FOOTNOTES:
[18] Ed. Med. and Surg. Jour.
[19] Ed. Med. and Surg. Jour. July, 1821.
[20] Dict. des Sciences Medicales.
[21] There can be no particular benefit derived from the distillation. The simple mixture of the materials, above indicated, is all that is necessary. Chabert's remedy is therefore easily prepared.
[22] Lond. Med. Repos. April, 1825.
Article X.—Researches Physiological and Pathological, instituted principally with a View to the Improvement of Medical and Surgical Practice. By James Blundell, M. D., Lecturer on Physiology and Midwifery at the United Hospitals of St. Thomas and Guy. London, 1824, pp. 146, 8vo.
Dr. Blundell is the author of some celebrated experiments on the physiology of generation, and the transfusion of blood. The work at present under consideration consists of physiological observations and experiments, the substance of a paper read before the Medico-Chirurgical Society of London, in the year 1823, and not heretofore published; of experiments on a few controverted points, respecting the physiology of generation; and lastly, of some remarks on the operation of transfusion.
The first part seems intended to ascertain what degree of lesion, or losses by extirpation, the body may sustain without inducing death; and thus, to open a way for improvements in surgery, by rendering the surgeon not only more bold and fearless, but more frequently successful in his attempts to preserve life, or counteract the inconvenient effects of disease and accidents. We shall make a short analysis of the first paper.
In four experiments, Dr. B. removed the left kidney of the rabbit, by incision on the outer edge. Ligatures were applied to prevent bleeding.
Two died; one in 60 hours, the other in 4-1/2 days: both of inflammation. One recovered, and lived 5 or 6 weeks, and then died. The 4th also recovered, but died in 5 or 6 weeks. On examination, a sac was found (in place of the kidney) filled with a semi-fluid substance, resembling custard, p. 4.
In seven rabbits, removed the spleen. One recovered permanently, and one lived six months. p. 5.
In five rabbits, opened the abdomen, and punctured the fundus of the bladder with a lancet. Three of them recovered entirely. p. 6.
In two rabbits, cut off one-fourth of the bladder with scissors, having applied a ligature first. One died in seven months; the other still lives in good health.
Into the peritoneum of four rabbits, threw ℥i of human urine; then washed it out by injecting tepid water. One died of collapse in less than 24 hours, and two of inflammation, in 60 and 19 hours respectively. The fourth is now (12 months) in good health. p. 7.
In seven, injected ℥xi decoct. quercûs into the peritoneum. Only one recovered.
Dr. B.'s inferences from the foregoing experiments are:
1st. "Large apertures into the peritoneum of the rabbit, do not immediately induce a dangerous prostration, of strength." p. 9.
2ndly. "Large apertures into the peritoneal sac of the rabbit, are not necessary, nor perhaps generally, productive of fatal inflammation."
3dly. "In the rabbit, the kidney, the spleen, and a large piece of the bladder may be extirpated, without necessarily causing death; though death under the first operation is probable." p. 10.
4thly. "When the abdomen is laid open, and parts are removed from it in the rabbit, the first danger arises apparently from collapse; the second from general inflammation; and the last from chronic disease." (Vide experiments.)
5thly. "The rabbit's abdomen is very tender, probably no less so than that of man." See exper.
6thly. "Success in abdominal operations on the rabbit, furnishes a presumption in favour of success in similar operations on the human abdomen; and, therefore, from these experiments, we may infer, presumptively, that moderate openings into the human peritoneum will not necessarily, nor even generally prove fatal from inflammation or otherwise; and further, that certain viscera or parts of viscera, not essential to the welfare of our structure, may be removed from the belly, without necessarily, or even generally, producing death. The extirpation of the kidney must be highly dangerous; but there is a presumption in favour of the successful removal of the spleen, the ovaries, or even of large pieces of the bladder." p. 11, 12.
Dr. B. having stated the foregoing results and inferences, proceeds by relating instances of severe injury sustained by the human body, without being followed by death. These are confirmatory of his inferences from the experiments on rabbits. The instances given are—an os uteri torn off; extensive laceration of the uterus and rectum in labour; four uteri extirpated on account of chronic inversion, (p. 13.) One of these last under his own care. It was removed by a wire, and came off in 11 days, without one bad symptom, (p. 14.) Rupture and laceration of the abdominal coverings, four fingers' breadth, the bowels hanging out, (p. 14.) Two spleens removed; one in a soldier after the battle of Dettingen, who recovered without inconvenience afterwards; the other in a Mexican, whose case is related by Dr. O'Brien, in his Inaugural Essay, Edinb. 1818, (p. 15.) Three cases of rupture of the dropsical ovary. Two cases of opening into the abdomen, for the extirpation of dropsical ovaries, (p. 18.) Five cases of laceration of the uterus by natural efforts. Four of the women died, but in the fifth, Dr. Blundell turned and delivered, after the child had escaped into the peritoneal sac, and the woman recovered, (p. 20.) Cesarian operation, three times by friend of Dr. Haighton; once successfully, (p. 22.)
Dr. B. says, "From these (facts) few as they are, I feel conscious that no certain inference can yet be drawn; though presumptive inferences certainly may, and they seem to me to be the following:
"1st. Small wounds, as tapping, hernia, &c. do not induce fatal peritonitis; and therefore the vulgar opinion that inflammation in a spot of the peritoneum will almost invariably diffuse itself over the greater part of it, is probably unfounded.
"2nd. Extensive divisions of the peritoneum are not necessarily fatal by inflammation or otherwise, and probably not generally so.
"3d. That the womb, spleen, and ovaries, may be removed in the mode mentioned, without necessarily, and, presumptively, without generally destroying life.
"4th. That the gravid uterus may be torn open; the child may escape into the peritoneal sac; the os uteri may be torn off: not indeed, so far as these cases may be relied on, without great danger, but twice, in seven instances, without death. p. 28.
"5th. The peritoneum and abdominal viscera will bear more injury than the British surgeons seem disposed to admit.
"6th. That the above observations on the human abdomen, are in unison with those drawn from observations on the rabbit; and that observations made on the brute have more correspondence with those on the human being, than is generally believed."
Dr. Blundell next remarks, that the facts related create a suspicion that a bolder abdominal surgery would not be unattended with success, and recommends the following operations to "consideration merely, and not to practice, except in otherwise desperate cases."
1st. "When the Cesarian section is performed, divide or remove a small piece of Fallopian tube, so as to prevent the danger of reimpregnation, without destroying the sexual propensity. The need for a second operation might thus be certainly prevented, without scarcely increasing the danger."
2ndly. "Extirpation of healthy ovaries."
3dly. "The extirpation of the ovarian cyst in scirrhus, combined with dropsy, or in simple dropsy." He remarks, "This operation will, I am persuaded, ultimately come into general use; and if the British surgeons will not patronize and perform it, the French and American surgeons will." p. 26.
4thly. "The removal of a large circular piece of the cyst in ovarian dropsy, when the sac itself cannot be extirpated."
5thly. "The removal of the cancerous womb, when the ulceration first makes its appearance. Might not the womb be taken out above the symphysis pubis, or through the outlet of the pelvis?" &c. 27.
6thly. "Extirpation of the puerperal uterus." He suggests the removal of the whole womb after the Cesarian section, in order that the smaller might take place of the larger and more formidable wound through the uterus—but says expressly, "No operation perhaps can be more unpromising, shall I say more unjustifiable, in the present state of our knowledge; but I thought it proper to mention it." &c. p. 28.
7thly. "Should the bladder give way into the peritoneum," he asks, "Why should we not lay open the abdomen, tie up the bladder, discharge the urine, and wash out the peritoneum thoroughly, by the injection of warm water?" p. 28.
8thly. - - - - -
9thly. Injection of astringents into the ovarian cyst or peritoneal sac, unjustifiable.
10thly. "In cases of strongly characterized introsusception," why not make an opening into the peritoneum; and "pass the small intestines, fold by fold, through the fingers." Dr. B. has repeatedly done this in the dog and rabbit, without producing death, or extensive and dangerous inflammation.
11thly. In the rabbit, he has tied an abdominal artery, and carried the end of the ligature with a broad needle out through the back, opposite to the place of the vessel. This ligature can come away, and is a better mode than to leave it hanging out at the abdomen, or entirely among the bowels, where it forms a sac of puriform matter, and to appearance lays the foundation of chronic disease. p. 30.
Dr. Blundell closes this paper by saying, that since the substance of it was read before the Medico-Chirurgical Society in 1823, Dr. Ritzius, a Swedish physician, had informed him in London, "that the complete removal of the cancerous womb had been, to his personal knowledge, performed on the Continent five times. All the patients recovered from the operation," &c. "The womb was removed through the outlet of the pelvis." p. 36.
Since we read Dr. Blundell's recommendations to the new operations, we have been astonished to notice in the Ed. Med. and Surg. Journal, July, 1825, that a German surgeon had actually treated a case of ileus in the manner recommended by Dr. B. It is from Hufeland's Journal of Feb. 1825. After it was ascertained that an immoveable introsusception existed—
"The patient was placed on a convenient table. We examined accurately the situation of the hardening, (which marked the diseased part), and determined on opening the abdomen at the outer edge of the right rectus muscle, about two inches above the navel. After dividing the integuments with a common scalpel, and making a small opening in the peritoneum, I introduced my finger, and with a blunt pointed scalpel divided the peritoneum, so as to make it correspond with the external opening, which was between two and three inches. I then besmeared my hand with oil, and carried it into the abdomen, in order to feel for the indurated part. Scarcely had I introduced my hand, than an attack of the pain came on, and a portion of the intestines was protruded through the wound, which was immediately replaced by my assistant. On continuing the examination, I discovered in a transverse portion of the ileum, a foreign substance, just where the hardened intestine was to be felt. I drew the intestine out, in order to examine it more minutely. The intestine was neither inflamed nor expanded, but it contained in its cavity a soft coherent and compact mass, which at its upper part was somewhat compressed, and thus felt harder than the rest. So far as I could follow this part of the intestine, this contained matter was to be felt: I also here immediately detected an intus-susception, but in spite of all my efforts I could not reach the commencement of it, so as to bring it out. Two modes of proceeding were open to me, in order to remove the intus-susception; either to make a transverse incision in the integuments, from the right to the left side, or to open the intestine itself. The last mode seemed to me the most adviseable, both because the patient was already very much exhausted, and because the operation would be sooner completed. The intestine was opened at the end of the discovered intus-susceptio, and immediately a part of the strictured intestine came into view. I introduced my finger into the opening in the intestine, which was made about two inches in length, and gradually pushed the intus-suscepted part back from the right to the left side, whilst I gently drew that part of the intestine which contained the intus-susceptio towards me. By this means I fortunately succeeded in unfolding the tangled intestine, which amounted to two feet in length. There was not the slightest trace of inflammation, nor any thing unnatural to be discovered in the part; there was merely a round worm, which was situated in the upper part of the intus-susceptio. The intestine was brought together by means of six spiral stitches, after the manner of the glover's suture, and the end of the silk was allowed to hang out of the external wound in the abdomen."
The sutures were removed on the 8th day. On the 14th day, the man was cured, and continues well up to the date of the account.
Article XI.—An Inquiry into the Nature and Treatment of Diabetes, Calculus, and other Affections of the Urinary Organs. By William Prout, M. D., F. R. S. From the second London Edition, published in 1825; with Notes and Additions, by S. Colhoun, M.D. Philadelphia, Towar & Hogan, 1826; pp. 308.
A very acceptable service has been done to the medical profession in this country, by the present republication of Dr. Prout's work on affections of the urinary organs. The American physician will now have it in his power, at a reasonable cost, to possess one of the best treatises on this interesting subject. From the known accuracy of Dr. Prout as a chemist, and his reputation as an accurate observer of nature, much new light was naturally expected as the result of his observations. Nor indeed have these high expectations been disappointed. After a careful perusal of his work, we have formed the highest opinion of his powers, both as an original thinker, and experimental inquirer.
Dr. Prout begins his treatise with some introductory remarks on the composition of the urine, and on urinary derangements generally. After giving a comparative tabular view of the composition of the blood, and healthy and diseased urine, he proceeds to notice in succession, their principal constituents. As albuminous urine is of frequent occurrence in dropsical complaints, and its presence regulates in some degree the practice proper to be pursued, the following characters, given to it by Dr. Prout, should be well understood.
"Albuminous urine, on being exposed to a temperature of about 150° becomes opaque, and deposites this principle in a coagulated state. The precipitate varies considerably in its appearance in different instances. Sometimes it is of a firmer character, and similar to that formed by the serum of the blood, from which, in this case, it may be supposed to be derived; at other times it is very delicate and fragile in its texture, and somewhat resembles curd, when it may be supposed to be of chylous origin. In some instances, the effects of heat upon albuminous urine are increased by the addition of nitric acid. But the most delicate test of albuminous matter in general is dilute acetic acid, and the prussiate of potash." p. 6.
Dr. Prout combats very successfully the opinion, generally entertained by chemists, that the power of healthy urine to redden litmus depends on the presence of free lithic acid.[23] That this power cannot depend upon lithic acid uncombined, is made evident to Dr. P. by its sparing solubility; it requiring, according to our author, 10,000 times its weight of water to dissolve it, or six times as much as is stated by Dr. Henry. The reddening power of the urine is attributed by Dr. Prout to the presence of lithate of ammonia, and superphosphate of ammonia: the former of which, contrary to what might be expected, is found capable of reddening litmus, and of remaining in solution with the latter, without decomposition.
The following interesting remarks are made by Dr. Prout on the effects of muriatic acid, in precipitating lithic acid gravel:
"The muriatic acid, in combination with soda and potash, occurs both in the blood and in the urine; thus appearing to pass through the kidneys unchanged. This acid and its compounds formerly appeared to be of less importance in a pathological point of view than any other similar principles existing in the urine: but since the unexpected fact has been ascertained, that muriatic acid in a free state exists abundantly in the stomachs of animals during the process of digestion, I have attended a little more closely to the appearance of this principle in the urine, and am disposed to believe, in consequence, that it is the cause of the precipitation of lithic acid gravel from the urine more frequently than any other acid. I do not mean to say, that it is the immediate cause of the precipitation of this acid; for in most instances, it acts like all powerful acids do under similar circumstances, namely, 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, while the latter precipitates the lithic, &c. If this opinion be well founded, as I believe is the case, the muriatic acid may be considered of very great importance, not only in a pathological, but a physiological point of view; for if the muriatic acid, found in the urine in such instances, be supposed to have its origin in the digestive organs, we see at once the reason why the deposition of gravel is so liable to be influenced by the derangements in general, and more especially by the acidity, of the stomach."
"The muriatic acid may be shown to exist in the urine by the white curdy precipitate insoluble in nitric acid, which is formed, when the nitrate of silver is added to it, after the sulphuric and phosphoric acids have been removed by the nitrate of barytes or lead." pp. 20 and 21.
After finishing these introductory subjects, Dr. Prout proceeds to the consideration of the diseases of the urinary organs themselves; which he divides into functional, mechanical, and organic. Under functional diseases, we have first, those, in which principles soluble in the urine are morbidly deranged in quantity or quality, embracing three chapters; and secondly, those affections, in which principles insoluble in the urine are morbidly deranged in quantity or quality, comprising six additional chapters. Under the first subdivision, the first chapter is on the affections, characterized by albuminous urine; the second, on diseases, in which an excess of urea is the characteristic symptom; and the third, on diabetes.
The diseased derangement, consisting in an excess of urea in the urine, has not been particularly noticed by any writer before Dr. Prout, who believes that it has probably been confounded with that form of diabetes, called diabetes insipidus. The state of the urine and symptoms in this species of urinary derangement are thus described by our author:
"The average specific gravity of the urine seems to be a little above 1.020, and occasionally to vary from 1.015 to 1.030. Most generally it is pale, but occasionally it is high coloured, and exhibits somewhat the appearance of porter, more or less diluted with water; and this variety in appearance not unfrequently takes place in the urine of the same person. When first voided, it reddens litmus paper. For the most part, it is entirely free from sediment, except the mucous cloud of healthy urine; and the only remarkable property which it appears to possess, is that of containing abundance of urea; so that on the addition of nitric acid, crystallization speedily takes place. From the quantity of urea present, it is very prone to decomposition, and soon becomes alkaline, especially in warm weather.
"There is almost constantly in these diseases, a frequent and urgent desire of passing water both by night and day. This desire is for the most part evidently excited by actual diuresis, or the increased quantity of urine; but frequently it cannot be ascribed to this cause, as the quantity voided at one time is often by no means considerable; though in almost every instance that has fallen under my observation, the total quantity voided during any given time has appeared to be greater than natural. The quantity appears also to be particularly liable to be increased by cold weather, and by all causes producing mental agitation. There is sometimes a sense of weight or dull pain in the back, but this is by no means a constant symptom. There is also occasional irritation about the neck of the bladder, which sometimes extends along the urethra. The functions of the skin appear to be natural; at least in every case which has come under my own observation, perspiration has been rather easily induced. The pulse is not affected. There is no remarkable thirst, nor craving for food, except in extreme cases; nor are the functions of the stomach and bowels much deranged. Hence for the most part the tongue is clean, and the dejections regular and apparently natural.
"In most of the cases of this disease, which have hitherto fallen under my own immediate observation, the subjects have been middle-aged men, of thin and spare habit, with a sort of hollow-eyed anxiety of expression in their countenance, free from gout and constitutional disease in general, and, as far as could be ascertained, from any organic defect in the urinary organs. In every instance they had been induced to apply for medical advice, not so much from the pain, as from the inconvenience of the disease, and the dread of its ending in something worse; and, what may be worth remarking, in several instances confessed, that they had been addicted to masturbation from very early youth," p. 41, et seq.
The remedy for this morbid derangement in the urinary secretion, most successful in the hands of Dr. Prout, was opium, either administered alone, or in conjunction with alkaline medicines. It is rather a rare affection. When not arrested, it is liable, according to Dr. Prout, to pass into diabetes.
In his chapter on diabetes, our author makes many interesting remarks; but the space we are enabled to devote to this analysis, will permit us only to make an extract, which seems to prove a close connexion between the disease characterized by an excess of urea, and diabetes.
"It has been mentioned in the preceding pages, that an excess of urea frequently precedes the appearance of saccharine matter in the urine. Now it is a remarkable fact, that in diabetes, in proportion as the saccharine matter diminishes, that of urea generally increases; and in such instances, the presence of the former principle can not only be no longer distinguished by the sensible properties of the urine, but scarcely be demonstrated by the utmost skill of the most experienced chemist, though the specific gravity of the urine may at the same time be nearly 1.040. I have recently been favoured by Dr. Elliotson with the most complete and remarkable change of this description that has yet occurred to me. The patient, besides being diabetic, was in the last stage of phthisis, of which he died shortly afterwards. The quantity of urine passed daily, when I first examined it, was six or eight pints; its specific gravity was 1.038, and it contained a large proportion of very white sugar and very little urea. Dr. Elliotson under these circumstances gave opium, beginning with gr. i, and increasing the dose to gr. iii, thrice a day. The opium produced stupor, and was obliged to be discontinued; but the effects produced upon the urine by its means were most remarkable. In about 60 hours, the quantity of urine diminished to two pints, its specific gravity was reduced to 1.0174, the saccharine matter had apparently disappeared, and was superseded by urea, the quantity of which had become excessive. This alternation of a principle containing nearly half its weight of azote, with another containing no azote at all, is perhaps, one of the most singular facts occurring in physiology." p. 74.
The second subdivision of functional urinary diseases comprises six chapters: first, on urinary gravel and calculi; second, on the data, showing the comparative prevalency of different forms of urinary deposite, and the order of their succession; third, on the lithic acid diathesis in general; fourth, on the mulberry or oxalate of lime diathesis; fifth, on the cystic oxide diathesis, and sixth, on the phosphatic, or earthy diathesis.
Under the first chapter, we have an account of I. Pulverulent or amorphous sediments; II. Crystallized sediments, or gravel; and III. Solid concretions, or urinary calculi. Of the latter, our author enumerates thirteen species.
1. The lithic acid calculus.
2. The lithate of ammonia calculus.
3. The oxalate of lime, or mulberry calculus.
4. The cystic oxide calculus.
5. The bone earth, or phosphate of lime calculus.
6. The triple phosphate of magnesia-and-ammonia calculus.
7. The calculus, composed of a mixture of the phosphate of lime, and triple phosphate of magnesia-and-ammonia, or fusible calculus.
8. The alternating calculus.
9. The mixed calculus.
10. The carbonate of lime calculus.
11. The xanthic oxide calculus.
12. The fibrinous calculus.
13. The prostate calculus.
Of these, the 2nd, 4th, 5th, 9th, 10th, 11th, 12th, and 13th species are more or less rare, and consequently of less interest. The remaining 5 are of much more frequent occurrence, and are thus described by our author:
"The lithic acid calculus is generally of a brownish-red, or fawn colour; but occasionally of a colour approaching to that of mahogany. Its surface is commonly smooth, but sometimes finely tuberculated; and upon being cu t through, it is usually found to consist of concentric laminæ. Its fracture generally exhibits an imperfectly crystallized texture, sometimes an amorphous or earthy one, in which case, it usually contains a mixture of other substances. This is one of the most common species of calculi.—Chemical characters. Before the blow-pipe, this calculus blackens, emits a smoke having a peculiar odour, and is gradually consumed, leaving a minute quantity of white ash, which is generally alkaline. It is completely soluble in caustic potash, and precipitable 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."
"The oxalate of lime, or mulberry calculus, is generally of a very dark brown colour, approaching to black. Its surface is very rough and tuberculated (hence the epithet of mulberry.) It is usually hard, and when cut through exhibits an imperfectly laminated texture. This species of calculus seldom surpasses the medium size, and is rather common. There is a variety of it remarkably smooth, and pale coloured. These are always of small size; and from their colour and general appearance, have been termed the hempseed calculus.—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 alkaline substance is the caustic lime deprived of its oxalic acid."
"The triple phosphate of magnesia-and-ammonia calculus is always nearly white; its surface is commonly uneven, and covered with minute shining crystals. Its texture is not laminated, and it is easily broken and reduced to powder. In some rare instances, however, it is hard and compact, and when broken exhibits a crystallized texture, and is more or less transparent. Calculi composed entirely of the triple phosphate of magnesia-and-ammonia are rare; but specimens, in which this salt constitutes the predominant ingredient, are by no means uncommon.—Chemical characters. 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 crystallized form.
"The calculus composed of a mixture of the phosphate of lime and triple phosphate of magnesia-and-ammonia, or the fusible calculus, is commonly whiter and more friable than any other species, resembling sometimes a mass of chalk, and leaving a white dust on the fingers. This species is generally not laminated. Occasionally, however, it separates readily into laminæ, 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 spongy friable whitish mass, evidently moulded to the contracted cavity of the bladder in which it has been formed. This species of calculus occurs very frequently.—Chemical characters. It may be readily distinguished by the ease with which it melts before the blow-pipe. It also dissolves readily in acids, and particularly in dilute muriatic acid; and if to the solution, oxalate of ammonia be added, the lime is precipitated alone, and the magnesium may be afterwards separated by the addition of pure ammonia.
"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 on the composition, and may be very varied. Most commonly it is composed of a lithic acid or mulberry nucleus, and an external crust of the fusible calculus. In some rare instances, it is composed of laminæ of all three of these substances, and sometimes of even more—the mixed phosphates still continuing to constitute the external crust. This species of calculus often acquires a very large size and is very common.—Chemical characters. The chemical characters must of course vary with the composition; and as the different substances of which it is composed must almost certainly be some of the preceding, the nature of the different laminæ can be readily ascertained by what has been already stated," p. 79, et seq.
In the chapter on the comparative prevalency of different forms of urinary deposite; and the order of their succession, we have a number of important facts and observations. Dr. Prout calculates, from the data collected by him, that about one-third of the urinary calculi which occur, are of the lithic acid species, and that another third are formed on a nucleus of this acid. Hence, "we may assert," says he, "that at least two-thirds of the whole number of calculi originate from lithic acid; that is to say, 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. This is a most important fact, and deserves to be constantly borne in mind."
The relative prevalency of the oxalate of lime calculus is very various. The average proportion, as determined by Dr. Prout is about one in seven. Of the calculi, examined by Mr. Brande, 1 in 25 was of the mulberry species; while in the Norwich and Guy's Hospital collections, the proportion is about 1 in 4. In the Bristol collection, one-sixth of the whole, was composed of oxalate of lime, nearly pure; while, including all the concretions containing more or less of the oxalate, the proportion was nearly one-half! This great disparity in the proportional frequency of this calculus in different districts of England, clearly shows the great influence of local causes, in determining the character of urinary concretions.
From a careful observation of the order of deposition of different species of calculous matter, Dr. Prout has been enabled to deduce the following general law; "that, in urinary calculi, a decided deposition of the mixed phosphates is not followed by other depositions." So that it would appear, that a redundancy in the earthy phosphates is the last link in the chain of diseased alterations, to which the urinary secretion is liable.
In the third chapter, under the second subdivision of functional urinary diseases, Dr. Prout describes the lithic acid diathesis, and communicates several important original observations. After remarking that the dyspeptic are particularly predisposed to lithic acid deposites, he enumerates, as exciting causes of this species of gravel, 1st. Errors in diet; 2nd. Unusual or unnatural exercise of the body or mind, particularly after eating, and the want of proper exercise at all other times; and 3d. Debilitating causes. Under errors of diet, an unusually heavy meal, especially of animal food, and the use of heavy, unfermented bread, or compact, hard-boiled, fat dumplings or puddings, salted and dried meats, acescent fruits, malt liquors, and acescent wines, are enumerated as particularly hurtful in the lithic acid diathesis.
The above remarks refer to the amorphous lithic deposites, consisting of lithate of ammonia. In regard to crystallized sediments, or, more properly speaking, gravel, our author makes the following remarks:
"Crystallized sediments, or red gravel, consist of lithic acid, nearly pure. Lithic acid, as has been before stated, exists in a state of combination in healthy urine; and in such a proportion, as to be held in a state of solution at all ordinary temperatures. Sometimes, however, a free acid is generated by the kidneys, which precipitates the lithic acid in the pure crystallized state we see it—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 the presence only of some free acid in that fluid; though such an excess does, for the most part, exist in this form of disease, as will be shown hereafter. With respect to the nature of the precipitating acid, it is probably not always the same. Most generally it appears to be the muriatic, sometimes the phosphoric or sulphuric, and occasionally other acids. In general, however, it is to be understood, as noticed elsewhere, that when the mineral acids are present in excess, these are the immediate cause of the preternatural acidity in the urine, and consequently of the precipitation of the lithic acid. The stronger acids act by decomposing saline compounds, into which destructible acids, such as the lactic acid, &c. enter, and setting them free. Hence the immediate cause of the deposition of lithic acid gravel is generally a destructible acid of very weak powers: even, perhaps, in some instances, the carbonic acid. When the urine contains a free acid, it is commonly more transparent than usual, and of a bright copper colour." p. 112.
The treatment recommended by Dr. Prout in this species of gravel is as follows: First, a strict attention to diet, avoiding the hurtful articles already enumerated. Secondly, the use of alkaline remedies; but those must not be depended upon, without the aid of other means, more especially of alteratives and purgatives. Accordingly we are informed that
"The pil. submur. hydrarg. comp., or a pill composed of the pil. hydrarg. and pulv. antimonialis, may be taken twice or thrice a week at bed time, and followed up the next morning by an active dose of the sub-sulphate of magnesia, or a mixture of Rochelle salts and magnesia, or carbonate of soda. A little of either of these compounds may be also taken twice or thrice in the day, so as to keep the urine constantly neutral or alkaline, and the bowels freely open; or gr. x to xx of magnesia may be taken for the same purpose in a glass of soda water, as often as it may be found necessary."
In the chapter on the mulberry, or oxalate of lime diathesis, Dr. Prout gives a number of cases, from which he draws the following conclusions:
"1st. That this form of disease occurs in both sexes; that it may exist before puberty, and at all ages between that and 40 or 50, at which time it seems to occur most frequently; but that no case occurs beyond the age of sixty. Hence that it is probably not a disease of old age.
"2nd. That it is not incompatible with gout, but seems occasionally to be associated with it. I have also seen it connected, as lithic acid frequently is, with a tendency to cutaneous disease.
"3d. That this variety of calculous affection occurs in individuals of sound constitutions, and who ordinarily enjoy good health; and that it rarely occurs a second time, except at long intervals, during which the intermediate health is good; which latter facts, it may be proper to observe, are confirmed by other observers, and particularly by Mr. Brande and Dr. Marcet.
"4th. That the urine is acid, and apparently but slightly deranged in this form of calculus, and remarkably free from all sorts of sediment and gravel.
"5th. That as renal calculi of the oxalate of lime often subsequently acquire considerable magnitude in the bladder, it may be inferred, that the formation of this compound is connected with a distinct diathesis, excluding the existence of other diatheses, and that is not an accidental occurrence, happening in common with many others to the urine.
"6th. That from the dissection of calculi, formerly mentioned, it appears that the oxalate of lime diathesis is preceded and followed by the lithic acid diathesis; a circumstance which seems to be peculiar to these two forms of deposite, and which, when taken in conjunction with the other circumstances, already related, appears to show, that they are of the same general nature; or in other words, that the oxalic acid merely takes place as it were of the lithic acid, and by combining with the lime naturally existing in the urine, forms the concretion in question.
"7th. That the diathesis being of a similar nature, the principles of treatment adapted for counteracting the original tendency to it must be also similar, that is to say, of an antiphlogistic character; great attention being at the same time paid to the digestive and assimilative functions." p. 137, et seq.
The diagnostic signs of the oxalate of lime diathesis are very obscure, as will appear from the following extract:
"With respect to the means of determining when this diathesis is going on in the system, I am sorry that I can give but little positive information. The absence of urinary sediment, &c. are of a negative character, and lead to no inference, where other circumstances are wanting, as is most generally the case. But if there be pain in the region of the kidney, and other symptoms of gravel, without any appearance of sediment; and if the urine be acid, and of the yellow tint above alluded to, the stomach deranged, and an inflammatory diathesis, either general or local (i.e. about the urinary organs), be present; and if all these are associated with suppressed gout, or tendency to cutaneous disease,—the existence of this form of the disease may be suspected, and means immediately taken to counteract it." p. 138.
We omit any analysis of the next chapter on the cystic oxide diathesis, on account of the rare occurrence of this state of the system.
The next chapter of our author is on the phosphatic, or earthy diathesis.
The phosphatic deposites are of two kinds; the crystallized, consisting almost invariably of the triple phosphate of magnesia-and-ammonia, and exhibiting the appearance of white, shining crystals; and the amorphous, consisting always of a mixture of the phosphate of lime, and the triple phosphate of magnesia-and-ammonia.
The causes apt to produce a deposition of the triple phosphate of magnesia-and-ammonia, are thus enumerated by Dr. Prout:
"Any thing acting generally, and producing a nervous state of the system, such as the distressing passions, and particularly mental anxiety or fear, will frequently produce in many people an excess of this salt in the urine. The same is also true of many articles of food or medicine that produce a hurried secretion of the urine, and act as diuretics; as the neutral salts in some cases, and particularly the Rochelle salts and other saline compounds, in which the acid is of vegetable origin. So also, a long continued use of alkaline remedies, or of mercury, in irritable habits more especially, will likewise produce a tendency to an excess of this salt, as well as of the phosphates in general, and even lead to an actual deposition of them from the urine. The same sediment also frequently abounds, or is easily induced, in the urine of those who have long been in bad health, and in whom the constitution may be considered as giving way, or, to use a common expression, breaking up. In general, it is to be understood, that the slighter causes affect only the predisposed, and those in particular who are subject to other diseases of the urinary organs or urine. It may be also remarked, that children are more subject to this form of deposition than adults; a circumstance, perhaps, to be referred to the irritability of the system at this age, and the great derangement of the digestive organs, to which they are subject." p. 151.
The above mentioned causes are stated to be equally productive of amorphous phosphatic sediments.
Our author next enumerates the very distressing symptoms, by which the deposition of the earthy phosphates is attended. They consist in great irritability; derangement of the chylopoietic viscera, evinced by flatulency, nausea, obstinate costiveness, or peculiarly debilitating diarrhœa; extremely unnatural stools, nearly black, or clay-coloured, and sometimes resembling yest; pain, uneasiness, or weakness in the back or loins; sallow, haggard expression of countenance; and finally, if the disease be not arrested, great languor and depression of spirits, coldness of the legs, and complete anaphrodisia, as occur in diabetes.
A curious and important fact has been stated in regard to the remote causes, producing the phosphatic state of the urine. It has been observed by Dr. Prout, that a large proportion of cases of this complaint may be traced to some injury of the back from mechanical violence, such as a fall from a horse, &c.
The remedies for this diseased state of the urine, found most successful by Dr. Prout, are,—opium, in from one to five grain doses, repeated two or three times a day, until the unnatural irritability of the system is relieved,—the same remedy in more moderate doses, in conjunction with the mineral acids, cinchona, uva ursi, and the different preparations of iron,—a large pitch, soap, or galbanum plaster to the loins,—and setons or issues in the back, when the disease manifestly arises from local injury. With respect to the bowels, Dr. Prout remarks, that they are very difficult to regulate. He has occasionally seen serious consequences to arise from the exhibition of a small dose of calomel, such as diarrhœa and debility, much aggravating the disease, and endangering the life of the patient. For the regulation of the bowels, small doses of castor oil, and laxative injections are most to be relied on; while saline purgatives, more especially Rochelle salt and Seidlitz powders, as containing vegetable and therefore destructible acid, must be avoided.[24] Mercury, in all its forms, is also inadmissible.
"Alkaline remedies of every description, must be most carefully avoided, their use in every point of view being most mischievous when the phosphates are concerned. Indeed all remedies that act as diuretics should, in general, be shunned, and the patient should be prohibited from drinking too much. With respect to drinks, in general, they should be of a soothing, demulcent character, and prepared with distilled or the softest water that can be procured; as hard waters are literally poison in this form of disease."
The second division of the work under review treats of the mechanical and organic diseases of the urinary organs. This portion of the subject is handled with the same ability as the first. We regret, however, that our space will not permit a further development of the author's views. We trust, nevertheless, that we have imparted to our readers adequate notions of the scope of the work, to render them sensible of its value as a manual of urinary diseases. It is illustrated by a good coloured plate, representing the principal varieties of urinary calculi.
The additions of Dr. Colhoun consist of foot notes, and paragraphs inserted in the text of the original work. We would not, however, wish to be considered as approving of the course, for the most part pursued by Dr. C., of inserting his amplifications in the text of the author, merely distinguished by brackets. Besides the absence of sufficient distinction between the matter of the author and commentator, the text of the former is thus injuriously disjointed, and dependent sentences sometimes widely separated.
In regard to the execution of the present edition, we regret to say that it is wanting in typographical accuracy.