dr. Johnson's Review. 
 
 A PRACTICAL FORMULARY OF HOSPITALS, BRITISH 
 
 AND FOREIGN ; including all the Medicines in use. By Michael Ryan, 
 M.D., Member of the Royal CoUege of Physicians. The Third Edition, 
 considerably Enlarged and Improved. 5s. 6d. cloth. 
 
 By the same author, 
 
 THE MEDICO-CHIRURGICAL PHARMACOPEIA; 
 
 OR A CONSPECTUS OF THE BEST PRESCRIPTIONS. Containing 
 an account of all New Medicines, Doses, &c. ; Magendie's and Lugol's For- 
 mularies ; the Improvements in the London Pharmacopoeia. New Nomen- 
 clature ; the Treatment of Poisoning, Dislocations, Fractures, and Natural 
 and Dif&cult Parturition. 3s. 6d. cloth. 
 " A vast mass of information in this little work, all useful at the bedside of sickness, or in 
 the short hour of leisure from professional toils and anxieties."— Dr. Johnson's Review. 
 
 NOTES ON THE MEDICAL HISTORY & STATISTICS 
 
 OF THE BRITISH LEGION OF SPAIN ; comprising the results of 
 Gun-shot Wounds, in relation to important questions in Surgery. By 
 Rutherford Alcock, K.T.S., Deputy Inspector General of Hospitals, &c. 
 Octavo, price 5s. 
 
 PRACTICAL OBSERYATIONS ON THE PRESERVATION 
 
 OF HEALTH AND THE PREVENTION OF DISEASES ; compris- 
 ing the Author's experience on the Disorders of Childhood and Old Age. 
 By Sir Anthony Carlisle, F.R.S., late President of the Royal College of 
 Surgeons, and Senior Surgeon to the Westminster Hospital. 8vo, cloth, 8s. 
 
1 6 WORKS ON Anatomy, surgery, midwifery, etc. 
 
 A TREATISE ON HUPTURES. BY ¥. LAWRENCE, 
 
 F.R.S., Surgeon to St. Bartholomew's Hospital. Tlie Fifth Edition, consi- 
 derably enlarged. 8vo, cloth, 16s. 
 
 " The peculiar advantage of the treatise of Mr. Lawrence is, that he explains his views on 
 the anatomy of hernia and the difiPerent varieties of the disease in a manner which renders his 
 book peculiarly useful to the student. It must be superfluous to express our opinion of its 
 value to the surgical practitioner. As a treatise on hernia, presenting a complete view of the 
 literature of the subject, it stands in the first rank ; and for the surgeon, who does not make 
 ■ it his incessant and intimate study, it must be impossible either to think correctly or to act 
 » with judgment and decision in those cases, always difficult and complex, in which it becomes 
 requisite to operate on a strangulated intestinal tumour." — Edinburgh Medical and 
 Surgical Journal. 
 
 PRINCIPLES OF MILITARY SURGERY; comprising Obser- 
 vations on the Arrangement, Police, and Practice of Hospitals ; and on the 
 History, Treatment, and Anomalies of Variola and Syphilis. Illustrated 
 with Cases and Dissections. By John Hennen, M.D., F.R.S., Inspector of 
 Militaiy Hospitals. Third Edition, with Life of the Author, by his Son, 
 Dr. John Hennen. 8vo, boards, 16 s. 
 
 " The value of Dr. Hennen's work is too weU appreciated to need any praise of ours. We 
 are only required, then, to brmg the third edition before the notice of our readers ; and having 
 done this, we shall merely add, that the volume merits a place in every library, and that no 
 military surgeon ought to be without it." — Medical Gazette. 
 
 MEDICAL BOTANY; OR, ILLUSTRATIONS & DESCRIP- 
 TIONS OF THE MED'iCINAL PLANTS of the London, Edinburgh, 
 and Dublin Pharmacopoeias ; comprising a popular and scientific account of 
 poisonous vegetables, indigenous to Great Britain. By John Stephenson, 
 M.D., and James Morss Churchill, F.L.S. New edition, edited by 
 Gilbert Burnett, F.L.S., &c.. Professor of Botany in King's College, 
 London. In three handsome royal 8vo volumes, illustrated by Two hundred 
 Engravings, beautifully drawn and coloured from nature, price Six Guineas, 
 cloth lettered. 
 
 " So high is our opinion of this work, that we recommend every student at coUege, and 
 every surgeon who goes abroad, to have a copy, as one of the essential constituents of his 
 library." — Dr. Johnson's Medico-Chirurgical Review, No. 41. 
 
 " The price is amazingly moderate, and the work deserving of every encouragement." — 
 Medical Gazette. 
 
 " The authors of medical botany have amply redeemed the pledge which their first number 
 imposed on them. The work forms a complete and valuable system of Toxicology and Materia 
 Medica. It will prove a valuable addition to the libraries of medical practitioners and general 
 readers." — Lancet. 
 
 " The figures are equal, if not superior, to those of any other botanical periodical."— 
 Louden's Gardener's Magazine. 
 
 UNIFORM WITH THE ABOVE WORK, 
 
 MEDICAL ZOOLOGY AND MINERALOGY; OR, ILLUS- 
 
 TRATIONS AND DESCRIPTIONS OF THE ANIMALS AND 
 MINERALS EMPLOYED IN MEDICINE, and of the Preparations 
 derived from them ; including a Popular and Scientific Account of Animal, 
 Mineral, Atmospheric, and Gaseous Poisons. By John Stephenson, 
 M.D., F.L.S. Forty-five Coloured Plates ; royal 8vo, cloth, £2. 2s. 
 
 T. C. Savill, Printer, 107, St. Martin's Lane.