1852. From his history it appears that when at Georgetown, Demerara, he was very irregular and intemperate in his habits, that on the voyage home he was attacked with sickness, vomiting, headache, and loss of appetite, by which he was greatly reduced in strength, and confined to his berth for the greater part of the voyage, and since his return on the 18th of Nov. 1851, he has been confined to bed. Complains of great feebleness, and of daily becoming weaker. The countenance is wan, and expressive of great anxiety. Tongue coated posteriorly, red at the point and edges; has no desire for food, and what he does take is often rejected, bowels loose, severe spasmodic cough, respiratory murmur healthy; profuse perspiration, particularly at night, and after awakening from sleep; pulse 120, weak and small, heart's action normal, urine of a dark amber colour, density 1035, contains oxalate of lime in octohedral crystals, with a large quantity of the urate of ammonia. A mild nutritious diet, tepid sponging night and morning, a teaspoonful of the acidulated tincture of calumba every four hours.

Under this course of treatment he continued to improve daily. About the 1st of Feb. he went for a few weeks to the country; on his return ro trace of the oxalate of lime could be detected. Since then he has enjoyed good health.

Case 4.-John Anderson, aged 34, nervous temperament, by trade a cabinetmaker, consulted me on the 6th of July, 1852, for what he conceived to be an affection of the stomach. He informed me that about the middle of April preceding he began to lose his appetite, had slight pain in, and distension of the stomach, freqnently accompanied by heartburn, palpitation of the heart, and pain in the loins. When he called on me in July these symptoms were considerably aggravated; his pulse was 84, strong and full, the slightest excitement caused palpitation of the heart, and severe headache. He has no appetite for food, which when taken causes pain in the stomach, flatulence, and sometimes vomiting. Bowels confined, urine of a pale yellow colour, specific gravity 1042, contains oxalate of lime in octohedral and dumb-bell shaped crystals; a small quantity of urate of ammonia and epithelial scales. Acidulated tinct. of calumba every four hours, a grain of nitrate of silver night and morning, tepid bath, and to abstain from vegetable food.

He continued his course of treatment for five weeks, when the oxalate of lime entirely disappeared from the urine, the specific gravity fell to 1020, and he felt quite well. Since then I have not seen him.

Case 5.-On the 13th Jan. 1853, I was consulted in the case of J. M., aged 43, melancholic temperament. From his history it appears that in Jan. 1852, he had an attack of jaundice, accompanied by vomiting and pain in the stomach. The jaundiced appearance disappeared about the beginning of April; the vomiting and pain in the stomach, however, continued, but in a modified degree; towards the end of April a small tumour made its appearance in the epigastric region. Up to this date he has been gradually getting weaker and more emaciated, and for several weeks back he has been unable to leave his bed.

When I first saw him his complexion was of a dark yellow hue, and emaciation very great. He complains of intense pain in the stomach, which comes on in paroxysms, and generally causes sickness and vomiting, after which he experiences partial relief; the matter ejected has a dark coffee colour. Tongue coated posteriorly, and red at the point; bowels confined; pulse 106, small and weak, breathing slow but regular; has occasionally a pain in the loins, and along the anterior and inner side of the thighs and legs. On examination I found a tumour extending from the scrobiculus cordis downwards, to the extent of five inches, and on either side of the linea alba three inches. For several nights back he has been very restless, and unable to procure sleep. This morning's urine has a dark brown colour, specific gravity 1038, it contains mucus, epithelial scales, urate of ammonia, and oxalate of lime in dumb-bell crystals. Nitrate of silver in grain doses every six hours, friction to the skin, and light nutritious food.

19th. Can now retain his food, looks more cheerful, the abdominal tumour is considerably reduced in size, the urine is not so high in colour or density, still contains oxalate of lime.

27th. The abdominal tumour has entirely disappeared, which seems to have depended upon spasmodic contraction of the upper division of the rectus abdominis, feels stronger, and is able to take his food with relish.

Feb. 14. The oxalate of lime has entirely disappeared, he is now able to take a little exercise. Continue the nitrate of silver, night and morning.

On the 22nd he went to the country, where he still remains. When I last heard from him (on May 4th), his general health had greatly improved, and he felt nearly as strong as before his first illness.

Remarks.-1. From the history of these cases it will be observed that the most prominent symptoms were the epigastric pain, vomiting and emaciation; indeed the emaciation in the first and last cases was so great as to resemble the emaciation in the last stage of scirrhous pylorus. In all, but particularly in the first and last cases, the symptoms and appearances of poisoning by oxalic acid were well marked, which led me to examine the egesta for this poison, but I could detect none. In such cases as the preceding, guided solely by the symptoms, we should most certainly form an erroneous diagnosis; and here the value of microscopic, as well as chemical analysis of the urine, becomes apparent. The symptoms should not, however, in any case be undervalued; but when we can with certainty, and by a simple process, discover the cause which produces certain symptoms, we can with more confidence select the proper therapeutic agent. We, moreover, observe from these, that in all cases where the oxalate of lime is in octohedral crystals, the nitro-muriatic acid, combined with a vegetable tonic, will in most, if not in all cases, effect a cure.

2. That in those cases where the crystals assume the dumb-bell form, nitrate of silver appears to be particularly serviceable.

3. That when both kinds of crystals are present, these medicines should be given alternately.

The internal use of nitrate of silver has been generally objected to, from the effect it produces on the skin. I have frequently given in repeated doses of one grain, as much as 60 grains, without producing any discoloration.-Glasgow Med. Journal, Oct. 1853, p. 311.

72.-ON MORBID CONDITIONS OF THE URINE CONNECTED WITH CHRONIC DISEASE.-INDIGESTION.

By DR. H. BENCE JONES, F.R.S., &c.

[Some time ago Dr. Bence Jones pointed out that frequently in a healthy person, when much acid exists in the stomach, the urine becomes alkaline. It becomes thick when boiled, but clears with nitric acid. This alkaline state of the urine is often caused by an irritable stomach, that is, indigestion, owing to insufficient air and exercise. It is not permanent, but varies in the same day, and exists only or chiefly when the stomach contains acid.]

The indications for treatment of alkalescence from fixed alkali are:

1st. To remove the cause; that is, to lessen the irritability of the stomach. 2ndly. To correct the state of the urine.

In the slight form of the disorder which probably is frequently to be met with in many of us, little or no medical treatment is requisite. Less work, more air and exercise, mild, unirritating, nutritious food, will remove the alkalescence, which for the most part can be found by emptying the bladder directly after breakfast, and again in two hours.

In severe cases, acids and tonics are indicated.

Of acids, the vegetable acids are most efficacious in correcting the state of the urine. They can be taken in larger quantities than the mineral acids, the intensely acid taste of which prevents a great increase in the dose.

The most frequent method of giving vegetable acid is in lemon juice, which has no definite composition. The specific gravity of one specimen I found was 1038'4; another, 1036-0; a third, 1037 9. Supposing that half an ounce saturates a scruple of carbonate of potash, then seventeen grains of dry citric acid are equivalent to half an ounce of lemon-juice. Each lemon contains about an ounce of lemon-juice, so that a lemon is equivalent to about thirty-four grains of citric acid, and twelve ounces of lemon-juice would equal six drachms, two scruples, eight grains of citric acid, or 408 grains. Now, I have found by experiment that this quantity of lemon-juice, taken in two doses of six ounces each dose, repeated in three hours, did not cause any pain in the bowels, and it occasioned very little uneasiness to the stomach, which XXIX.-10.

was empty when the first dose was taken. It very decidedly increased the acidity of the urine, and it distinctly precipitated uric acid when the urine stood for some hours. This may be considered as resembling the effect of about 408 grains of citric acid in twelve ounces of water. Tartaric acid was taken dissolved in distilled water, in two doses of fifty-four grains each, in an hour and a quarter, without any uneasiness, but it caused very considerable pain in one hour. The pain, which was marked intermitting at short intervals, lasted nearly three hours. Then the bowels were inclined to act, but no action took place. This was the effect of 108 grains of tartaric acid. A second experiment, in which 162 grains were taken in an hour and threequarters, caused the same symptoms. The acidity of the urine was considerably increased.

It is probable from these experiments, that—

1. The solution of tartaric acid was not absorbed from the stomach, but passed into the intestines, and would have passed, partly at least, through them. 2. That the stomach is less sensitive than the intestines. The pain was not felt in the stomach, but was very severe in the bowels. 3. Tartaric acid is more than twice as irritating as citric acid in lemon-juice. The quantity of potassa in lemon-juice is too small to produce any very decided neutralising effect, the total ash in an ounce of juice being less than a grain and three quarters.

[But there is another kind of alkaline urine, viz., that from volatile alkali, the first being from fixed alkali.]

The alkalescence from volatile alkali, whether caused by injury of the spinal cord, or from any other cause, owes its origin generally, if not always, to inflammation of the mucous membrane of the urinary organs. This gives rise to altered mucus and pus. The mucus determines the decomposition of the urea, changing it into carbonate of ammonia, which neutralises the acidity of the urine, and finally precipitates the phosphate of lime, and forms phosphate of ammonia and magnesia, which afterwards crystallises out. The carbonate of ammonia lastly acts on the mucus and pus globules, making them adhesive, and forming the so-called ropy mucus, or, as it often had better be called, ropy pus, which is seen by the microscope to consist of crystals of phosphate of ammonia and magnesia, and of granules of phosphate of lime as well as of adhering mucus or pus cells.

The causes of inflammation of the mucous membrane of the urinary organs are innumerable. I should weary you by relating cases of acute or chronic inflammation of the bladder or kidneys from foreign bodies irritating the membranes, from injuries, whether cutting or crushing, from pressure caused by stricture or prostatic disease, from idiopathic or specific inflammation, as the extension of gonorrhea; the action of strongly stimulating medicines; from the secondary effects of many other diseases, as scarlet fever, Bright's disease, malignant diseases, scrofulous diseases. The ultimate results of alkalescence from volatile alkali are the formation of a fusible calculus and an irritable bladder.

Instances of the former result appear in very many of the calculi in the Museum. The white deposit, scarcely in a single instance is succeeded by any other deposit; that is, the inflammation of the bladder, when once it is set up, does not yield to treatment as long as the cause of the inflammation (the foreign body in the bladder)

remains.

From whatever cause inflammation of the bladder arises it must be treated in the acute stage, as you would treat acute bronchitis, remembering that the urine is to the inflamed bladder what the air is to the inflamed bronchial tubes. The acidity of the urine must be lessened in order to lessen its irritating property. In doing this the opposite extreme must be carefully avoided, because the tendency is to alkalescence of the urine, and if this is produced a greater degree of irritation results.

Special remedies are generally to be used only when the inflammation becomes more chronic. Judging, however, from the treatment of acute gonorrhoea and acute conjunctivitis, it is possible that the early use of astringent remedies might be beneficial; but as yet I can give you no exact information on this treatment.

Some of the special remedies for chronic inflammation of the bladder are, buchu, pareira brava, turpentine, cubebs, copaiba. The properties of the three lastmentioned substances are so well known that I shall not dwell on them here. But, regarding the use of the two first named remedies, I think there is some

uncertainty. At least, I remember well the time when I was unable to determine the rules which might guide me in prescribing buchu, pareira, and uva ursi. The last medicine, you will remember, has been already mentioned in these lectures. It is an astringent. It acts like gallic and tannic acids, and therein is its use and distinction from the other two medicines. It has been said buchu does good when pus is present in the urine, and pareira brava is good when there is ropy mucus. From what I have said in this lecture, you will immediately see that this rule says, buchu is good when the urine is acid; pareira when it is alkaline. Now, there is nothing in the composition of the active ingredients of the two medicines which would make this a good reason for the rule. The buchu contains a peculiar extractive and a volatile aromatic oil; this last brings it into the class with camphor, turpentine, cubebs, &c.; while pareira brava contains starch, nitre, and a peculiar tonic extractive matter. Now, from this it would result, that it is more a demulcent than a stimulant; and the reason for the rule may be contained in this,—that, for the most part, when the pus is ropy from alkalescence, there is more irritability of the bladder than when the urine is acid and the pus globules separate. And, in accordance with this I find that pareira brava is of more service than buchu when there is much irritation. When there is a languid, sluggish state, without much irritation, the buchu is then the most useful remedy. Shortly, then, the rule which I propose to you is this:-When you want a stimulant give buchu; when you want a demulcent, give pareira brava; when you want an astringent, give uva ursi. [It is scarcely necessary to add, that when the urine is foul from a retention of the residue in making water, the bladder should be emptied twice daily.]—Med. Times and Gaz., April 15, 1854, p. 368.

73.-ON PASSIVE HEMORRHAGE FROM THE KIDNEYS.

By DR. E. G. CROOKE, Chorley, Yorkshire.

[It is not always easy, when we are quite certain that the urine contains blood, to be able to state definitely from what part of the urinary apparatus it proceeds. Dr. Crooke is of opinion that it often precedes that condition in which albumen is present in the urine, viz: "chronic albuminous nephritis," and that it often insidiously follows "acute desquamalive nephritis," which is supposed to have yielded to treatment.] Symptoms.-Passive renal hemorrhage offers to our notice two classes of symptoms-the general and the local. The general are those of anemia, the result of a continual draining away of that vital fluid, the blood; the local refer chiefly to the bladder. The general symptoms are, a pallid complexion, of a dirty-white or muddy colour; with dilated pupils; occasional headache and singing in the ears; the tongue is large, flabby, and furred, the edges thereof indented by the teeth; the bowels are open and loose; there is much flatulence and nausea, with irregular appetite; palpitation is frequent; the surface of the body is cool; the skin soft and relaxed, but dry; the pulse full, soft, and bounding, or small and soft, putting on the former condition upon change of posture; there is gradual but progressive emaciation, irritability, and gloominess of temper, with great disinclination to any exertion, bodily or mental. These symptoms vary in degree according to the longer or shorter duration of the disease.

2nd. The local symptoms are in some cases an aching pain in the loins, but this is perhaps, rather an exception than the rule. They, the loins, are rather the seat of an uneasiness and feeling of weakness, which is increased upon pressure; the calls. to micturate are frequent and urgent, attended with pain, sometimes referrible to the penis, sometimes to the inside of the thighs and to the perineum; the urine is not much, if at all, increased in quantity when compared with the amount of fluids imbibed.

Pathological Indications of the Urine.-The usual quantity of fluids being taken into the stomach, the average daily amount of urine excreted may be stated at about fifty ounces. The specific gravity ranges from 1015 to 1033, the latter being the standard of the urina sanguinis. A gradual reduction in the weight of the urine has been observed in those cases which have been attended with frequent relapses. The colour is that of pale golden sherry; the odour is sweet; when recently passed, it has barely any action on litmus paper. A distinct alkaline reaction upon reddened.

litmus has not, however, been observed. When poured into a test-tube, a very slight cloud may be seen floating near the bottom; if allowed to stand for an hour or so, a small opaline deposit, easily dispersible, will form. The recent urine is unaffected by heat, or NO, HO; but if allowed to stand after their action, a small flocculent precipitate sometimes forms; occasionally, however, no precipitate is visible to the naked eye. Of that portion which is allowed to stand, the supernatant liquid is unaffected by heat, and NO, HO: the deposit, however, is dissolved by the latter, indicating the presence of phosphates; and when heat is applied to the mixed fluid, as in the recent urine, a precipitate may or may not be the result. Upon submitting a drop of the recent urine to the field of the microscope, blood-discs, turgid or collapsed, single and not aggregated, together with epithelial cells and occasional cases of the uriniferous tubes, are seen; no pus-globules have been detected. Such are the usual characteristics of the urine; but the action of concurrent causes, as exposure to cold and the imbibition of diuretic fluids, renders the urine acid for a time, when crystals of uric acid and of the lithates, with blood-discs, are seen.

66

It will be observed that the symptoms, general and local, are those of that form of renal disease termed by Rayer Chronic Nephritis," but that there is an impor tant difference in the character of the urine. In treating of this " chronic nephritis," Dr. Christison states (‘Lib. of Med.,' vol. iv. p. 270) that the urine very seldom contains blood or albumen, unless other renal diseases concur." However, of that form of renal disease now under notice, blood-globules have been invariably contained in the urine, but could only be detected with certainty by the microscope. Liability to passive renal hemorrhage appears to be either constitutional or acquired. Persons constitutionally predisposed are those of lax fibre, fair complexion, with skin soft and supple, easily excited to action, but as readily depressed; persons of a tuberculous tendency, prone to affections of the mucous membranes, as catarrh, bronchitis, diarrhoea, &c., whose arterial system is in that state which may be termed irritable. Such!a constitution appears, as it were, acquired by two other classes, who are specially prone to this hematuria-viz., those who are in the habit of consuming large quantities of diluent fluids, as haymakers, reapers, engineers, stokers, bleachers, tenters, dressers, and spinners in cotton mills-persons who, after exciting great cutaneous action by severe manual labour, or by working in a high artificial temperature, check the same by exposure to a much cooler atmosphere after the cessation of their daily employment. The habitual dram drinker is most prone to the acute form of Bright's disease, or to that stage which probably supervenes upon this-viz., that in which the urine is of low specific gravity, and contains free albumen. May not the frequent use of spirits, from their direct action upon the kidneys, by over-stimulating the organs, produce this hematuria, which may ultimately pass on to "chronic albuminous nephritis"? It may be observed, that of several cases of "passive renal hemorrhage" which have occurred in the practice of the writer, not one could, as far as the patient's recollection served, be traced to any dropsical affection, proximate or

remote.

The average age of the persons affected was above thirty-five years; they were chiefly of the male sex, probably on account of the greater exposure of males to the predisposing and exciting causes, which latter appeared, as far as they were traceable, to be exposure to cold damp air when in a state of perspiration, frequent use of diuretic spirituous liquors-in fact, any circumstance which, depressing the heat of the body, produced congestion of the viscera.

Pathology of the Disease. The presence of blood in the urine affords ample proof of the existence of hemorrhage from some part of the genito-urinary passages, the state in which the blood-discs are found, the inadequacy of chemical re-agents to detect them, the occasional casts of uriniferous tubes, and the natural colour of the urine, indicate that the hemorrhage is renal, yet not of an active kind. But the comparative paucity of the globules discharged would lead to the conclusion that the kidneys are not suffering from any organic lesions, but from an unbalanced state of their circulation. This state of venous engorgement may probably exist for some time without any structural change in the glands themselves, but unless relieved it is apparent that exudation will ultimately occur, and derange the whole action of these excernent organs. The actual progress of this hematuria into chronic albuminous nephritis has not been traced, the remedies used in the cases, of which this