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state of heart, are frequently quite free from dropsy, and generally have it only to a slight amount. The presence of abundant fat-cells, fatty casts, and free oil, with albumen in large quantity, in the urine, would indicate fatty kidney, although, for a time at least, such a state of disease may exist without these appearances; whereas, in the contracted kidney, fat-cells or fatty casts are either not present in the urine, or exist in but small number, and only occasionally, and in its more advanced stages, and the albumen is never by any means so abundant as to render the urine nearly solid under nitric acid and heat.
“The waxy kidney exhibits clinical phenomena sufficiently distinct from those of the fatty disease. Instead of the white anæmic complexion, with puffy face, which accompanies the latter malady, you will find the patient looking sallow, and, generally speaking, free from any swelling of the face. Dropsy either does not exist at all, or is very triling. It does not show itself until the disease has advanced considerably, and it rarely, if ever, is so prominent and chronic a symptom as in the fatty disease, nor is it often as much as in the contracted kidney. . ... In most of the cases the peculiar waxy degeneration is not limited to the kidneys, but affects the liver and spleen, causing enlargement of these organs. The increased size of these viscera, therefore, becomes an aid to the diagnosis of this affection, in addition to those signs which may be obtained from the altered urinary secretion.
“The condition of the urine resembles that found in the waxy (?) disease as regards the quantity of albumen, which is generally large. But fat-cells are not found, nor the fatty casts; transparent fibrinous casts and the debris of epithelium are the most common appearances. But these may be absent : and in both forms of enlarged kidnes this absence of all sediment is not uncommon." (pp. 105-107).
With regard to the contracted kidney, Dr. Todd remarks :
* The different varieties of contraction of the kidneys are due, so far as our knowledge at present enables us to state, to one and the same pathological condition, .... and the rationale of the morbid process by which the contraction is effected may probably be explained in some such manner as the following:-Some causes or other come into operation which excite disturbances of the nutritive processes to a greater or less degree, and interfere with the normal derelopment of the blood, this fluid becomes contaminated, and some or all of the contaminating ingredients are conveyed to the kidneys to be eliminated by these organs. In their passage through these glands, these poisonous elements create a highlr disturbed state of their nutrition-a state, possibly, in some degree intiammatory, but chiefir atrophic, the tendency of which is to cause the organs to waste and shrink. The kidneys, thus injured, are rendered unable to carry off in due quantity some of the elementary constituents of the urine; and these, accumulating in the blood, become a further source of mischief, in fact, a further source of poisoning, not only to the kidneys, but also, scoondarily, to almost all the other organs of the body.
* Now, one state in which this train of symptoms is very apt to occur, is that condition of the system which we call cont; a peculiar state, in which some morbid materialurie acid, perhans or some compound of unic acid, of, at all events, something very nearly allied to this substance-becomes developed in abnormal quantity in the blood operates as a poison upon the joints, and likewise irritates the kidners, and thus tends to keep up a gradual process of retention of morbid matters in the system, which ultimately leads to the destruction of these organs. You will not suppose that I limit the causation of this contracted state of kidney soldlr to gout: there are mnany cases in which we find no trace of gout; yet there is a general constitutional condition, analogous in many respects to that which gives rise to gout, where
the assimilative processes are much at fault, and where the blood is ill-supplied and poor.” (pp. 107-111.)
The term “waxy,” we think, is not the best to apply to the form of disease it is intended to designate. We are familiar with the appearance of the so-called material, but are quite unable to imagine in what respect it is like wax. It is very much like bacon, cooked, the fat being then translucent; and therefore we have always used the German term speckig, or bacony, in speaking of it. The characteristic of this deposit is, that it is always unorganized : it shows no cells, no fibres, but looks under the microscope like fragments of clear stiff jelly, with a vitreous fracture. It always indicates a grave deterioration of the nutritive processes, and may be produced by various debilitating causes, of which the scrofulous habit is one. After a good deal of study of degenerative disease, we have been led to classify the various forms in the following way. There appear to be two principal ones: the first in which organs enlarge by the deposition of cacoplastic matters in their substance; the second in which they simply atrophy and shrink. Of the first, we have examples in hypertrophy of the brain, in scrofulous enlargement of lymphatic glands, in hypertrophic cirrhosis of the liver, and in bacony deposit affecting the liver and spleen. Of the second, we have examples in certain softenings of the brain, where there is local decay of the tissue, in the contracted kidney, and the small fatty heart. In some cases the stomach-tubes are involved in a quantity of nucleated fibroid tissue, amid which they degenerate; in others they undergo simple wasting of themselves. The character of the first of these two forms of degeneration is per. version of the normal nutritive force of the part, so that it either turns good plasma into abnormal structure (low fibroid), or allows deteriorated plasma to be deposited, and to accumulate. The essential character of the second is simple decay and loss of assimilative force. In both of these forms of degeneration the wasting part may contain more or less of oily matter. Either the cacoplastic deposit may change into oil, by adipocerous transformation, or the normal tissue as it perishes may be replaced by the same. No doubt the presence of oil indicates a difference in the nature of the morbid change, but not, we think, a very important one.
It does not very clearly appear to us why it is necessary to assume that, in the case of the contracted kidney, the first step is contamination of the blood, poisonous matter from which seeking to be eliminated by the kidneys disturbs their healthy nutrition. May not failure of the vital power of the kidney be simply the whole of the evil ? may it not be quite possible that the organ undergoes atrophy and wasting, just as the muscular tissue of the heart often does, or the suprarenal capsules more rarely? We have seen patients die of mere anæmia-of a condition which appeared, as far as one could judge, to be simply degeneration of the blood-cells. Why in such like cases should we go beyond what we are sure of, and advance into the regions of hypothesis without having adequate reason for so doing? Each organ has a life of its own, and there seems no room to doubt that this life may
fail or deteriorate as a primary change, not due to any prior disorder elsewhere. To take the case of gout,--Dr. Todd says that uric acid, or some compound of it, “becomes developed in abnormal quantity in the blood," irritates, and ultimately disorganizes the kidneys. But why does it come to be in abnormal quantity in the blood ? We greatly doubt that it is because it is formed too rapidly in this fluid, in consequence of errors in the diet, &c. Its amount in the urine is so small, and is liable to vary so much, that it cannot be thought improbable that the kidneys, if sound, might easily do a little extra duty in the way of excreting it. Dr. Garrod tells us that uric acid accumulates in the blood, because its quantity is diminished in the urine, because it is not excreted by the kidneys. Before the gouty paroxysm, the amount in the urine was not more than one-twelfth the healthy mean, and in chronic gout, with tophaceous deposit, the uric acid was always deficient in the urine, both absolutely and relatively to the other organic matters, and was always present in the blood. Surely, then, in the case of the gouty kidney, it is not the morbid blood that spoils the kidney, but the failure of the renal function that spoils the blood.
Lecture V. contains a good résumé of the known facts relating to dropsy. We shall only remark on one point respecting which we can offer some observations of our own. Dr. Todd justly observes, that “ the limb in hemiplegia which has suffered most in its nervous power, is in general that which exhibits the greatest amount of dropsy." In a case of general paralysis now under our care, there was very notable dropsy of all the limbs, the urine not being albuminous, nor the heart diseased. This dropsy very materially diminished under the use of iron and quinine. In another case, that of a lady who had long been the subject of chronic aguish disorder, with innumerable neuralgiæ and neuroses, there was most marked puffiness of the hands and feet, so much so that sometimes she could not put on her laced boot in the morning, though she could later in the day. Here also there was no renal or cardiac disease. The only cause for the dropsy in both these cases appeared to be debility of the vaso-motor nerves.
Lectures VI. and VII. are devoted to scarlatinal dropsy. The author expresses his opinion that the dropsy is not fully developed without the concurrence of the three following conditions:-1st, a peculiar irritated state of the kidneys; 2nd, an analogous morbid state of the skin; 3rd, a certain depravity of blood, which is not only deficient in its proper constituents, but likewise contains morbid poisonous ones. “If any one of these is absent, you may have a threatening of the dropsy, but the full result does not follow." Granting this, though we are not prepared to give our entire assent to it, and how shall we reconcile it with the theory above enunciated, of the production of this dropsy? If when the peculiar conditions of the blood and skin are present, the kidneys can be healthy (see p. 157), then surely the passage of the scarlatina poison through these organs cannot be the cause of their inflammatory condition, and the consequent dropsy. In his directions respecting the treatment of this
affection, Dr. Todd's practice is dominated by his view of the necessity of eliminating the poison, we think unduly. He objects to local bloodletting because the poison is there irritating the kidneys, and detraction of blood will not take it away. Purgatives and diaphoretics are his main confidence, and diuretics of an unirritating kind. His treatment is “not antiphlogistic, but calmative and eliminatory." The use of port wine is frequently attended with most signal benefit" (of course in cases that need a stimulus). The directions given by Dr. West, in his excellent lectures, differ materially from those of Dr. Todd, and in some respects we prefer them. He thinks tartar emetio a very valuable remedy, and the abstraction of blood from the arm in severe cases indispensable. Dr. Copland also is in favour of bleeding, and says that it “is not unusual to find the sequelæ of scarlatina to require, and the patient affected by them to tolerate, the bleeding more than in any of the previous stages of the malady." In our opinion, antimony given decidedly and early, will generally control effectually the morbid action in the kidney when it is of sthenic type. When this state has passed away, or when it is asthenic from the outset, we shall find the ferri pot. tart., combined with potass. acetat., or small doses of tinct. ferri. muriat., efficient remedies. They tone the relaxed vessels, improve the quality of the blood, and act as diuretics at the same time. The principles of treatment are in fact those of inflammation generally; the local afflux of blood is to be stayed, and subsequently, if hyperæmia persist from relaxation of the arterial coats, their tone is to be aroused by the usual agents. We quite agree with Dr. Todd as to the injurious influence of scarlatina on the blood globules : the anæmia of the dropsical from this disease is certainly very marked.
Lecture VIII. is on the subject of acute renal dropsy. We are glad to see that Dr. Todd does not consider this, or scarlatinal dropsy, or any similar state, as any necessary precursor of either form of degenerative disease, a3 Frerichs does. In a note at p. 110, he disallows the term chronic nephritis, applied by Dr. Johnson to the pathological state connected with the wasted granular kidney. He observes correctly, “the evidence of an inflammatory process having any share in the production of this state of kidney, appears to me very unsatisfactory:" and so it has always seemed to us.
Lecture IX. illustrates cardiac dropsy. We could have wished that Dr. Todd had here laid stress on a point which seems to us of the very highest importance, but which is very much neglected or uncared for. It is the absolute need there exists for maintaining a steady, upholding, tonic treatment in all cases of cardiac disease, where there is a tendency to dropsy, and where the power of the heart is inclined to fail. It is lamentable to see a patient leave a hospital just cleared of his dropsy, and feeling comparatively well, and to know that no attempt is to be made to invigorate the system, and especially the enfeebled organ whose imperfection constantly tends to reproduce the symptoms. It is now nearly four years since we took under our care a discharged soldier, who could not walk more
than a hundred yards without being exhausted from dysnæpa. He had hæmoptysis, cough, and the physical signs of considerable cardiac dilatation, mitral and tricuspid insufficiency. Under treatment by tinct. ferri mur. and ol. morrh., long sustained and repeated at need, he continued, though in very poor circumstances, to act as a messenger, and afterwards as a light porter in a shop, till January of this year. He has walked three or four miles a day, carrying a pretty heavy load
Lectures X. and XI. treat of ascites. Cases are related illustrating its production by enlarged and by contracted livers (Glisson's capsule being thickened in both), by omental cancer, subacute peritonitis, and renal disease. Dr. Todd thinks it is “highly probable that the enlarged liver with thickened Glisson's capsule, is a different disease from the contracted liver.” According to our observation, the difference is merely one of more or less fibroid formation in the portal canals and interlobular spaces. There may be a very great quantity of newformed fibroid tissue, and then the bulk of the liver is enlarged, or there may be very little indeed; but that little may contract strongly, and compress the small portal veins. The directions respecting the operation of paracentesis are highly judicious—they relate to the adoption of the recumbent posture, the exhibition of opium, and the leaving the bowels quite quiet for several days. Dr. Todd advises that the operation should not be postponed too long, as there is then less probability of the system being able to “ resist inflammation or withstand exhaustion."
Lecture XII., on the gouty kidney, contains several interesting cases well worth perusal, but not requiring any special notice.
In Lecture XIII., seven pages are given to direct us how to distinguish pus in the urine from other deposits. Surely it would have been better to sy in as many lines that microseopic examination and the nitric acid test, with heat, are fully snfficient. In this lecture and the succeeding, the subject of gouty inflammation of the bladder is very ably treated and illustrated. The remarks which Dr. Todd makes respecting the various modes in which gout affects the bladder, are very instructive and important. 1. It may cause inflammation of the mucous membrane 2. It may render it very irritable, and so cause incontinence of urine. 3. It may affect the muscular coat, so as to paralyne it and occasion distention of the bladder. 4. It may cause violent pain in the region of the bladder. We feel some doubt whether the last mode can always or often, be very decidedly attributel to gout. It has certainly happened to us on several occasions to meet with a very similar state in persons of a neuralgic habit, in whom we regarded it as a local atletion of the same kind, whose exact locality could scarcely be determined, whether in the abdominal parietes er the peritoneum, or the viscers of the second mode we met some time ago the following marked instance: fifty-seven, who had suttered seven or eight times from gout, but who
A gardener, aged had always had, as he stated, the best of health," complained of com. plete incontinence of urine, and great emaciation. The bladder was