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favourable opinion.* Had our space permitted it, we should have been glad to have entered upon a fuller consideration of some of the more important doctrines which at various times were supported in the different schools of medicine, and to which in this article we have scarcely been able to do more than to allude. As regards these, the most suitable place for their discussion is no doubt the lecture-room; and we hope before long to find that in every important school of medicine in this country, opportunities will be afforded to students, whereby they may be enabled to attain some knowledge, at least, of the history of that profession to the practice of which their lives are to be devoted.
Clinical Lectures on Certain Diseases of the Urinary Organs: and on Dropsies. By Robert Bentley Todd, M.D., F.R.S., Physician to King's College Hospital.—London, 1837. Small 8vo, pp. 435.
Ik our day much is done, laudably done, and well done, by aspirants. The goddess who presides over medical affairs in London will not bo approached by any who bring not in their hand some votive offering, as a testimony of their ability and diligence. It may be a heart, a lung, or a kidney, nor will she disdain an uterus, liver, or stomach. Something her worshippers must do to attract her regard, and obtain at least permission to be distinguished from the ignobile vulgus. And for their future it is much the same. The same efforts, the sameofferings, are needful to obtain her further and higher favours as were required for the first. 'EpydfcoOt is her response to all the petitions that daily beset her. And of a verity the oracle is obeyed, and on. all sides work is done, and by very many right good work, that bears. well-deserved golden fruit. But apart from these, though once of them, are a few, the elect (not those of the College of Physicians), who are accepted and privileged. To them the gates of the golden shrine are open, they enter when they will, and on them the goddess sheds her choicest favours. They have attained above the region of strife and contest, and walk (or rather drive) in calm and secure dignity!
'Perfecto inunere Diva— Devenere loco* hctos, ct amcena vireta Fortunatorum ncmorum, sedesque beutas."
Now, to the praise of some of these, it is to be said that they still pursue their labours, though for their own sakes unneeded. They use their advantages, and improve them, moro for the good of others than their own. Their work is from the purest motive, and can scarcely fail to be of the highest order.
Among these distinguished worthies, Dr. Todd holds his place most deservedly. He has steadily laboured for the promotion of rational medicine, not only by his personal exertions, but by calling forth and
• Dr. Comcgys also has allowed many errors of the press to escape his notice. At p. 39 there is a very stupid one. Cleyer fcpecimen Mttlica .Sim'a, should be Cleyer specimen Medicinae Siuicae; and at p. 42, the author's name Cleyer appears as Fleyer. Many others might be noticed.
encouraging those of others. It is no small merit that the ' Cyclopaedia of Anatomy and Physiology' owes its existence to him : it required no little endurance and effort to bring this great work to a conclusion. The Todd-Bowman (as Germans call it) Text-book of 'Physiological Anatomy' was a work of love for one of the principal sciences on which rational medicine relies, which does its authors the greatest credit. To it the rising generation of medical men will owe in great measure a familiar acquaintance with all the chief truths respecting the healthy structure and working of the frames which are to form the subjects of their care. The possession of such knowledge will do more to make sound and able practitioners than auything else. For his share fti these two undertakings, now happily completed, in which self-interest -could have been little, if at all, concerned, we think Dr. Todd deserves the best thanks of his generation. Of his other well-known labours we cannot say anything now, but must hasten on to the especial consideration of the last, whose title forms the heading to this Article.
Remembering that a preface is really a postscript, we shall defer the consideration of some admirable suggestions contained in this part, until we have given our readers some idea of the contents of the "volume. The first two lectures are devoted to the subject of Haematuria; the third and fourth to that of Penal Disease attended with Albuminuria and Dropsy; the succeeding seven to Dropsy of various kinds; and the remaining five chiefly to Gout, its various manifestations and treatment. It seems to us that Dr. Todd has done very wisely in taking such prominent and visible symptoms as haematuria, dropsy, and gout, as texts for his discourses. The object of clinical teaching is to impart to the student facility in dealing with the problems of disease which are ever coming before him. It is therefore a great advantage to him to have large and striking phenomena so opened out and explained to him in all their possible causes and relations, that whenever and wherever he meets them, they may have to him all the significance that really belongs to them. The mind is so prone to take partial and narrow views of the objects it contemplates, that it needs frequently to have them set out before it in a comprehensive manner. It is the privilege of genius, especially when aided by -experience, to put common and trite things before our mental view in a fresh manner, so that we come to see in them more than we did before, and to see in clearer light what we saw before more obscurely. The good old parable of Eyes and no Eyes, is continually verified in medical life. One man sees in disease only dim, misty images, representing to his mind some name about which he has read and been taught. To another, each form of morbid action stauds out sharp and -clear—if not in all its lesser features, at least in the main outlines. It is a great benefit to the student to be led by one who himself sees clearly.
Dr. Todd notices the occurrence of haematuria in connexion with rheumatic fever and pericarditis; in acute renal dropsy; in an inflammatory state of kidney; in scarlatinal dropsy; as vicarious of catamenial flow; as concurrent with phlegmonoid inflammation of the kidney; as dependent on renal calculus; as associated with inflammatkm and ulceration of the ureter; in connexion with erysipelas of the fauces; as dependent on fungoid disease (cancer) of the bladder; and as an endemic affection of the Mauritius. Other conditions giving rise to haematuria are incidentally referred to also, so that on the whole the two lectures afford a very good guide to all the various diseases in which this symptom may arise. The diagnosis between renal and vesical haemorrhage is well stated, and the difficulty of determining in many cases whether a calculus is the cause of the bleeding or not. Dr. Todd states that "by far the most common cause of bloody urine is the disturbance of a calculus formed and lodged in the kidney." This we incline to doubt, as well from the results of various cases in which the symptom has disappeared under treatment, as from the following positive evidence :—In 100 post-mortem examinations, where the history of the symptoms during life was obtained, haematuria is noticed as having occurred in 5 only. In one of these it was from purpura, in a second from diffuse cellular inflammation, in a third from morbus Brightii (large kidney), in the fourth from cardiac aud renal disease, and in the fifth from scrofulous renal disease. In not one of the hundred was there renal calculus. Of 18 cases occurring under our own notice, in which haematuria was a notable symptom, the attendant conditions were as fallows:—In 4 scarlatina; in 4 chronic renal degeneration; in one of these, pregnancy acted as a special promoter of the haematuria; in 1 purpura and debility; in 1 the patient suffered from the endemic of the Mauritius, passing the so-called chylous urine; in 1 the urine was of high specific gravity, and deposited oxalates copiously: there had been severe aching in the loins for years; very great benefit was obtained by the steady use of nitromuriatic acid and liq. opii. It is possible there was calculus in this case, but it is certainly doubtful. In 1 case the haemorrhage came on after a fall on the back, and continued more or less for many weeks, in spite of the recumbent posture and remedies. There did not appear to be any sufficient ground for believing in the existence of a calculus^ it seemed more probable that there was renal degeneration in progress, and that the tone of the Malpighian tufts was notably impaired. In one case the attendant symptoms were those of nervous depression, evening chills, <fec. Under gallic acid, quinine, and opium, the haemorrhage speedily ceased, and the general health improved. la one case orchitis was the first affection, which was replaced by an. inflammatory aflection of the kidneys, and this again was subdued easily by cupping and salines with antimony. The urine did not lose its smokiness, however, until after quinine had been administered. In one case there were vesical symptoms, and reason to suspect strongly the existence of malignant disease; the patient had had a tumour removed from the left breast four years previously. In one case there was great vesical irritation, but a cure was effected by copaiba and gallic acid; the disorder appeared to be catarrhal. In one case the luematuria, which had resisted astringents, became immediately very much diminished as soon as calomel aud colchicum were given, so as to produce a cholagogue effect, and entirely disappeared for some time under the additional use of nitro-muriatic acid and liq. taraxaci. In the last case the haemorrhage was decidedly renal. It ceased under the use of strychnia, and subsequently chlorate of potassium with pulv. jalap, co. at intervals. There was some dropsy and a patch of erythema nodosum, but no material impairment of the general health. The hwmaturia appeared to result from a congestion of nerve origin—paralysis of the renal plexus. The conclusion from. the above evidence must, we think, be counter to Dr. Todd's. Renal congestions of an acute kind are evidently the principal causal conditions of haematuria. Considering the peculiar disposition of the bloodvessels of the kidney, one would expect d priori that bleeding from this organ would be very liable to occur—that, in fact, it would be more common than epistaxis. No doubt both haemorrhages may result from similar causes.
Dr. Todd frequently alludes to the elimination of various morbid matters through the kidneys, and the irritation of these organs thereby, thus explaining the congestions of acute and scarlatinal dropsy. We wish to take some exception to this popular doctrine of poisons being carried to special organs, which then undergo irritation in their efforts to carry them out of the system. That a poison is received into the blood in such cases is pretty certain; that it causes inflammatory irritation in various parts is also certain; but that this indicates a necessary and real eliminative action seems to us very doubtful, and rather likely to mislead us in our practice. Turpentine passes off very positively by the skin and lungs, which it does not irritate, as well as by the kidney, which it is apt to irritate. Cantharides act quite as much on the bladder and genital organs as on the kidneys. Are we to suppose that the pulmonary inflammations of measles and hooping-cough, or the cutaneous eruptions of smallpox and scarlatina, or the intestinal exanthem and ulcerations of typhoid fever, are in any more than a faint and superficial resemblance eliminative actions? Are we to think otherwise of the serous exudations of pemphigus and eczema 1 Surely, if so, then much more the sweats of an ague are eliminative, and ought to be greatly promoted as a means of getting rid of the malarious poison. In our belief, the various inflammations of the exanthemata are simply reactions of the tissues in which they occur against the poison, and if they did not occur, so much the better; so much the more chance would there be of the poison being quietly eliminated through some other channel. Take the case of a family among whom scarlatina makes its appearance. All have been alike exposed to the poison, all must have imbibed it: but in some it produces slight, in others deadly effects. What is this, but the tissues of some resenting the poison violently, of others but little i Some persons have an immunity towards one or other of the exanthemata, though the poison enters their blood when exposed to contagion (as by the laws of gaseous diffusion it must), the system does not succumb under it; it is, in fact, not a poison to them. This is particularly the case with infants as regards scarlatina. How striking is the now ascertained fact, that eight grains of quinine daily will preserve a man in health amid the deadly miasmata of African rivers! From all that we know of the nerve-toning action of quinine, and the similar beneficial effect of generous diet, and a cheerful animation, in preserving soldiers and sailors from sickness, it seems impossible to doubt that these and all like means act by increasing the resisting power of the system, not by neutralizing the poison which surrounds it. To the same purpose is the striking case quoted by Dr. Watson (vol. i. p. 708).
The practical lesson of all this is very important. It tells us that we are not to think of getting this mischievous agent eliminated, as the only means of restoring our patients, but that we are just to "obviate as far as we can the morbid action that the poison has set up. If the system is labouring under variola, we do not encourage the eruption on the skin, and congratulate our patient the more abundant the pustules are. On the contrary, Dr. Watson says, "The object is to prevent if possible a copious eruption, upon which, as we have seen, the severity and peril of the disorder entirely depend." The treatment, then, of all such like cases is to be simply that of inflammation and congestion, modified according as the affection is sthenic or asthenic. An excellent instance of judicious management of the latter state is given at p. 50, where a man with severe erysipelas of the fauces and haematuria, is restored to convalescence in ten days — not by sweating or purging, but "by the free administration of quinine and beef-tea by the rectum, wine, and the local application of nitrate of silver to the throat."
Dr. Todd regards the instances of dropsy concurring with albuminuria as naturally dividing themselves into two great classes: those in which dropsy is an urgent and prominent symptom, and those in which it is much less so. The causes giving rise to the first class are exposure to cold and wet, and scarlatina. Those producing the second are various, but are chronic in their action. The following table, given at p. 104, sets forth the author's views most clearly:
I Acute dropsy. 1
Chronic f Fatty disease
of kidney. \ Gouty kidney."
After giving the histories of a case of fatty, and one of waxy, kidney disease, the diagnosis of these states is thus described:
"The contracted state is much more frequent than that of enlargement, whether fatty or waxy. The fatty condition is generally attended with dropsy, much greater in amount and of a more persistent and obstinate character than (in ?)citherofthc others, which,unless accompanied by some diseased or enfeebled
13. Cases in which dropsy is not a prominent symptom—is very variable in amount—chronic—and may be absent. Albumen variable.