«<■•*" '.vv.w.vv,v.- /.~ v^v/.'./v. «-f-\..V-:" .•■"'.','.■; .v."" *u«r' ,v*".," .■_" \r.''*^^**"*"*jj.'/."".v*j*'"'r'2v v.* "^ **. ^C;^,7.v^f*v'f^^;^^f< ::ri":---irv-t?'' '-v-jr-:'; -:";.' X x>.v. s-^>>^ %•>:->>>: :•■;■:-.- - -*■;: x ■'*>. :v.-. «;•>•; 5.^UJ«jj«r,«»J).....r 1.*^. Jrpi»v^_a.. »«,.^..».k»,.> .*>-...... . j .»»..„.. '. .,. ^^^„r^^Tr,'r%sv.v-*r^.--:.t^ -v.-.'.lT-'.v.r.v -, .• ■ •. .•■-.r.-.-v , ^2^^^w^vv-v-v^^.:v^,.j5-'.v:,w.v^..v. ■' -■■■' ■■:--.• ■■-'■ -<■ i^rHT&r&^V^^^--'."^ ■•■* ■••'■'■■".-v.w■'■' " "T-'.'!"<»i.*;;, ;. :•; nm^ .-..lire. ■,•;'" . )'iji;.<*-i -71> ; *-.'>•",• ."-^i" '.;'•" ";"'"''. '■' " " - !'i.^i'!.T;'" j.'.-:t:~- •■■'..' ..•.'' '■'' :. ~ . „'. ' ~ K&itij,',.'--X-. :<:■■■■■>-> '■■"■■' /.'.■.'*..•■ ". ■■; ■■' 7. '•' '.:'". UNITED STATES OF AMERICA FOUNDED 1836 WASHINGTON, D. C. GPO 16—67244-1 r^_> X • ^-.$ .1-S^N URINARY DEPOSITS, THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. GOLDING BIRD, A.M. M.D. ASSISTANT PHYSICIAN TO, AND LECTURER ON MATF.RIA MEDIC A AT, GUY'S HOSPITAL ; LICENTIATE OF THE HOYAL COLLEGE OF PHYSICIANS ; LATE PRESIDENT OF THE WESTMINSTER MEDICAL SOCIETY; FELLOW OF THE LINNEAN SOCIETY OF LONDON; CORRESPONDING MKMHKR OF THE PHILOSOPHI- CAL INSTITUTE OF BASLE, OF THE PHILOSOPHICAL SOCIETY OF ST. ANDREWS, OF THE MEDICAL SOCIETY OF HAMBURGH, &C. &C. PHILADELPHIA: LEA & BLAN CHARD. 1845. 31'as, ftlj trflrcifc, tins fst i;eut jrucbmjbv nut sfcfj;cntoefse rjOO IM5 u- TO DR. ADDISON, SENIOR PHYSICIAN TO GUY'S HOSPITAL, &c r My dear Sir, It is now thirteen years ago since I first found myself within the walls of Guy's Hospital, a stranger and unknown. In a short time, my admiration and respect were excited for your profound i knowledge and experience as a physician, and for your zeal as a teacher. But I soon experienced another feeling, that of gratitude, for numerous acts of the most disinterested friendship; and for which I must ever remain your debtor. I cannot look back upon my past career, so far as it has ex- tended, without gratefully acknowledging how much I owe to your example, and to the exertion of your friendly influence, from the time I took my seat upon the pupils' benches, until I had the high honour of being appointed your colleague. That your health may be preserved, so that our profession may, through a long series of years, possess you as an ornament, and Guy's Hospital long enjoy your assistance as its distinguished physician and teacher, is the sincere wish of Your obliged and grateful friend, Golding Bird. Myddelton Square, October 20th, 1844, PREFACE. In the early part of last year, I delivered, to the pupils of Guy's Hospital, a short course of lectures on the diagnosis and pathology of urinary sediments, which were reported in the Lon- don Medical Gazette. I have been repeatedly requested to arrange them for publication in a separate form, but from pressure of other engagements, I was unable to turn my attention seriously to the subject, until a few months ago, and had not proceeded far with my task, when I received from Vienna a translation into German of the lectures reported in the Gazette collated into a volume* with my papers in Guy's Hospital Reports, by Dr. Sigis- mund Eckstein. The perusal of this, induced me much to ex- tend, indeed, nearly to re-write the whole subject, and I now venture to place this work before my professional brethren, as the result of many years' close observation, in the field of public ex- perience which I have been fortunate enough to have at my com- mand. In coming in contact with pupils in the course of my duties as a teacher of my profession, and in mixing with medical men, in practice, I have often found them in want of some work which would enable them readily to discover the nature of a deposit in the urine, and succinctly point out its pathological and therapeu- * Die Harnsedimente in diagnostischer, pathogenetischer und therapeutischer Beziehung, von Dr. Golding Bird.—Wien, 1844. 1* 6 preface. tical indications. To be available, it was necessary that such a work should not exceed the size of a small manual, and its con- tents be so arranged as to admit of ready reference, and thus be more fitted to act in the humble office of pioneer to more elabo- rate, and more diffused sources of information. Anxious to avoid all topics unconnected with the practical bearing of the subject, every thing partaking of a controversial character has been omitted, wherever it could be done. It has been a subject of deep regret to me to be obliged, in some instances, to dissent from the ingenious and beautiful hypo- thetical views of one of the greatest chemists of the present age, the illustrious Liebig—I should personally have felt better pleased if the results of observation at the bedside had enabled me to have supported the view of this philosopher in regard to chemical pathology. For I feel convinced that had Prof. Liebig any time or opportunity for acquiring a knowledge of the phenomena of disease, so as to test the accuracy of many of the opinions sug- gested by his fertile mind, he could not fail to confer discoveries of the utmost importance upon medical science. The objection often urged against the possibility of a minute acquaintance with urinary deposits being available in practice, on the plea of the time required for their investigation, no longer exists, since the re-introduction* of the microscope for their exa- mination ; a minute or two being sufficient for the observer to learn the nature of any variety of sediment. * It is not generally known that Van Swieten, the celebrated commentator on Boerhaave, applied the microscope nearly a century ago to the examination of cal- culous deposits ; he minutely described a uric acid sediment as composed of crys- tals " having the figure of a rhombus, whose opposite angles are obtuse and equal, other parallelopiped molecules ran between them, redder and larger than the former." Commentaries, 1776, Edinburgh, vol. xvi. page 81.) Even long prior to this, De Peiresc, born in 1580, described the same deposit as resembling under the micro- scope, a " heap of rhomboidal bricks." This observation is recorded by the cele- brated Gassendi, in his biography of De Peiresc, and is quoted by Van Swieten. preface. 7 Whilst endeavouring to describe the diagnosis and pathology of urinary deposits as minutely as appeared necessary, the consi- deration of their treatment has been dismissed in a briefer manner, as the valuable volumes of Dr. Prout and Sir Benjamin Brodie must render any more minute account of the special treatment o* calculous affections unnecessary. The only exception to this, has been in the instance of oxalate of lime, and I have felt it neces- sary to enlarge particularly on the pathology and treatment of cases of this disease in consequence of the scanty amount of in- formation to be found elsewhere. The chapter upon the thera- peutical employment of remedies intended to influence the func- tion of the kidneys, is, I am conscious, very imperfect; I, how- ever, felt anxious to allude to this important subject, in the hope of drawing the attention of the practitioner to its careful consider- ation. For minute chemical details connected with the contents of this volume, I beg to refer the reader to the excellent manual on the " Analysis of blood and urine in health and disease," by my friend and colleague Dr. G. Owen Rees, whose investigations in con- nection with animal chemistry have gained for him a deservedly high reputation. The " Practical Manual" of Dr. Griffith contains some most accurate microscopical drawings of the different depo- sits. Whilst for an account of the chemical discrimination of calculi, the translation of Prof. Scharling's work, by Dr. Hoskins of Guernsey, will prove a safe and excellent guide. In conclusion, I may venture to indulge a hope that this work may be of service to the practitioner, in removing any difficulties which may have prevented his interpreting into intelligible lan- guage, the invaluable indications furnished by deposits in the urine. Myddelton Square, October, 1844. ANALYTICAL INDEX. Preface Introductory Remarks . List of microscopic woodcuts page 5 17 23 CHAPTER I. PHYSIOLOGICAL ORIGIN AND PHYSICAL PROPERTIES OF THE URINE. Value of the indications afforded by the urine Proximate origin of Metamorphosis of tissue Three species of urine . Stages of the assimilative processes Liebig's theory of metamorphosis Illustrated in muscular tissue Relation of the renal to other secretions Physical character of urine—Density or specific gravity Relation of quantity of solids to the density Table for determining the weight of solids Weight of urine determined from its bulk Variation of the density of the urine in the day Schweig's speculations on Effects of imbibition of fluids on the bulk of urine Average normal density of urine Variations of colour ---------- consistence Circular polarising power Paragraph 1 2 3 4 5 6, 7 8 9 10, 11 12 13 14, 15 16 17 18 19 20 21 22, 23 CHAPTER II. CHEMICAL PHYSIOLOGY OF THE URINE. Composition of the urine Results of average analyses 24 25,26 10 ANALYTICAL INDEX. Urea ........ Pat ugraph 27 Physiological origin of . 28 Influence of food on the quantity of .... '29 Relation of urea to carbonate of ammonia 30 Uric or lithic acid ....•■ 31 State in which it exists in urine .... 32 Origin of urate of ammonia ..... 33 Theory of its production ...... 34 Physiological origin of uric acid .... 35 Liebig's hypothesis of . . . • 36 Objections to Liebig's hypothesis .... 37, 38 Probable origin of uric acid ...... 39, 40 Lactic acid; a new crystalline body mistaken for it 41 ito ,„i„i;,,,,, *„ 0-«;„i„0 «f fnnA 42 Hippuric acid ........ 43 Origin of, and probable relation to bile .... 44 Butyric acid ........ 45 Colouring matter of urine ..... 46 Purpurine ....... 47 Source of the fixed salts of the urine . . . . . 48 Composition of the urinary phosphatic salts . 49 Source of sulphuric acid ..... 50 Terms applied to urinary deposits .... 51 Classification of deposits . 52 CHAPTER III. CHEMICAL PATHOLOGY OF URIC ACID AND ITS COMBINATIONS. Colour of uric acid deposits Diagnosis of Characters of urine depositing uric acid Microscopic characters of the uric acid deposits . Diagnosis of urate of ammonia . Character of urine depositing . . : Microscopic characters of ------------------■-----urate of soda . Pathological changes in the quantity of uric acid Influence of suppressed perspiration on . Liebig's theoretical pathology of uric acid Ed. Becquerel's researches Causes of excess of uric acid Detection of . . . , Traced to the ingesta .... Conditions for deposition of the free acid 53 54 55 56, 5S 59 60 61, 62 63 64, 65 66, 68 69 70 71 72 73 74, 76 ANALYTICAL INDEX. 11 Uric acid considered as a calculous affection Treatment, by diaphoretics ---------, by correcting the digestive functions ---------, by ferruginous tonics ---------, by solvents,—alkalies Treatment, by solvents, alkaline salts ---------------------, biborate of soda --------------------, phosphate of soda --------------------, benzoic and cinnamic acids Paragraph 77 . 78, 79 ■ • 80, 82 83 84 • 85 86 87 . 88 89 CHAPTER IV. CHEMICAL PATHOLOGY OF URIC OXIDE. Rare occurrence of this substance Diagnosis of uric oxide . Its generally exclusive occurrence Characters of urine depositing uric oxide Microscopic characters of Pathological indications 91 92 93 94 95 96 CHAPTER V. CHEMICAL PATHOLOGY OF PURPURINE. Affinity of urate of ammonia for purpurine Diagnosis of purpurine in urine Microscopic characters in deposits Characters of urine containing purpurine Pathological indications 97 98 99 100 101 CHAPTER VI. CHEMICAL PATHOLOGY OF CYSTINE. Discovery of cystine Diagnosis of Liebig's test for Characters of urine depositing cystine Spontaneous changes in cystine Microscopic characters of .___________________simulated by chloride of sodium Pathological origin and indications of cystine The treatment ..... 102 103 104 105 106 107, 108 109 110, 111 112 12 ANALYTICAL INDEX. CHAPTER VII. CHEMICAL PATHOLOGY OF OXALATE OF LIME (OXALURIA). History of discovery of oxalate of lime in deposits Diagnosis of oxalate of lime Characters of urine containing it Presence of epithelial debris and excess of urea Complication with other deposits Pathological origin of oxalate of lime . Absence of sugar in oxalic urine Formation of oxalic acid from urea and uric acid General symptoms of oxaluria . Exciting causes of ... Treatment ..... Illustrative cases .... Possible development of hydrocyanic acid in oxaluria Paragraph 114 115,118 119 120 121, 122 123 124 125 126 127 128 129 Appendix. CHAPTER VIII. CHEMICAL PATHOLOGY OF THE EARTHY SALTS. Phosphates existing in urine Diagnosis of earthy phosphates Chemical constitution of Phosphate of lime Appearance of phosphatic deposits Deposition of phosphates by heat Characters of phosphatic urine . Microscopic character of deposits of phosphates Pathological indications of phosphates generally ------■--------------of triple phosphates Occurrence of triple phosphates without organic disease ----------------------------in extreme old age -----------mixed phosphates ----with alcaline urine Urine in paraplegia Mr. Curling's hypothesis of alcaline urine Secretion of phosphates in diseased bladder Formation of calculi . . , Alcaline urine in fever . General indications of phosphatic deposits Secretion of phosphate of lime by mucous surfaces Treatment of phosphates 130 131 132, 133 134 135 136 137 138 139 140 141 142 143 144 145 146, 147 148 149 150 151 152 153 ANALYTICAL INDEX. 13 Treatment of, when complicated with dyspepsia ----------------------------_ oxaluria . marasmus diseased bladder Deposits of carbonates of lime and magnesia --------■----------—— in graminivora silicic acid Paragraph 154, 155 156 . 157, 159 . 161, 162 163 163* 164 CHAPTER IX. DEPOSITS OF BLACK OR BLUE COLOURING MATTERS. Nature of these colouring matters Cyanourine of Braconnot ---------, diagnosis of Indigo . -----, diagnosis of Percyanide of iron ■--------------■, diagnosis of . Black deposits of M. Braconnot, Dr. Marcet, and Prof. Dulk 165 166 167 168 169 170 171 172 CHAPTER X. GENERAL PATHOLOGY OF NON-CRYSTALLINE ORGANIC, AND ORGANISED DEPOSITS. Use of the microscope ..... 173 Elements of the blood in urine .... 174 Diagnosis of 175 Albumen in urine ..... 176 Tests for ..... . 177 Haematosine ...... 178 Blood-corpuscles, their microscopic characters . 179 Pathological indications of the elements of blood in urine 180 Therapeutical indications of bloody urine . 181, 182 183 184 Purulent urine ..... Diagnosis of . . . . . 185 Microscopic characters ...... 186 2 14 ANALYTICAL INDEX. Pathological indications Paragraph 187 Mucous urine .... 188 Tests for ... . 189 Microscopic characters . 190 Pathological and therapeutical indications 191, 192 Large organic globules . . '. 193 Small organic globules 194 Epithelial debris 195 Milky urine . 196 Kiestein . 197, 199 Diagnosis of 200, 201 Connexion with pregnancy 202,203 Fatty and oily urine . ; 204 Diagnosis of . . • 205 Microscopic characters . 206 Pathological characters . 207 Spermatic urine . . . 208 Microscopic characters . 209 Connexion with oxaluria 210 Pathological indications 211 Therapeutical indications 212 Growth of torulae in urine 213 Microscopic characters for 214 Tests for sugar in urine 215,216 Development of vibrio lineola . : 217 CHAPTER XL THERAPEUTICAL EMPLOYMENT OF REMEDIES INFLUENCING THE KIDNEYS. Uncertain action of renal remedies . r First law regulating . Second law . . : . . Conditions for the absorption for remedies into the blood ---------illustrated in alcaline salts . . -------------——— mineral waters Diuresis opposed by irritable mucous membrane ——------------diseased liver or heart Dr. Barlow's researches . . . Explanation of the uncertain action of remedies Practical conclusions .... 218 219 220 221 222 323 224 225 226 227 228 ANALYTICAL INDEX. 15 APPENDIX. Forms of calculi, and list of those in Guy's Museum . . Page 209 Chemical composition of products of vital chemistry . . . 217 List of references to authors occurring in this work' . . • 219 Alphabetical index .....:. 223 NOTE. In the following pages, the figures included in the parentheses, refer to the num- bered paragraphs, the smaller ones to the table of authorities at page 219. INTRODUCTORY REMARKS 05T THE CLINICAL EXAMINATION OF URINE. In the investigation of diseases at the bedside, the physician is called upon to avail himself not only of every general symp- tom presented by the patient, but of every indication afforded by the secretions and excretions; and among these guides to a cor- rect diagnosis, an examination of the urine is of essential import- ance. The following observations may be of service to the prac- titioner, both as a guide to his proceedings in the superficial examination of the urine, which can be readily performed in a few moments in the sick-room ; and as a reference to the contents of this volume, which will direct him to the completion of his in- vestigations when at leisure. Premising that the urine presented for inspection is either an average specimen of that passed in the preceding twenty-four hours (19), or at least that resulting from the first act of emission after a night's rest (16). A.— Urine without any visible deposit. A piece of litmus paper should be immersed in the urine, which, if acid, will change the blue colour of the paper to red. Should no change occur, a piece of reddened litmus paper must be dipped in, and if the secretion be alcaline, its blue colour will be restored; but if no change occur, the urine is neutral. 2* i 18 INTRODUCTORY REMARKS. Some of the urine should then be gently heated in a polished metallic spoon over a candle, or what is preferable, in a test-tube over a spirit-lamp (177), and if a white deposit occurs, albumen or earthy phosphates are present; the former, if a drop of nitric acid does not redissolve the deposit (176), the latter if it does (136). If the urine be very highly coloured, and undergoes no change by boiling, the colouring matters of bile, blood, or purpurine are present. To determine which, pour a thin layer of urine on the back of a white plate, and allow a few drops of nitric acid to fall in the centre ; an immediate and rapidly ending play of colours, from green to red, will occur if bile (20), but no such change if purpurine (98) alone exists. Should the highly-coloured urine alter in colour or transparency by heat, the presence of blood must be suspected (178). If the addition of nitric acid to deep red urine, unaffected by heat, produces a brown deposit, an excess of uric acid exists (72). If the urine be pale, immerse the gravimeter (10), and if the spe- cific gravity be below 1.012, an excess of water exists in the urine, but if above 1.025, the presence of sugar, or excess of urea is indicated. To determine which, place a few drops in a watch-glass, add an equal quantity of nitric acid, and allow the glass to float on some cold water; crystallisation of nitrate of urea will occur in two or three minutes, if the latter exists in excess (27). Should this change not occur, the urine must be examined specially for sugar (216), which, it must be remembered, may exist in small quantities, without raising the specific gravity of the fluid. Should the urine be alcaline, add a drop of nitric acid; if a white deposit occurs, albumen is present (179) ; if brisk efferves- cence follows the addition of the acid, the urea has been con- verted into carbonate of ammonia (30). INTRODUCTORY REMARKS. 19 B.— Urine depositing a visible sediment. If the deposit is flocculent, easily diffused on agitation, and scanty, not disappearing on the addition of nitric acid, it is chiefly made up of healthy mucus (88), epithelium (195), or in women, an admixture of leucorrhceal discharge (185). If the deposit is ropy and apparently viscid, add a drop of nitric acid; if it wholly or partly dissolves, it is composed of phosphates (135), if but slightly affected, of mucus (189). If the deposit falls like a creamy layer to the bottom of the vessel, the supernatant urine being coagulable by heat, it consists of pus (185). If the deposit is white, it consists of urate of ammonia, phos- phates, or cystine ; the first disappears on heating the urine (59), the second on the addition of a drop of diluted nitric acid (131), whilst the third dissolves in ammonia (105), and the urine gene- rally evolves an odour of sweet-brier. If the deposit be coloured, it consists of red particles of blood, uric acid, or urate of ammonia, stained with purpurine. If the first, the urine becomes opake by heat (178); if the second, the deposit is in visible crystals (56); if the third, the deposit is amorphous, and dissolves on heating the fluid (59). Oxalate of lime is often present diffused through urine, without forming a visible deposit; if this be suspected, a drop of the urine examined microscopically will detect the characteristic crystals (115). Much of the little time required for the investigation thus sketched out, may be saved by remembering the following facts. If the deposit be white, and the urine acid, it in the great ma- jority of cases consists of urate of ammonia ; but should it not dis- appear by heat, it is phosphatic. If a deposit be of any colour inclining to yellow, drab, pink, or red, it is almost sure to be urate of ammonia, unless visibly crys- talline, in which case it consists of uric acid. 20 INTRODUCTORY REMARKS. The only apparatus and re-agents required for these investiga- tions at the bedside are— A gravimeter, made small enough to float in an ounce of fluid. Red and blue litmus paper.* A test-tube and watch-glass. Nitric acid. All these are readily arranged in a little case, and can thus be always at the convenience of the practitioner. For the micro- scopic examination of the urine, a vertical instrument on a firm tripod stand, and large ring-stage, provided with a good half-inch achromatic object glass, is alone required.! The following table briefly points out the best mode for the analytical examination of saline deposits, either by chemical tests or the microscope. The latter mode of investigation is infinitely preferable to all others, both for accuracy and economy of time, but is of course not readily available in the sick-room. A.—# Table for discovering the nature of saline deposits by che- mical re-agents. 1. Deposit, white - - - 2. -------coloured - - 5. 2.-------dissolves by heat - Urate of ammonia. -------insoluble by heat - 3. 3.-------soluble in liquor ammonite Cystine. -------insoluble in - - 4. 4.--------soluble in acetic acid - Earthy phosphates. -------insoluble - . Oxalate of lime. 5.-------visibly crystalline - Uric acid. --------amorphous - - 6. 6.--------readily soluble by heat - Urates. -------slowly dissolves by heot - -------stained by purpurine. * The most convenient test-paper is that prepared by Griffin at Glasgow, in the form of little books, like bankers' cheque-books. They can be procured of Mr. Ward, operative chemist, Bishopsgate Street. f A cheap microscope of this kind has been constructed by Mr. Pritchard, opti- cian, of Fleet Street. INTRODUCTORY REMARKS. 21 B.— Table for determining the nature of saline deposits b"y the microscope. 1. Deposit, white - . - 2. -------coloured - - - 5. C Insoluble by heat — Phosphate of 2.-------■ an amorphous powder - < lime. Soluble by heat—Urate of (_ ammonia. -------in defined crystals - 3. — in prismatic crystals - Triple phosphate. -- in octohedral or tabular ) . crystals ------in octohedra - - Oxalate of lime. ------in simple or compound \ n .- tables £ ^ ------in transparent crystals - Uric acid. ------amorphous, or in spheri- ) TT . r • i . v > r \ Urates of ammonia or soda. cal masses - - ) LIST THE MICROSCOPIC VIEWS OF DEPOSITS. Fig. page 3 Uric acid, lozenges .--...-66 4--------square crystals ..-.-- 66 5 ■ modified lozenges ...--. 67 6 ---------thick lozenges, resembling cylinders 67 7--------- thin tables, with internal markings 67 8 ---------cohering prisms ------ 67 9------------------lozenges - - ... - 67 10 Urate of ammonia, in linear masses - - 70 11-----------------in globular crystals 71 12-----------------in fine needles - - - - - 71 13 Urate of soda, globular crystals - - - - - 71 14--------------needles and stellae ----- 71 15 Cystine, flat tables ------- 98 16-------compound tables ------ 98 17 Chloride sodium, modified by urea ----- 99 18-----------------------in crosslets - - - - 99 19 Oxalate of lime, in octohedra - - - - - 103 20--------------in the dry state - - - - - 104 21--------------in dumb-bells - - - - - 104 22 Triple phosphate, neutral, prismatic - - - - - 134 23-----------------------stellae ----- 134 24-----------------------penniform ----- 135 25 Triple phosphates, basic, follaceous ... - 135 26 Carbonate of lime, spherical crystals ----- 158 27 Blood-corpuscles, healthy - - - - - -169 28----------------altered by the urine - - - - 169 29 Pus particles, showing the nuclei - 174 30 Organic globules, and epithelium - 179 31 Epithelial debris - - - - - - - 180 32 Spermatozoa - - - - - - - -195 33 Torula cerevisia, in diabetic urine - - - - - 197 I t URINARY DEPOSITS, THEIR DIAGNOSIS, PATHOLOGY, &c. CHAPTER I. PHYSIOLOGICAL ORIGIN AND PHYSICAL PROPERTIES OF URINE. Indications of the urine, 1—Proximate source of, 2—Metamorphosis of tissue, 3— Three species of urine, 4—Stages of the assimilative processes, 5—Liebig's theory of the destruction of tissue, 6—illustrated in muscle, 8—Relation of urine to other secretions, 9—Physical characters—Density, 10, 11—Formulae for solids in, 12— Table of ratio between density and solids, 13—Weight of a pint of urine of dif- ferent densities, 14, 15—Variation of density, 16, 17—Effects of fluid potations on, 18—Average density, 19—Colour, 20—Consistence, 21—Circular polarising power, 22—applied to diabetic urine, 23. 1. In availing himself of the phenomena presented by the urine in disease, it is essential that the practitioner should not fall into the error of regarding a knowledge of the morbid condition of the secretion as alone essential in directing his treatment; nor must he commit the equally serious mistake of regarding every deviation from the natural conditions of the urine as constituting a disease per se. The only view that can be legitimately taken of such conditions is to regard them, not as constituting entities of morbid action, but as one of a series of pathological changes going on in the system, and more valuable than others as an index of disease, in consequence of the facility with which it is de- tected. Hence every abnormal state of the secretion in question 3 26 PHYSIOLOGY OF URINE. should be regarded rather as an indication of some particular phase of morbid action, than as constituting the ailment itself. It is true, that those pathological states of the urine accompa- nied by the formation of deposits, or gravel, as they are popu- larly termed, may, and do, frequently acquire so serious a cha- racter as to lead to the formation of the much-dreaded stone or calculus ; and thus have a claim, from their importance, to be re- garded as definite and independent diseases. Still, both in their pathological and therapeutical relations, although frequently compelled, from the irritation they produce, to make the deposits or calculus primary objects of attention, yet we must never lose sight of the fact, that these are but effects not causes ; the termi- nal links in a chain, of which it should be the endeavour of the physician to grasp the beginning. 2. In a physiological sense, the urine must be regarded as arising from three several sources, each acting alike in preserv- ing the equilibrium of the delicately adjusted balance of the secre- ting functions of the body. The effects of copious aqueous pota- tions in producing a free discharge of pale urine, at once indi- cates one source of the great bulk of the urinary secretion, and demonstrates one of the most important functions of the kidneys in their pumping off any excess of fluid which may enter the cir- culation. A second great duty of these organs is shown in the physical and chemical characters of their secretion after the di- gestion of food is completed. Here it is no uncommon circum- stance to detect the presence of some traces of the elements of an imperfectly digested previous meal; and in unhealthy and irritable states of the digestive functions, to discover some ab- normal constituent in the urine, arising from the primary mal- assimilation of the food. Of the former of these states, the pecu- liar odour and colour of the urine after the ingestion of aspara- gus and some other bodies affords an example; and a good illustration of the latter condition is met with in the copious elimi- nation of oxalic acid from the blood shortly after a meal in cases of irritative dyspepsia. Hence the kidneys have the duty of re- moving from the system any crude or indigested elements of the food which had been absorbed whilst traversing the small intes- tines and entered the circulating mass; and of excreting the often noxious results of imperfect or unhealthy assimilation. The ASSIMILATIVE PROCESSES. 27 third function performed by the kidney is its serving as an outlet to evolve from the animal organism those elements of the disor- ganisation of tissues which cannot serve any ulterior process in the economy, nor be got rid of by the lungs or skin. The disor- ganisation of tissues here alluded to, is a necessary result of the conditions for the growth and reparation of the body. 3. It is admitted by all, that during each moment of our exist- ence, every atom of the frame is undergoing some change or other; the old matter is absorbed and thrown off by some of the excreting outlets of the body, and new matter is deposited from the blood to supply its place. The old and effete atoms of the animal structure are not excreted in the form of dead tissue, but their elements become re-arranged ; one series of combinations thus produced, rich in nitrogen, is excreted by the kidneys, whilst the more highly carbonised products are called upon to perform, chiefly through the medium of the liver, an important office previous to their final elimination. 4. It is therefore necessary to recognise three distinct varieties of the urinary secretion in every case under investigation : Firstly, that passed some little time after drinking freely of fluids, generally pale, and of low specific gravity, (1.003—1.009) urina potus. Secondly, that secreted after the digestion of a full meal, varying much in physical characters and of considerable density. (1.020—1.028 or even 1.030,) urina chyli vel cibi. Thirdly, that secreted from the blood independently of the immediate stimu- lus of food and drink, as that passed after a night's rest, urina sanguinis ; this is usually of average density, (1.015—1.025,) and presents in perfection the essential characters of urine. 5. As the elements of urine are thus assumed to owe their ori- gin to a process by which the effete elements of the body are re- moved, it may be useful to inquire how far we are enabled to trace the exhausted tissue through its several changes until it disappears as a fluid excretion. This, as well as many other portions of chemical physiology, have been invested with a peculiar charm by the bold inductions of Professor Liebig, who has, with great apparent success, endeavoured to trace the different stages of the metamorphosis of tissue through the various secondary offices the secreted products are called upon to perform in the economy, until their final separation as effete and useless matter. 28 PHYSIOLOGY OF URINE. Food is taken into the stomach, and undergoes certain changes by which such of its constituents as are capable of forming albu- men, as the protein elements of all animal and vegetable ingesta, are separated unchanged, and portions of its saccharine and amy- laceous elements are converted into fatty or oily matters. This act constitutes the first stage of what has been aptly termed by Dr. Prout1 primary assimilation. The elements of food thus separated or re-arranged by this process, being absorbed by the lacteals, reach the right side of the heart, and being exposed to the influence of the air in the lungs, become converted into blood. This act con- stitutes the second stage of primary assimilation. From the blood all the tissues of the body are formed, and the waste of the animal structures supplied ; a process forming the first stage of secondary assimilation. The old and exhausted material has then to be re- moved, to make room for the deposition of new matter by a pro- cess referred to the second or destructive-stage of the secondary assimilation of Dr. Prout, the metamorphosis of tissue of Professor Liebig.2 Dr. Prout has expressed an opinion, that the elements of the albuminous tissues of the body are, during the process of metamor- phosis, so arranged as to be converted into uric acid, or urate of ammonia, and the atoms not entering into the composition of these bodies, are so combined as to form" certain ill-defined principles."3 The ulterior changes which the gelatinous tissues undergo in the act of destructive or metamorphic assimilation, are supposed by this distinguished physician to be intimately connected with their con- version into urea, and some saccharine principle, or its close ally, the lactic acid. These opinions do not admit of positive proof, and hence can only be regarded as conventionally correct. 6. Professor Liebig has, in following the track thus pointed out by our illustrious countryman, with a boldness which at least ex- cites our admiration, endeavoured to express in numbers the changes occurring during the stage of destructive assimilation. He has assumed that the ultimate composition of animal flesh, as a mus- cle, and of blood, can be expressed by the same formula, and are consequently chemically identical. When, therefore, animal fibre is taken into the stomach, it undergoes a kind of imperfect solu- tion, and reaches the circulation, possessing nearly the same che- mical composition as the blood with which it becomes mixed. It MULDER'S RESEARCHES. 29 then undergoes certain changes in the lungs, assuming probably a more highly vitalised condition connected essentially with the conversion of its albumen into self-coagulating fibrin ; bodies, how- ever different in their physical and molecular arrangement, iden- tical in composition. Reaching in their course the nutrient capil- laries, the elements of the food are deposited in the substance of a tissue, as a muscle, whose waste they thus supply. Ere these new molecules can be deposited, room must be made for them by the removal of old matter, and then the following beautiful results of vital chemistry are supposed to come into play. The exhausted atoms of the muscle cannot be removed as fibres (3), but their ele- ments must be re-arranged, so as to enter the circulation and be carried to other organs. They therefore undergo metamorphosis ; water and oxygen a*e conveyed to the muscle, the former in the fluid of the blood, the latter in the red particles, and the result is the re-arrangement of elements, which, whilst it enables the old tissue to be removed with facility, furnishes the pabulum for other and important secretions. The late researches of Professor Mulder4 of Utrecht, on the com- bination of protein with oxygen, have thrown much light on a very obscure part of the act of metamorphosis of tissues, and which constituted the least tenable part of Liebig's hypothesis: he having, as already stated, assumed that oxygen is conveyed to the ca- pillaries in the arterial blood-corpuscles, combined with iron, as sesqui-oxide—which giving up part of its oxygen, reaches the ve- nous blood as protoxide. This idea can be only regarded as an ingenious assumption, for which no proof is offered by its talented author. All the elements of our food capable of being organised into albuminous tissues, consist of protein (C , N6, H , 0 ) com- bined with varying proportions of sulphur and phosphorus. Pro- fessor Mulder has discovered two oxides of protein, a binoxide and tritoxide, both of which are formed in the animal economy, and constitute, when combined with fatty matter, the buffy coat of inflamed blood. He believes that the protein of the food reaches the right side of the heart, circulates through the lungs, and. combines with oxygen, forming oxy-protein (binoxide, tritoxide, or both) ; this reaches the nutrient capillaries, and all or part is decomposed ; the oxygen being employed for the disorganisation of worn-out tissue, the protein thus de-oxidised being deposited 3* 30 PHYSIOLOGY OF URINE. to supply its place. If more protein is set free than is wanted for the growth of tissue, it passes unchanged into the veins, to be again oxidised in the lungs. The tritoxide of protein being so- luble in water, is better enabled to traverse the minutest capilla- ries than if it existed merely diffused through the fluid contain- ing it. 7. On Liebig's hypothesis, the elements of muscular tissue are carried into the circulation, combined with water and oxygen, the latter by its union with the carbon of the effete tissue, is supposed to aid the conservation of the temperature of the body. On reaching the glandular structure of the liver, 50 atoms of carbon, 1 of nitrogen, 45 of hydrogen, and 10 of oxygen, are supposed to be filtered off from the portal blood, in the form of bile, a secre- tion which has to play an important part in the animal functions, prior to its final elimination. The more highly nitrogenised por- tions of the metamorphosed tissue are separated by the kidneys from the blood conveyed to them by the renal arteries chiefly in the form of urea and uric acid, whilst the carbonic acid formed by the slow combustion of the carbon of the original atoms of muscle, is exhaled from the surface of the skin or pulmonary mem- brane. In this mode, by a wonderful influence of vital chemis- try, the exhausted fibre is ultimately expelled from the animal structure. An analogous explanation to the above, may be applied to the destructive assimilation of all the other animal tissues. 8. The following example will afford a good illustration of the results flowing from these views. According to Becquerel's re- searches,5 the average proportion of uric acid and urea excreted in 24 hours by a healthy adult amounts to 8-1 grains of the former, and 255 of the latter, being in the ratio of one atom of the acid to 82 atoms of urea. From the accurate experiments of Allen and Pepys, it appears that 18,612 grains of carbonic acid gas are ex- haled by an adult man in 24 hours; a quantity, as compared to the uric acid and urea, equivalent to about 800 atoms of carbon and 1600 of oxygen. The average proportions of bile cannot be determined with sa- tisfactory accuracy, but from the lowest assumed quantity secreted by a man in 24 hours 9,640 grains may be regarded as near the truth. As bile contains about 90 per cent, of water, the amount METAMORPHOSIS OF TISSUE. 31 of solids secreted in the bile during 24 hours will amount to 964 grains. Dried human bile contains about 69 per cent, of carbon, and hence 964 grains may be represented by about 14 atoms of solid bile, according to* the provisional formula suggested by Dr. Kemp.6 For the purpose of yielding these products about 35 atoms of muscular tissue must be acted upon by at least 1788 atoms of oxygen. The heat evolved by this slow combustion aids in keep- ing up the temperature of the body; and the products of this oxi- dation of exhausted tissue will be— 14 atoms of solid bile, excreted by the liver. ■t c ■ •, > excreted by the kidneys. 1----of uric acid ) J J 800 atoms carbonic acid excreted chiefly by the lungs. 403----water, diffused through all the excretions. Carbon Nitro-gen. Hydro-gen. Oxygen. 35 atoms of muscular tissue - 1680 210 1365 525 1788 1680 210 1365 2313 14 atoms of solid matter of bile 82 ------ urea - 1 ------ uric acid 800 ------ carbonic acid 403 ------ water - - - In excess 700 14 630 140 164 164 328 164 10 4 4 6 800 - - - . 1600 403 403 1674 182 1365 2313 6 28 1680 210 1365 2313 The 6 atoms of carbon and 28 of nitrogen here unaccounted for, are probably eliminated in combination with the constituents of water, forming some of the less defined elements of the excre- tion—as compounds of ammonia, fatty, colouring, and odorous principles, &c. Theories of this kind, notwithstanding the seductive interest with which they are invested, must be admitted with extreme caution, and as in every case in which we endeavour to explain vital phenomena, by the physical or chemical laws governing dead 32 PHYSIOLOGY OF URINE. matter, be admitted as only provisionally correct. Their minute, and even general details being liable to partial or complete alte- ration on the detection of a comparatively slight error in the analysis, or even on a mere difference of opinion regarding an atomic weight. It will be difficult to make the physiologist be- lieve that the laws which regulate the phenomena presented by inert matter in the laboratory, retain their supremacy as completely in that complex and wonderful structure in which Life is the pre- siding chemist. , 9. The physiological relations borne by the urine to other se- cretions both in regard to quantity and quality, are exceedingly interesting. The fact of this fluid constituting the stream by which a host of noxious ingredients, either formed within the body or derived from without, is washed away, has been already al- luded to (2). But there is another very important function which it performs in common with other secretions, depending upon the power possessed by the kidneys, of temporarily compensating the deficient action of other secreting organs. Thus, so long as the function of the liver and the kidney bear a normal relation to each other, all goes on as in health, a limpid secretion from the one and insensible exudation from the other, announce that a just balance obtains between the two functions. But if the energy of the cutaneous function be increased so that more than a normal amount of fluid escapes from the skin, the kidneys compensate for this great loss by secreting a smaller quantity of fluid, so that the urine becomes concentrated and its specific gravity is increased; and conversely, the bulk of the urine is often greatly increased when the skin is imperspirable. In this way the balance is for a time preserved, and no greater amount of fluid is drawm from the body than is consistent with health. Again, if the function of the liver be impaired, either from mechanical or organic causes, highly carbonised products are eliminated in the urine, the kidneys per- forming temporarily the function of separating some or all of the elements of bile from the blood, as every case of jaundice teaches us. In these and many other analogous modes (44) the quantity and quality of the urine may become so modified as to lead to serious errors; and to induce a suspicion of the presence of renal disease where none really exists. The fact of an excessive or diminished secretion of urine existing in any particular case can- PHYSICAL PROPERTIES. 33 not per se be regarded as indicative of disease of the kidney, any more than the excessive sweating so frequent in rheumatism or phthisis, or the diminished perspiration in fever, can be regarded as implicating the existence of disease of the skin. 10. In the investigation of urine in connexion with diagnosis, it is very important to notice its physical properties, especially its density or specific gravity, colour, consistence, and in some particu- lar cases its optical properties. Almost every one is familiar with the modes of discovering the density of the urine. This may be most readily accomplished by pouring some of the fluid into a cylindrical glass vessel, and im- mersing in it the little instrument known as the hydrometer, gra- vimeter, or urinometer. This is generally made of glass or metal, and consists of two bulbs a b, and a narrow stem ef. The instrument is made sufficiently heavy to sink to e, when placed in distilled water. Then, as all bodies immersed in fluid displace a bulk equal to them- selves, it follows that in a denser fluid a part of the instrument will not sink so deeply, and less of the stem will be immersed :7 the space e to f is graduated into degrees corresponding to different densities. When such an instrument is allowed to float in distilled water it sinks to the line e, from which the graduation com- mences ; if then it be removed into a vessel of urine, the degree in the stem corresponding to the level of the fluid, will correspond very nearly with its specific gravity. Thus if the de- gree 18 be on the surface of the urine, its specific gravity is said to be 1018 (the number 1000 being always added to the number on the stem). This shows that a vessel holding when quite full 1000 grains of distilled water, will contain just 1018 grains of the urine under examination. 11. If a gravimeter be not at hand, any small stoppered phial may be substituted. For this purpose, counterpoise the empty bottle and stopper in a tolerably good balance, with shot or sand. Then fill it with distilled water, insert the stopper, and carefully ascertain the weight of the water it contains. Empty the bottle, fill it with urine, and again weigh it; the specific gravity of the fluid will be readily found by merely dividing the weight of the urine by that of the water. 34 PHYSIOLOGY OF URINE. As an example, if a carefully counterpoised ounce phial, holding 478 grains of distilled water, and 498 of urine, the specific gravity of the latter will be 1.0418, for ||f =1.0418. The importance of a knowledge of the density of the urine is very considerable, as it puts us in possession of the data necessary for the calculation of the proportion of solids excreted by the kidneys ; and thus not unfrequently enables the physician to detect a previously unsus- pected cause of emaciation. For the purpose of becoming acquainted with the proportion of solids in the urine, it is absolutely necessary to preserve all the urine passed by the patient in 24 hours, and to ascertain its density, by actually weighing a portion (10), or by means of the urino- meter. The precaution of taking the mean specific gravity of the urine for 24 hours is quite essential, as no approach to accuracy can be arrived at by merely examining a single specimen voided during the day (16). 12. It is often of importance to ascertain not merely the pro- portionate, but the actual quantity of solids existing in a given quantity of urine. To determine this with accuracy, a small quantity of the fluid should be carefully evaporated over a vapour- bath in a counterpoised glass capsule, and when the extract has acquired a syrupy consistence its further desiccation should be effected in an air-pump vacuum over a saucer of sulphuric acid. Then, by a simple, arithmetical process, as the quantity of solids in a given quantity of urine is known, the proportion existing in the urine of 24 hours can be readily calculated. On account of the time and tact required for the performance of the above-described process, a serious obstacle is opposed to its being so frequently had recourse to as is often desirable. It has, therefore, been proposed to calculate the quantity of solid matter present in the urine from its specific gravity ; and for this pur- pose, the following different formulae have been proposed by the late Dr. Henry, Dr. Becquerel,0 and Dr. Christison.9 If D = the density or specific gravity of the urine, and a = the dif- ference between 1000 and its density, The quantity of solids in 1000 grs. is, according to Dr. Henry, A X 2*58 - Dr. Christison, A X 2-33 - Dr. Becquerel, A X 165 Although by formulae of this kind only an approximation to the RATIO BETWEEN SOLIDS AND DENSITY. 35 truth can be gained, in consequence not only of the different den- sities of the various elements of the urine, but from their not al- ways existing in the same proportion, yet they are of great value to the physician in his investigation of disease at the bedside, as affording an approach to an accurate knowledge of the solids re- moved from the system in a given time. Of these three formulae that of Dr. Christison has been shown by the researches of Dr. Day10 to be the most exact, and to afford results generally suffi- ciently accurate for the guidance of the practitioner. 13. The following table, calculated from Dr. Christison's for- mula, shows at a glance the quantity of solids and fluid in 1000 grains of urine of different densities. Table 1. Specific gravity. Solids. Water. Specific gravity. Solids. Water. 1001 2.33 997.67 1021 48.93 951.07 1002 4.66 995.34 1022 51.26 948.74 1003 6.99 993.01 1023 53.59 946.41 1004 9.32 990.68 1024 55.92 944.18 1005 11.65 988.35 1025 58.25 941.75 1006 13.98 986.02 1026 60.58 939.42 1007 16.31 983.69 1027 62.91 937.09 1008 18.64 981.36 1028 65.24 934.76 1009 20.97 979.03 1029 6757 932.43 1010 23.30 976.70 1030 69.90 930.10 1011 25.63 974.37 1031 72.23 927.77 1012 27.96 972.04 1032 74.56 925.44 1013 30.29 969.71 1033 76.89 923.11 1014 3262 967.38 1034 79.22 920.78 1015 34.95 965.05 1035 81.55 918 45 1016 37.28 962.72 1036 83.88 916.12 1017 39.61 960.39 1037 86.21 913.79 1018 41.94 958.06 1038 88.54 911.46 1019 44.27 955.73 1039 90.87 909.IS 1020 46.60 953.40 1040 93..20 906.80 The mode of using this table is exceedingly simple ; for having discovered the density of the urine passed in 24 hours by means of the gravimeter or specific gravity bottle, a single glance at the table will be sufficient to show the proportion of solid matter and water in 1000 grains of the urine. Then by weighing the whole quantity of urine passed in 24 hours, the weight of solids ex- creted by the kidneys may be calculated by a simple rule of pro- portion. 14. As it is much easier to obtain the measure than the weight 36 PHYSIOLOGY OF URINE. of urine passed in a given time, the following table becomes of use in enabling us to calculate the weight of the urine (in grains) from its bulk. A pint of distilled water weighing 8750 grains. Table 2. Specific gravity. Weight of one pint. Specific gravity. Weight of one pint. Grains. Grains. 1.010 8837 1.023 8951 1.011 8846 1.024 8960 1.012 8855 1.025 8968 1.013 8863 1.026 8977 1.014 8872 1.027 8986 1.015 8881 1.028 8995 1.016 8890 1.029 9003 1.017 8898 1.030 9012 1.018 8907 1.031 9021 1.019 8916 1 032 9030 1.020 8925 1.033 S038 1.021 8933 1.034 9047 1.022 8942 1.035 9056 15. The following example will be sufficient to point out the mode of using the preceding tables. Ex. : A patient passes in 24 hours 2\ pints of urine of the spe- cific gravity 1.020, what is the weight of solid matter thus ex- creted by the kidneys ? 1000 grains of urine, specific gravity 1.020, hold dissolved 46.6 grains of solids (Table 1) and a pint will weigh 8925 grains (Table 2); then, 8925v46.6 aif. n • c rj —-^-—= 415.9 grains of solids in a pint; and 415.9 X 2\ = 1039.72 grains, being the total quantity pre- sent in urine of 24 hours. 16. Much difference of opinion has existed regardingthe average density of healthy urine (19), a discrepancy admitting of ready ex- planation by a reference to the state of health of the individual by whom it was secreted, the period of the day at which it was passed, the bulk of fluid drank in the course of the day, and the character of the previous ingesta. Nothing can be more absurd than attempting to determine the state of the average density of the urine by the examination of specimens voided at different periods of the day. So seriously is the state of this secretion affected by comparatively slight causes, that from a neglect of this caution, a patient told only to " bring his water," might be supposed one day, from its density, to be SCHWEIG'S SPECULATIONS. 37 suffering from diabetes, and on the following he may surprise his medical attendant by presenting him with a specimen as light as spring water (18). In all cases where any approach to accuracy is required, an average sample from the urine passed in 24 hours into the same vessel must be selected : as this is, however, not always practicable, I am accustomed to request the patient to fur- nish specimens of the urine passed immediately before going to bed, (urina chyli,) and of that voided on rising in the morning (urina sanguinis). The average density of these two specimens will give a near approach to the truth. 17. The law of the density of the morning urine being less than that passed at night, holds good in disease, certainly in the ma- jority of cases. A remarkable exception, however, occurs in some neuralgic and hysterical affections, in which immediately after a paroxysm of the disease, the urine falls to its minimum of density at whatever period of the day it is secreted, often after a hysteric fit being scarcely heavier than pure water. The follow- ing table shows the results of some observations on the respective densities of night and morning urine in different diseases: Density of urine papsed nt r\ igin. Morning, Disease. Uui\A Chyli. Ur. Sanguinis. 1.027 1.022 Irritable Bladder. 1 026 1.026 1.024 1 024 1.022 1.022 1.020 1.024 1.014 1.016 Haemoptysis. Dyspepsia. Dyspepsia. Dyspepsia. Phthisis. 1.021 1.019 Oxaluria. 1.005 1.015 Hysteria. 1.020 1.018 | Healthy. A very curious statement has lately been made in Germany by Dr. Schweig,11 that the density of urine presents a constant rate of increase and decrease during the day, and that cceteris paribus it ranges from 1.017 to 1.022 in the forenoon, 1.023 to 1.028 in the afternoon, 1.019 to 1.028 in the evening, and 1.012 to 1.025 during the night. Taking the night urine alone, he states its density to vary through certain limits in a cycle of six days, so that twice in this period its density attains a minimum; on the third and fourth night being higher than on the fifth and second, 4 38 PHYSIOLOGY OF URINE. but then being lower than on the first. Five of these cycles occur,' according to Dr. Schweig, in each lunar revolution, counting the night before the new moon as the second day of one of his cycles. The following is the density of night urine taken from an average of 20 such periods : Nights of the cycle. Density of the urine 1 - - - - 1.022 2 . - - - 1.017 3 . - - - 1.019 4 - - - 1.020 5 - - - - 1.019 6 - - - - 1.017 18. It is quite impossible to aasign any limits within which the specific gravity of the urine secreted at different periods of the twenty-four hours may possibly range. In addition to the bulk of water eliminated from the circulation of the kidneys in a given time being materially affected by the state of surface (9) and other causes, the amount of fluids drank will exert an important effect in modifying the density and bulk of the urine. In many persons mere mental anxiety, or the ingestion of a few cups of tea, a glass or two of hock, or a goblet of soda-water, will at once determine the secretion of urine of a density as low as 1.002 or 1.003. The free use of aqueous diluents will also greatly increase the bulk and in a corresponding degree diminish the density of the urine. And from some recent observations of Prof. Liebig12 it appears proba- ble that the purer the water the more freely is it absorbed into the blood and eliminated by the kidneys, the presence of small quan- tities of saline matter considerably retarding its absorption and sub- sequent excretion. It was observed by Becquerel13 that a man whose normal average of urine in 24 hours was 30 ounces, passed 56 ounces after swal- lowing about a quart of water in the day. In another case the natural average, or 32 ounces, was raised to 87 ounces after the imbibition of half a gallon of water in the 24 hours. Severe mental emotion, especially a paroxysm of hysteria, will also obtermine the secretion of pale aqueous urine, of low density (17). A young woman who naturally passed in 24 hours about 35 ounces of urine, voided 86 ounces after the occurrence of a hysteric fit in the course of the day. VARIATIONS OF COLOUR. 39 19. Dr. Prout's experience has led him to assign 1.020 grains as the average specific gravity of healthy urine. From a number of careful observations made by Becquerel, it appears that the mean density of all the urine passed in 24 hours, and examined by him is, in man 1.0189, and in woman 1.0151, the mean in the two sexes being 1.017. The average quantity of urine secreted in 24 hours varies from 30 to 40 ounces; this is Dr. Prout's estimate, and is certainly the most correct. It is, however, capable of varying at least from 20 to 48 ounces, without exceeding the possible limits of health. 20. Among the physical characters of urine, the tints not unfre- quently present in different maladies are of great importance, and worthy of being carefully studied. Whatever may be the nature of the colouring ingredients of healthy urine (46), it is pretty evi- dent that they are capable of generating but a small series of tints ; varying according to the degree of dilution from nearly colourless, to the usual pale amber colour, and up to deep brown. When much diluted, urine presents a faint greenish tint, as in the urine of early infancy, and in that of chlorosis and hysteria. If bile or blood be present, a variety of colours varying from red to brown, blackish-green, or apple-green, are produced, the latter hue being occasionally indicative of the presence of cystine (107). It is often of great importance to distinguish between the substances causing some of the various colours possessed by the urine. The following table will be found of great use for this purpose. 40 PHYSIOLOGY OF URINE. Colour. Cause of colour. Chemical and Physical characters. Pathological indica-tions. Red A. Purpurine. Nitric acid produces a deposit of uric acid almost immediately— No change by heat— Alcohol digested on the extract, acquires a fine crimson colour— Density moderate. Portal conges-tion : it is generally connected with or-ganic mischief of liver or spleen. B. Blood. Becomes turbid by heat and nitric acid its colour changing to brown. — The micro-scope discovers float-ing blood-discs. Hemorrhage in some part of the urinary passages. Fever. Brown C. Concentration. Nitric acid precipi-tates uric acid readily —Density high—The addition of hydrochlo-ric acid to some of the urine previously warm-ed, produces a crimson colour. D. Blood. See B, coagulation by heat, and nitric acid less marked. Obstruction to the escape of bile from the liver or gall- E. Bile. A drop of nitric acid allowed to fall in the centre of a thin layer of urine on a white plate, produces a tran-sient play of colours, in which green and pink predominate. bladder ; and the presence of some or all the elements of bile in the circula-tion. Greenish Brown. Blood. See B ; occurring F. in alcaline urine. G. Bile. See E ; occurring in very acid urine. Grass-green. H. Excess of Sulphur 1 Unchanged by heat or nitric acid. Presence of cys-tine. 21. Urine occasionally varies in consistence, and instead of being very fluid, as is generally the case, acquires a considerable amount of viscidity. This is sometimes only to be detected by the readiness with which it froths on agitation, and the length of time the bubbles are retained, as in diabetes mellitus. In other cases the urine may be so viscid as to allow of being drawn into threads from the presence of mucus (188), although the latter generally forms a dense layer at the bottom of the vessel. The same thing occurs if pus is present in rather concentrated or alcaline urine, as the saline matters, or alcali present, re-act CIRCULAR POLARISATION. 41 upon the albuminous constituents of the pus, and convert it into a mucous magma as pointed out by Dr. Babington and myself.14 The urine is occasionally, although rarely, fluid whilst warm, becoming semi-solid, like a mass of jelly, on cooling. This change depends upon the presence of self-coagulating albumen or fibrin, a state of things generally connected with severe or- ganic mischief in the kidneys, although in some instances de- pendent only upon mere functional disturbance. (205) In a few rare instances occurring chiefly in urine loaded with oxalate of lime, I have found it quite fluid whilst cold and gela- tinizing when heated, retaining, however, its transparency. This curious change is best observed when water is poured on the warmed urine, when the gelatinous mass floats for some seconds in the water before it completely dissolves. 22. The optical properties of the urine have scarcely been applied to diagnosis, with the exception of the action saccharine urine exerts on polarised light, which has been proposed by M. Biot,15 and applied by M. Bouchardat16 to the detection of dia- betes mellitus. It is quite out of place to notice the theoretical action of diabetic urine on polarised light ; for an account of which I would refer the reader to works especially devoted to the investigation of physical phenomena :17 and now simply content myself with pointing out the readiest mode of applying this pro- perty to diagnosis. Let a mirror a composed of half-a-dozen pieces of thin window glass be fixed to an arm of a common retort-stand. A brass tube b, open at top, and closed below with a plate of glass, is fixed to a second arm : this tube should be an inch in diameter, and 6 or 8 inches long. In a third arm, at c, is fixed a ring of wood, supporting a doubly refracting rhomb of calcareous spar. Let the tube b, be filled with water, and allow the light of a candle, or of the clouds, to be incident on the mirror a, at an angle of 56.°45. A ray of light, polarised in a verti- cal plane, will consequently be reflected through the column of water in b. Then look through the crystal c, and two images 4* 42 PHYSIOLOGY OF URINE. of the bottom of the tube b will be visible : these images are colourless, and differ merely in the intensities of their illumina- tion. Slowly revolve the crystal c, and one of the images will cease to be visible four times in an entire revolution. Having thus become familiar with the management of the instrument, empty the tube b, and fill it with a tolerably strong solution of sugar. Again revolve the eye-piece c, and now, instead of two uncoloured images only being visible, two, tinted with the most vivid colours of the spectrum, will be seen. These will change their hues by revolving the crystal c. These beautiful tints are generated by a physical change produced by the solution of sugar on the transmitted plane-polarised light, giving rise to the phe- nomena of circular polarisation. 23. If then diabetic urine, carefully filtered to render it as clear as possible, be placed in the tube instead of the solution of sugar, the coloured images will be visible, not, however, with the vivid tints presented by the syrup, as their hues will be modi- fied by the colour of the urine, and quantity of sugar present. Whenever in this apparatus, two images possessing different co- lours, however faint, are seen simultaneously, it is certain that the fluid in the tube possesses the power of circular polarisation. And, as in the case of urine, but two bodies have been found which produce this physical change in light, viz., sugar and albu- men, it is easy to discover the substance which communicates this property to the urine. If, therefore, a specimen of urine which does not coagulate by heat, produces the coloured images when examined in the polariscope, it is certain that sugar is present. There are many practical difficulties in the application of the polarising power of urine to the detection of sugar, which will probably ever prevent its being generally employed. But as M. Bouchardat has lately drawn the attention of the profession to it it was necessary to give some explanation of it. ) COMPOSITION. 43 CHAPTER II. CHEMICAL PHYSIOLOGY OF THE URINE. Composition of urine, 24-6—Urea, 27—Physiological origin of, 28—Influence of food on, 29—Relation of Urea to carbonate ammonia, 30—Uric acid, 31—State in which it exists in urine, 32—Origin of urate of ammonia, 33—Theory of its formation, 34—Physiological origin of uric acid, 35—Liebig's theory, 36—Ob- jections to, 37-8—Probable origin of the acid, 39—Lactic acid,41—Relations to food, 42—Hippuric acid, 43—Physiological origin and relation to bile, 44—Bu- tyric acid. 45—Colouring matter of urine, 46—Purpurine, 47—Fixed salts of urine and their source, 48—Composition of phosphates, 49—Source of Sulphuric acid, 50—Urinary deposits, 51—Classification of, 52. 24. The chemical composition of urine has been the subject of repeated investigations during the present century, and numer- ous statements have from time to time been made public, re- specting the elements contained in this important fluid. In a phy- siological point of view, the urine of health may be regarded as naturally made up of the following classes of ingredients dissolved in water. I. ORGANIC PRODUCTS. 1st. Ingredients characteristic of the secretion, I . .... | Urea, uric acid, CO- produced by the destructive assimilation ' ,ouring amJ odorous of tissues, and separated from the blood f principles. by the kidneys. J 2d. Ingredients developed principally from ] Hippuric acid, lactic the food during the process of assimila- r acid ? accidental con- tion. J stituents- II. SALINE PRODUCTS. 3d. Saline combinations, separated from 1 phosphale8> Chlori(le the blood, and chiefly derived from the [of sodium. food. J 4th. Saline combinations chiefly generated 1 during the process of destructive assimi. r Sulphates. lation. J 44 PHYSIOLOGY OF URINE. III. INGREDIENTS DERIVED FROM THE URINARY PASSAGES. 5th. Mucus of the bladder. 6th. Debris of epithelium. Of these, the first class of ingredients can alone be considered as really essential to the urine, and characteristic of it as a se- cretion, the kidneys being the only organs which normally secrete these elements from the blood. The saline ingredients of the second class are met with in most secretions of the body, with the exception of the sulphates, which are rarely found except in the urine. The third class of elements is met with in all fluids passing over mucous surfaces. 25. As all unnecessarily minute chemical details of the analysis of urine, are more interesting in their abstract consideration than in relation to physiology and pathology, it would be quite out of place to insert any of the very elaborate views which have been given by some writers of the composition of the secretion under consideration. I prefer adopting the analyses of M. Becquerel, as the most practically useful, especially as they are corroborated by the results of the researches of most recent and trustworthy ob- servers. The following table presents a view of the normal com- position of the urine passed by healthy persons in the course of twenty-four hours ; the weight of the constituents being expressed in grains. Urine of men. Urine of women. Mean j{ both. In 24 hours. In 1000 grains. In 24 hours. 21124 1.0151 526.8 In 1000 grains. In 24 hours. In 1000 grains. Weight of Urine Specific Gravity Solids 19516 1.0189 610. 1000 31.1 1000 24.95 20320 1.01701 568. 1000 28. Urea Uric acid Fixed Salts Organic Matters } and Volatile Sa- > linecombinations ) 270 7.6 150. 176. 12.8 0.391 7.63 9.26 240. 8.6 126. 145. 10.366 0.406 6.14 8. 255. 8.1 138. 160.5 12. 0.398 6.9 8.6 26. The fixed salts referred to in this table consist of combi- nations of chlorine, phosphoric and sulphuric acid, with lime, UREA. 45 soda, potassa and magnesia, or their metallic bases: these sub- stances exist normally in the following proportions:— In the urine of 24 hours. In 1000 grains. Chlorine - 10.15 grains 0.502 grains Sulphuric acid - 17.3 0.855 Phosphoric acid 6.4 ... 0.317 Soda ^ Lime 1 Magnesia C 106.1 5.244 Potassa J 139.95 6.918 57. Urea.—Chem. Comp. C2, N2, Hi, 02, =60. This very im portant substance constitutes the form under which a large quan- tity of nitrogen is expelled from the system ; 270 grains, or more than half an ounce, being excreted by a healthy man in the course of twenty-four hours. Urea, in consequence of its combining with acids like a weak base, can be very readily discovered in urine. The nitric or ox- alic acids may be usecj for its detection; the former being the most convenient for clinical observations. For this purpose let about a dram of urine be placed in a watch-glass, and about half that quantity of colourless nitric acid be carefully added. If a normal proportion of urea exist, no change, except a darkening in tint, and the evolution of a few bubbles will be observed, un- less the weather be exceedingly cold, or the glass be placed in a freezing mixture, and then a delicate plumose crystallisation of nitrate of urea will commence at the edges of the fluid. Under ordinary circumstances, however, no crystals will appear, unless the urine be concentrated by previous evaporation. In some cases, indeed, an excess of urea exists, and then a rapid formation of crystals of nitrate of urea occurs, occasionally so copiously that the mixture becomes nearly solid. It is important, whenever this is the case, to measure, and ascertain the specific gravity of the whole quantity of urine passed by the patient in twenty-four hours; for unless this equals or exceeds the average proportion of health, there is no proof that an actual excess of urea is excreted by the kidneys. A particular specimen of urine may appear richer in urea than natural, simply from the diminished amount of water present. On this account, the urine secreted shortly after a full 46 PHYSIOLOGY OF URINE. meal, especially of animal food, as well as that voided after ex- cessive perspiration, generally crystallizes on the addition of nitric acid. 28. Physiological origin of urea.—This has been already traced to the destructive assimilation of the tissues of the body (8). That urea is one of the products of this important process, and that it constitutes the mode in which the greatest portion of the nitro- genised elements are secreted, is unquestionable. In man and warm-blooded, carnivorous and omnivorous mammalia, its quan- tity far exceeds that of uric acid ; whilst, in carnivorous birds, serpents, and insects, the latter substance predominates, and often quite replaces the urea. Dr. Prout is inclined to believe that the urea is the peculiar product of the metamorphosis of gelatinous, and uric acid of albuminous, structures.19 Liebig, on the other hand, considers that uric acid is the immediate product of the change in all nitrogenised tissues, and that urea is the secondary product, arising from the action of oxygen and water in the uric acid.20 The fact that in sea-birds and many insects the uric acid remains in the state of urate of ammonia, and does not become converted into urea, notwithstanding all the conditions necessary on Liebig's views for this change exist, must cause this hypothe- sis to be received with great caution. The following table shows the average quantity of nitrogen and carbon evolved from the system in twenty-four hours in the form of urea and uric acid. Quantity excreted in 24 hours. N itrogen existing in Carbon existingin Nitrogen calculated in cubic inches. Urea Uric acid grains. 255. 8.1 grains. 118.95 2.52 grains. 50.92 3.23 cubic inches. 391.4 8.3 Total 263.1 121.47 54.15 399.7 29. The influence of the composition of food on the quantity of urea, is beautifully shown by the late experiments of Dr. Leh- \ mann22 0f Leipsic. This philosopher examined the quantity of urea secreted by his kidneys whilst living for some days on a strictly animal diet, as well as when he restricted himself to vege- table food, to a mixed diet, and to one quite free from nitrogen, consisting of starch, gum, oil, sugar, &c. The mean weight of UREA. 47 the urea obtained from the urine of twenty-four hours, under these circumstances, is expressed below in grains. Diet. Animal. Vegetable. Mixed. Non-nitro-genised. Urea in the urine of) 24 hours - \ 819.2 346.5 500.5 237.1 No one can avoid observing the great disproportion existing between the quantity of urea existing in Lehmann's urine, and that generally met with ; the quantity secreted whilst confined to a strictly non-azotised diet, nearly equalling the normal propor- tion (25). Still, whatever may be the idiosyncrasy of the inge- nious experimenter on this matter, the results of his researches prove to a demonstration, the influence of food in modifying the proportion of urea separated by the kidneys. M. Lecanu23 has made some interesting observations on the connexion between the amount of urea secreted, and the age of the individual. The fol- lowing presents the average results of his experiments on the quantity of urea and uric acid excreted in twenty-four hours, at different ages. Urea. Uric acid. Adult men ... 431.9 grains - 13.09 grains Adult women - - - 294.2 - - 10.01 Very old men (84 to 86 years old) 124.8 - - 6 77 Children (under 8 years) - 138.2 ■ - 3.98 30. As urea consists of 2 at. carbon, 4 at. hydrogen, 2 at. ni- trogen, 2 at. oxygen, its elements are so arranged that its com- position exactly resembles that of carbonate of ammonia, minus two atoms of water. O. N. H. O. 2 at. carbonic acid - - 2 4 +2 at ammonia ... 2-(-6 24-2+6+4 —2 at. water - - - 2+2 = 1 at urea ... 2+^+4+2 In accordance with this view, urea is decomposed by boiling with a concentrated acid, a salt of ammonia being formed, whilst carbonic acid is evolved ; and, on the other hand, by ebullition with a solution of potass, ammonia is given off, and a carbonate 48 PHYSIOLOGY OF URINE. of potass remains. The mere act of boiling the urine is sufficient to decompose a portion of urea into an ammoniacal salt, and by long keeping, even in close vessels, a similar change occurs. The rapidity with which this conversion is effected, varies remarkably in different specimens of urine. I have known urine become al- caline within an hour of its emission, and yet, in one instance, I detected urea in a specimen of urine which had been preserved in a closely-stopped bottle for upwards of ten years. The pre- sence of a mucoid body in a state of change, acting as a ferment, certainly explains the rapid conversion of urea into carbonate of ammonia in some urine (144). The elements of urea not only are thus related to those of car- bonate of ammonia, but are identical with those of cyanate of ammonia with water (170), a circumstance which explains the occasional occurrence of cyanogen-compounds in urine. 31. Uric Acid. (Chem. Comp. C10, N4, H4, 06,= 168.) From the analysis of healthy urine, we learn that on an average 8.1 grains of this substance are excreted from the blood by the kidneys in twenty-four hours (25). There can be no doubt of the correctness of Dr. Prout's opinion, that the greatest proportion of the acid exists in combination with ammonia. From the accurate obser- vations of this physician, we learn that uric acid requires 10,000 parts of water at 60° for solution, whilst there does not exist in urine quite 2500 times its weight. It is hence utterly impossible to be in a free state without supposing the existence of causes modifying its solubility, by no means justified by the present state of chemical knowledge. If, on the other hand, the acid is com- bined with ammonia, it must of necessity remain dissolved at or- dinary temperatures. Urate of ammonia is soluble in 480 times its weight of pure water, and in the state in which it occurs in urinary deposits, requires for solution 2789 parts of urine, ac- cording to the researches of Dr. B. Jones ;24 who has also shown that the presence of a moderate quantity of saline matter increases its solubility. The 8.1 grains of uric acid normally secreted in twenty-four hours, require but 0.82 grains of ammonia for satu- ration, and the 8.92 grains of urate of ammonia thus formed, would be held in solution by less than half a pint of water, or about one-fourth the quantity separated from the blood by the kidneys. If healthy urine be slowly evaporated in an air-pump vacuum, it soon becomes turbid from the formation of clouds of URIC ACID. 49 urate of ammonia, which ultimately subside in minute globules on the sides of the vessel. The same thing occurs when urine of rather high specific gravity is exposed to cold. These facts ap- pear conclusive in favour of Dr. Prout's opinion. The most plausible objection against this view, is the one advanced by M. Becquerel and others, viz., that a single drop of nitric acid is sufficient to precipitate all the uric acid naturally contained in a considerable quantity of urine, which, it is stated, could hardly be the case if it were combined with a base. This is an objection more apparent than real, for if it be granted that 8.92 grains of urate of ammonia are dissolved in about 40 ounces of urine, a moment's reflection will show that less than a single drop of uric acid ought to be sufficient to precipitate all the uric acid present in half a pint of urine. For the quantity of ammonia combined with the uric acid in half a pint would be about 0.2 grains, which would be exactly neutralised by 0.8 grains of nitric acid, or less than a single drop. 32. It is, of course, quite possible that uric acid may be se- creted combined with ammonia from the elements of the disor- ganised albuminous tissues (35). It is, perhaps, more probable that the acid is first generated and subsequently unites with a base, which it meets, either in the nascent state, or in its progress through the tubuli of the kidneys. Late researches of Professor Liebig have thrown much light on this matter, in developing the mutual reaction of uric acid with alcaline basic phosphates. It is well known that an aqueous solution of tribasic phosphate of soda exerts an alkaline action on reddened litmus paper. If uric acid be heated in such a solution, it dissolves in consequence of com- bining with part of the soda, and setting free part of the phos- phoric acid, which probably forms a super-salt with some of the undecomposed phosphate.25 The fluid thus becomes acid, and reddens litmus. On cooling, the phosphoric acid reacts on the urate of soda, and about one-half the uric acid is deposited in fine prismatic crystals, resembling in shape some varieties of uric acid sand. These crystals are not pure uric acid, but contain, chemi- cally combined, some phosphate of soda, of which they are not deprived either by boiling water, or hydrochloric acid. The ad- dition of an acid to the fluid decanted from the crystals causes a deposition of tabular crystals of uric acid. These observations 5 50 PHYSIOLOGY OF URINE. are amply sufficient to explain the natural acidity of urine, and the deposition of crystals of impure uric acid on cooling ; all that is required, being to suppose that the .398 grains of uric acid, the average quantity existing in 1000 grains, are dissolved in about 2.5 grains of tribasic phosphate of soda, the proportion found by Simon in that quantity of healthy urine. 33. The deposits more frequently occurring in the urine on cooling, by evaporation in vacuo, or exposure to a freezing mix- ture, are, however, (61) neither crystalline nor composed of uric acid alone. They consist of urate of ammonia, more or less con- taminated with colouring matter; are amorphous, and readily dissolve in warm water, which scarcely acts on uric acid. We are hence compelled to seek for another explanation of the proxi- mate formation of these deposits ; and this, I believe, is found in the action of uric acid on the microscopic salt or double phos- phate of soda or ammonia; which salt, or its elements, may be regarded as a constant constituent of healthy urine. When uric acid is mixed with a warm solution of this triple phosphate, urate of ammonia is formed, and phosphoric acid evolved, either free or combined with a base and forming an acid salt. This urate of ammonia is not decomposed on cooling, but is simply deposited in delicate microscopic needles, readily re-dissolving on the ap- plication of heat, if sufficient water is present. On the addition of urine to a hot solution of these minute needles, they are de- posited on cooling, combined with the colouring matter of urine, completely amorphous and presenting all the characters of the commonest forms of urinary deposits.27 If, after the separation of the urate of ammonia, a fresh quantity of uric acid be heated in the supernatant fluid, more urate is formed, up to a certain point; when the phosphate of soda yields, and urate of soda is formed, which on cooling is decomposed in the manner already de- scribed (32). 34. I therefore venture to propose the following view of the mode in which uric acid exists in healthy urine. Uric acid, at the moment of separation from the blood, meets the double phosphate of soda and ammonia, derived from the food, and forms urate of am- monia evolving phosphoric acid, which thus produces the natural acid reaction of urine. If the whole bulk of the urine be to the urate of ammonia formed, not less than about 2700 to 1, the secretion URIC ACID. 51 will, at the ordinary temperature of the air, remain clear, but if the bulk of fluid be less, an amorphous deposit of the urate will occur. On the other hand, if an excess of uric acid be separated by the Icid- neys, it will act on the phosphate of soda of the double salt, and hence, on cooling, the urine will deposit a crystalline sediment of uric acid sand, very probably mixed with amorphous urate of am- monia, the latter usually forming a layer above the crystals, which always sink to the bottom of the vessel. 35. Physiological origin of uric acid. — It will be sufficient to merely allude to some of the more recent opinions entertained on this subject, and the first which demands attention is that of the celebrated Liebig.28 He believes that when, in the tissues con- taining protein, (i. e., albuminous structures,) the vital force is no longer able to resist the chemical action of the oxygen, which is conveyed to them in the arterial blood ; (6*) it combines with their elements and forms products, among which uric acid is the most important. Thus, the elements of one atom of the essential ingredient of all muscular and fibrous tissues, (protein,) with 91 atoms of oxygen, produce the elements of uric acid, carbonic acid) and water, thus — CNHO CNHO I atom protein =48+6+36+14"^ ri5+6+ 6 + 9=1£ at. uric acid. 91 — oxygen = 91 1 { 33 66=33 — car. acid. ------------->=-^ 30 + 30=30 — water. 48+6+36+105 j j^8+6+36+105 If, then, sufficient oxygen and water be conveyed in the arterial blood, the greatest part of the uric acid is converted into urea and carbonic acid, so that the effete nitrogenised elements of the tissue reach the emunctories in a soluble form, a condition neces- sary for their ready secretion. CNHO CNHO 1 atom uric acid=10+4+4+6 "\ r 4+4-f-8+ 4=2 at. urea. 4---water = 4-J-4 | [ 6 12=6 — car. acid. 6---oxygen = 6 10+4+8+16 I I 10+4+8+16 36. It is, therefore, obvious, on this hypothesis, that the larger the proportion of oxygen which circulates through a tissue in the 52 PHYSIOLOGY OF URINE. act of destructive assimilation, the more complete will be the con- version of uric acid into urea, and in proportion as this oxygena- tion is perfected the latter will disappear from the urine. Hence in the urine of carnivorous animals the quantity of uric acid in relation to the urea, will be in the inverse ratio of the rapidity of the circulation. Thus the boa-constrictor eats an enormous meal of nitrogenised food, but being a cold-blooded, slowly-respiring animal, it takes in too little oxygen to convert the uric acid form- ed by the metamorphoses of its tissues into urea ; and hence the semi-solid urine of this animal consists almost entirely of bi-urate of ammonia. On the other hand, the lion and tiger, equally car- nivorous with the serpent, are rapidly-respiring, warm-blooded animals, and although from their violent muscular exertions, rapid and great destruction of tissue must occur, scarcely a trace of uric acid is found in their urine, as it is all converted into urea at the moment of its formation, in consequence of the abundant supply of oxygen. As combination with oxygen is the necessary condi- tion for the metamorphosis of tissue, it follows that we should be in constant danger of oxydising to death, unless either the vital force is generated in sufficient intensity to oppose the action of oxygen, or some substance be present which opposing a less re- sistance to its influence than organized tissues, protects them from corrosion. The mucus covering the air-passages and the bile in the intestines, are thus supposed to be the conservative agents which protect the structures imbued with them from destruction by oxidation. In a like manner the non-nitrogenized elements of our food, as all fatty and amylaceous substances, interfere with the conversion of uric acid into urea, as they monopolize great part of the oxygen ; hence man, being an omnivorous animal, partakes of a sufficient amount of food, rich in carbon, to prevent the complete conversion of insoluble uric acid into soluble urea, consequently the former substance appears in the urine. The average proportion borne by the uric acid to urea in healthy urine being about 1 to 32. 37. If these views be correct, it will follow that other things being equal, the proportion of uric acid in the urine will increase in the urine of a man who takes food rich in carbon, and decrease if he confines himself to a nitrogenized diet, thus becoming a carnivorous animal. Further, the proportion of uric acid will de- URIC ACID AND UREA. 53 crease and urea increase, with the perfection of respiration and abundance of blood-discs, the reputed carriers of oxygen (6 — 8). It appears to me, however, that these views, ingenious and full of interest as they are, are not supported by any experience hitherto recorded, in fact, are, in many cases, totally opposed by it. The experiments of Lehmann, already alluded to (29), performed upon himself, demonstrate that vegetable diet and one quite free from nitrogen decreases, and an animal diet increases the quan- tity of uric acid; the urea also increases in the same manner. The following table presents the results of Lehmann on himself. Diet. Quantity excreted in 24 hours of PROPORTION OF URIC Unic Acid. Ukea. ACID TO UREA. Exclusively animal Mixed animal and > vegetable - - \ Exclusively vegetable Food free from ni-^ trogen - - - 3 22.64 grs. 18.17 . 15.7 . 11.24 . 819.2 grs. 500.5 346.5 237.1 1 : 36.1 1 : 27.5 1 : 22. 1 : 21. From this table we learn that when living on a diet as free from nitrogen as possible 11.24 uric acid and 237.1 grains of urea were excreted by Lehmann's kidneys in twenty-four hours. These quantities may be assumed as solely produced by metamorphosis of tissue, inasmuch as there existed no other source for them. On confining himself to a strictly animal diet, Lehmann found in his urine 22.64 uric acid, and 819.2 urea, being 11.4 more of the former and 582.1 more of the latter than can be accounted for by the disorganization of the tissues of his body, and consequently, must have been derived from the ingesta. On mixing vegetable food with his meat, instead of finding an increased proportion of uric acid, as the theory of Liebig would indicate, this substance decreased, not only in the actual amount, but in the ratio it bears to the urea. The statement, that in animals which eat flesh, the use of ve- getable food increases the amount of uric acid, is quite opposed to the fact recorded by Magendie,29 that uric acid disappears from the urine of carnivorous animals which have been fed for about three weeks on non-nitrogenised food. 5* 54 PHYSIOLOGY OF URINE. 38. The theory of the perfection of oxidation in increasing urea and diminishing the uric acid, scarcely appears to be in accord- ance with the well-known fact, that in carnivorous birds, as sea- fowl, the mortar-like urine is constituted of urate of ammonia, like the urine of serpents, and yet the former class of animals are ra- pidly-respiring, warm-blooded animals, provided with an abun- dance of oxygen, totally opposed to the serpents in their physio- logical characters, and appearing to present all the conditions required by the theory alluded to, for the total conversion of uric acid into urea. This change nevertheless does not occur, and so large a quantity of urate of ammonia is excreted by sea-birds that many islets and rocks in the tropics inhabited by them, are covered to a considerable depth with this substance, which is now an important article of commerce as a manure under the name of guano or huano. Zimmermann30 has attempted to defend Liebig's view against this objection when it was first urged, on the ground that the feathered skins of birds prevented contact of air to capillaries of the surface, and thus cut off one supply of oxygen. This remark, however, applies with equal force to the thick hides of the lion, tiger, and leopard, as well as to the scaly armour of serpents, and hence gives no support to either opinion. This question will, however, again come before us (70). 39. What then is to be regarded as the physiological sources of the uric acid of the urine ? There can be no question that all the phenomena of health and disease point out the probability of there being a double origin of this substance, one from the nitro- genised elements of tissues, and the other from the elements of food rich in nitrogen which escape the completion of the process of primary assimilation. No experience yet collected, justifies our assuming that uric acid bears any definite relation in quantity to urea; in all probability, Dr. Prout's opinion that the latter is de- rived from the metamorphoses of a different set of tissues (28), from those yielding the former, is correct, although it obviously does not admit of positive proof. 41. Lactic acid and lactate of ammonia.—The existence of these compounds in healthy urine first announced by Berzelius, and ad- mitted generally by chemists, has lately been called in question by Prof. Liebig, who, in a careful repetition of the processes of Berzelius, failed in detecting the slightest evidence of the pre- HIPPURIC ACID. 55 sence of lactic acid. It appears evident that what was mistaken for lactic acid, is really a peculiar crystallisable matter not hitherto described. In conversing lately on this subject with Prof. Liebig, he informed me that when a solution of chloride of zinc is added to an alcoholic solution of the extract obtained by evaporating urine nearly to dryness, a combination of the new substance with the oxide of zinc is formed. It is this which was mistaken for lactate of zinc by preceding chemists. The substances thus com- bined with zinc is soluble in water and alcohol, and crystallizes from its solution in either, in needles. It contains a very large quantity of nitrogen, and is weakly basic, uniting with acids like urea. Lehmann31 has stated that 1.52 grains of free lactic acid, and 1.20 grains of lactate of ammonia, are contained on an ave- rage in 1000 grains of healthy urine. Since the discovery of the new nitrogenised body just alluded to, these numbers must be regarded as indicating the proportion of this, and not of lactic acid or a lactate, as was previously supposed. 42. The composition of lactic acid (C6, H5, 05 = 8l) bears so simple a relation to that of some of the most ordinary elements of our food, that its presence in the secretions at least under many circumstances might almost be anticipated. Thus the elements of 1 atom of starch are equal to 2 atoms of lactic acid 1 ------cane-sugar - - do. - - - +1 atom of water. 1 ----- gum - - - do. --- do. 1 ----- milk-sugar - - do. - - - +2 atoms of water. 1 ------ grape-sugar -do. - - - + 4 - Lactic acid can be readily formed out of the body by digesting a solution of sugar with rennet; which is merely a piece of mu- cous membrane of the calf in a state of slow decomposition. 43. Hippuric acid. Chem. Comp., C,8, H8, N, 05+ HO=179. This substance, long known to exist in the urine of herbivorous animals, and according to some, occasionally in that of man, has been shown by Liebig to be a normal constituent of the latter fluid. The best mode of detecting this substance is to evaporate a few ounces of urine to a syrupy consistence, and then add an excess of hydrochloric acid. A mixture of hippuric and uric acids will then be separated and fall to the bottom of the vessel. After a few hours' repose the supernatant fluid should be de- 56 PHYSIOLOGY OF URINE. canted, and the deposit washed in a little very cold water. On boiling the residue with alcohol, in which uric acid is insoluble, the hippuric acid will be dissolved, and by spontaneous evapora- tion, is left in thin delicate needles strongly coloured from ad- hering impurities. Hippuric acid requires nearly 400 times its weight of cold water for solution, and hence can be separated from even a dilute solution of any of its alcaline salts by the ad- dition of a stronger acid. 44. Physiological origin. — It is believed by its discoverer to be a derivative of some of the non-azotized elements of the food,* and to exist nearly in the same proportion as uric acid. From my own researches, whilst they fully agree with the re- sults of Liebig as to the existence of hippuric acid, I am in- clined to believe that its quantity, in health, is not constant, and always, unless after the ingestion of Benzoic or Cinamic acids (88), much less than has been stated. It is possible that hip- puric acid may constitute a means by which carbon may be evolved from the system by the kidneys, and it is probable that in cases in which the proper emunctories of this substance, the lungs and liver, are deficient in their function, the kidneys may partially compensate for this, by secreting a larger proportion of hippuric acid. It is remarkable that this substance, next to the bile, is the richest in carbon of any of the products of vital chemistry, and hence it very probably performs an office of great importance in the body. A comparison of the per centage com- position of the organic material of human bile, from the analysis of Dr. Kemp, with that of hippuric acid, will show the relation between them, quoad the amount of carbon.32 Carbon Human Bile. 68.40 Hippuric Acid. 63.93 Nitrogen Hydrogen -Oxygen 3.44 10.13 18.03 8.21 4.64 23.22 100. 100. * Prof. Liebig mentioned to me a very curious fact, lately observed at the hos- pital at Wurzbuig, regarding the formation of this acid, from vegetable food. A girl labouring under what appears to have been some form of hysteria, refused all food excepting apples, of which she devoured an enormous quantity. On examining her urine, it was found to be alcaline, and contained a large quantity of hippuric but no uric acid, like the urine of a horse or cow. COLORING MATTER. 57 45. Butyric acid. — Occasionally present in urine, and in all probability owing its origin to an imperfect assimilation of sac- charine matter. As a product of disease, it is met with in the white creamy deposit occasionally observed in diabetic urine. The opinion of the origin of this acid being traceable to a change in the elements of sugar, is supported by the fact that, out of the body, it may be generated by digesting a solution of sugar with a piece of curd of milk, which plays the part of a ferment, the sugar being converted into butyric acid with the evolution of hydrogen and carbonic acid. C H O^i f C H O One at. of sugar=12+10+10 ! | 8+ 7+4 = 1 at. butyric acid. Two — water= 2+ 2 I__J 4 +8 = 4 carbonic acid. -----•---- [ "S 5 =5 hydrogen. 12+12+12 | 12+i2+i2 -) V- 46. Colouring matter. — The nature of the pigments existing in urine is but very imperfectly known. It has been supposed that there are at least two essentially distinct colouring matters. One of these is probably of a yellow tint, and as Dr. Prout has long shown, unites with urate of ammonia, causing this substance, which when pure is white, to assume a yellowish-brown colour. Simon considered the yellow colouring matter of urine to be identical with a yellowish-brown matter which ether and alcohol extract from dried serum of blood. This substance is termed Haemaphaein,33 and it is probably to its presence in excess, that the jaundiced hue of persons in a state of ansemia and chlorosis is owing. The normal amber colour of urine is probably owing to a mixture of this pigment with'a red one, or at least with one which readily assumes that tint on the addition of hydrochloric acid to the previously warmed fluid. This colouring principle becomes, under certain circumstances, highly developed, and then the urine, if not already deeply tinted, assumes a fine rose, or even purple colour, on the addition of hydrochloric acid. If from such urine a deposit of urate of ammonia occurs, it pos- sesses a colour varying from pale pink to the deepest carmine. This pigment I have proposed to name Purpurine,34 (uro-ere- thrine of Simon,) and its presence in excess is often of great importance as indicative of various diseases (101_). 5S PHYSIOLOGY OF URINE. 47. This peculiar colouring matter has been regarded by the highest authority on these matters to be identical with purpurate of ammonia, the murexid of Liebig. I have long ago made public the reasons which have induced me to dissent from this opinion, and to agree with those who consider the pigment as a substance sui generis. I may remark that purpurine is readily soluble in alcohol, which menstruum is without action, on pur- purate of ammonia (murexid). The following table, which pre- sents a view of the action of different reagents on watery solu- tions of these two colouring matters, is, I think, sufficient to decide the question of their independent nature.35 Reagent. Solution of Purpurine Solution of Murexid. r No alteration until after j Dilute sulphuric acid< the application of heat, when it becomes paler > Colour destroyed Liquor potassse Greenish brown color Purplish-lilac colour Hydrochloric acid No change in the cold Colour destroyed Ammonia Greenish yellow color Deeper crimson Carbonate potass Yellow color Deeper pink Proto-chloride iron No change Colour destroyed Hot acetic acid No change Colour destroyed Liebig has lately suggested that the colouring matters of urine are resolved by putrefaction into acetic acid and a resinous sub- stance ; and in this way accounts for the production of that acid in putrefied urine. 48. Thefixed salts met with in the urine, amounting on an average to'upwards of 138 grains in the course of twenty-four hours, demand an especial examination. These consist, as has been shown, of combinations of chlorine, sulphuric and phosphoric acid, with soda, lime, magnesia, and potass. To show how readily the supply of earthy phosphates is derived from without, I have calculated from the best authorities the quantity of these salts which exist in an ounce of eleven different articles of food. The number must not be assumed as rigidly correct, as in some of the analyses the sulphates and carbonates were included with the phosphates. INORGANIC SALTS. 59 Articles of Food. Phosphate in I ounce. Authority. Pease (Pisum Sativum) - - -French Bean (Phaseolus Vulgaris) Wheat (Triticum Hybernurn) -Beans (Vicia Faba) .... Potatoes (Solanum Tuberosum) Rice (Oryza Sativa) .... Milk....... 9.26 grs. 7.2 4.7 4.7 4.7 2.35 1.92 1.2 0.96 0.756 0.38 Braconnot Gorham Braconnot Liebig Binhoff Liebig Braconnot Liebig Payer and Braconnot Do. Liebig Artichoke (Helianthus Tuberosus) Vetchling (Lathyrus Tuberosus) 49. It is impossible to state with certainty in what manner, and with what bases, the phosphoric acid exists in the urine. Phos- phates of soda and lime are certainly present, and in all proba- bility the former is combined with phosphate of ammonia forming the double, or microscomic salt; ammonio-phosphate of magnesia perhaps is also an element of healthy urine, as on the addition of \l ammonia a mixture of this salt and phosphate of lime is precipi- tated. The following formulas represent the atomic composition of these different salts. They are all tri-basic. Phosphate soda .... (HO, 2Na 0, P2 0.)+24 HO Ammonia-phosphate of soda - (HO, NH4 O, Na O, P2 05)+ 8 HO Phosphate of lime .... (HO, 2Ca O, P2 05) Ammonio-phosphate of magnesia - (NH4 O, 2Mg O, P2 05)+12 HO The soluble phosphates must be regarded as derived directly from the food, and from the blood when in the act of being or- ganised into muscle. The insoluble phosphates forming part of the structure of the body, derived originally from the blood, are conveyed to the urine in the process of metamorphoses of tissue. Some of the phosphoric acid of the urine is in all probability gene- rated from the action of oxygen on many of the structures of the body, into the composition of which phosphorus largely enters, as in the brain and nervous system generally. The chlorine exists in combination with sodium, and is in all probability derived from the common salt taken with food. The greatest part of the phos- phoric acid is derived, ready formed, from without, as it occurs in considerable proportion in most elements of food derived from the vegetable kingdom in combination with lime and magnesia ; 60 PHYSIOLOGY OF URINE. whilst the basic alcaline phosphates exist in flesh, in wheaten flower, leguminous seeds, as beans and peas, &c. The ashes ot blood contains the basic alcaline phosphates; and muscle, when incinerated, yields much phosphate of lime and some phosphate of magnesia. The alcaline and earthy phosphates, in the opinion of Liebig, are chemically combined, the former with albumen, the latter with fibrin. During the formation of muscular tissue, whilst blood is becoming converted into muscle, the earthy phos- phates remain in the new-formed tissue in a state of chemical com- bination ; the greater amount of the basic phosphates of soda and potass re-enter the circulation, are separated by the kidneys, and thus find their way into the urine. A part only of the earthy phosphates contained in the food is absorbed into the circulation, the greatest proportion escaping by the intestines. Berzelius found in three ounces of human excrements, 6 grains of earthy phosphates. 50. The proportion of sulphuric acid present in the urine, nearly double that of the phosphoric acid, is too large to be entire- ly explained by its presence in the food in a state of saline com- bination. Indeed an abundance of sulphuric acid may be detect- ed in the urine, whilst food absolutely free from sulphates is taken into the stomach. The presence of this acid is rather to be traced to the oxydation of the sulphur which exists with phosphorus in the elements of those tissues which contain albumen and fibrin. These two substances consisting, according to Mulder, of Albumen. Fibrin Carbon 54.84 54.56 Hydrogen - 7.09 6.90 Nitrogen 15.83 15.72 Oxygen 21.23 22.13 Phosphorus 0.33 0.33 Sulphur 0.68 0.36 100. 100. Thus during the destructive assimilation or metamorphosis of tissue (9), oxydation of the sulphur and phosphorus occurs and explains the presence of the greater proportion of the sulphuric acid, or part, at least, of the phosphoric acid met with in the urine. INORGANIC SALTS. 61 51. Whenever the different constituents of the urine maintain their proper relation to each other, the fluid, as it leaves the ure- thra, is clear and of a pale amber colour, its transparency being but slightly affected on cooling by the gradual subsidence of a slight mucous cloud occasionally entangling in its meshes a very few microscopic crystals of uric acid. Whenever, however, one or other of the ingredients exist in real or comparative excess, or a new substance is superadded, the urine does not generally re- main clear, but either immediately on being voided, or at least on cooling, becomes more or less turbid. Different names have been applied to the different degrees and states of turbidity, viz., pellicle, cloud, eneorema, and sediment, the hypostasis of the an- cients. When the urine, on cooling, becomes covered with a thin membrane-like serum, a pellicle is said to exist; when the sub- stance producing the opacity floats in detached portions near the surface, it is said to form a cloud, and when this falls towards the base of the vessel, it is termed an eneorema ; the term sediment or hypostasis being applied to a positive deposit collected at the bottom of the vessel. Of these, the terms pellicle, cloud, and sediment, or deposit, are still retained as general terms, but not now used for the purpose of distinguishing any particular form of deposit. It very frequently happens that deposits do not become visible in the urine until after it has cooled down to the tempera- ture of the air; this is particularly the case with those which are soluble in warm water, as the urates, more especially the urate of ammonia (59), which constitutes the great bulk of the red and fawn-coloured amorphous sediments. A crystalline deposit may escape detection by fixing itself in translucent crystals on the sides of the vessel, as sometimes happens with pale uric acid and triple phosphate (138). It is quite possible also for a crystalline substance to be present in large quantity, and yet, on account of the minuteness of the crystals and their refractive power not greatly differing from urine, to remain unnoticed. This is re- markably the case with oxalate of lime, and such deposits are best detected by gently warming the urine, and, after a few moments' repose, to pour off the greater part of the fluid ; on replacing this with distilled water, the previously overlooked deposit will be- come visible. 6 62 PHYSIOLOGY OF URINE. 52. Urinary deposits, including under this term all substances which disturb the transparency of urine by their presence, whether they subside to the bottom of the vessel or not, may be conve- niently divided into the four following classes. Class 1. — Deposits composed essentially of ingredients formed directly or indirectly from the metamorphosis of tissues, or from the organic elements of food. Uric acid and urates. Uric oxide. Oxalate of lime. Cystine. Class 2. — Deposits composed of ingredients of inorganic origin ; including. — Phosphate of lime. Ammonio-phosphate of magnesia. Carbonate of lime. Silicic acid. Class 3. Highly coloured deposits (black or blue) of doubtful origin. Cyanourine. Melanourine. Indigo. Prussian blue. Class 4. — Deposits consisting of non-crystalline organic pro- ducts; including — a. Organized. Blood. Pus. Mucus. Organic globules. Epithelium. b. JYon-organised. Milk. Fatty matter. c. Possessing independent vitality Spermatozoa. Torulae. Vibriones. COLOUR OF URIC ACID DEPOSITS. 63 CHAPTER III. CHEMICAL PATHOLOGY OF URIC ACID AND ITS COMBINATIONS. Colour of uric acid deposits, 53—Diagnosis of, 54—Characters of the urine, 55— Microscopic characters of the deposits, 56-8—Diagnosis of urate ammonia, 59— Character of urine, 60—Microscopic characters of the deposit, 61, 2—Urate of soda, 63—Pathological changes in quantity of uric acid, excess, 64—Deficiency, 65—Influence of perspiration, 66-8—Seguin's experiments, 67—Liebig's theory, 69—Becquerel's researches, 70—Causes of excess of uric acid, 71—Detection of, 72—Excess traced to congestion, 73—Conditions for separation of the free acid, 74-6—Uric deposits considered as calculous affections, 77—Therapeutical indi- cations,—by diaphoretics, 78, 9—By correcting the digestive functions, 80, 1— By iron, 83—By solvents, alkalies, 84—Alkaline salts, 85—Biborate of soda, 86 —Phosphate of soda, 87—Benzoic and cinnamic acids, 88, 9. 53. When uric acid occurs in an urinary deposit, uncombined with a base, it is invariably in a crystalline form, never occurring in the state of an impalpable amorphous powder. The crystals are often sufficiently large to allow their figure to be defined without the aid of the microscope ; sometimes, however, they are so minute, that the deposit has been mistaken for urate of am- monia, or even for mucus, until microscopic examination has dis- covered the error. Uric acid never occurs quite colourless; in- deed, excepting when mixed with urate of ammonia, which is frequently the case, is so strongly coloured as not even to present an approach to whiteness. Every shade of intensity of tint, from the palest fawn-colour to the deepest amber or orange-red, is ob- served in these deposits ; and hence the terms yellow or red sand are applied to them. In general, the deeper the colour of the urine, the darker the sediments. 54. Diagnosis of uric acid deposits. — When heated in the urine, the uric acid deposit does not dissolve ; the crystals merely become opaque. It generally becomes more distinct from the solution of urate of ammonia, which is frequently mixed with it, and sometimes completely conceals it from view. Hence the C4 PATHOLOGY OF URIC ACID. best mode of discovering this deposit, is to warm urine, turbid from excess of urate of ammonia, in a watch-glass ; the acid be- comes visible in the centre of the glass, as soon as the urate dis- solves. Heated with liquor potassae, the uric acid deposit dis- solves, from the formation of an urate of potass of sparing solu- bility. Hydrochloric and acetic acids are without any action, but the nitric readily dissolves it, and by careful evaporation a residue of a beautiful pink colour becoming of a rich purple, on being held over the vapour of ammonia, is left. This coloured residue is the murexid of Liebig, the purpurate of ammonia of Dr. Prout. Exposed to heat in a platinum spoon, the uric acid deposits burn, evolving an odour of bitter almonds; and finally leave a small quantity of a white ash, which generally contains phosphate of soda or lime. 55. Characters of urine depositing uric acid.—When urine con- tains an excess of this acid, it generally lets fall crystals on cool- ing, uric acid being very seldom deposited before emission. It usually possesses a deeper amber-tint than natural, sometimes being of a reddish-brown colour. Very high-coloured urine, however, seldom deposits uric acid until after the addition of a stronger acid. Urine never lets fall spontaneously all its uric acid as a deposit, for after being filtered from a sediment of this substance, the ad- dition of a drop of nitric acid generally causes the depcsition of an abundance of crystals of uric acid in a few hours. Urine depositing uric acid always reddens litmus paper, and often contains an excess' of urea, so as to crystallize slowly when mixed with nitric acid in a watch-glass (27). Its specific gravity is generally rather above 1.020. An exception to the above cha- racter is presented by the pale urine of infants at the breast, among whom deposits of uric acid are common. These often appear as a yellow crystalline sand, whilst the supernatant urine is frequent- ly of low specific gravity, often 1.006, as pale as water, and nearly destitute of urea. 56. Microscopic characters.—The varieties presented by uric acid in its crystalline form, are very remarkable ; all of them, however may be traced to some modification of the rhombic prism, which may be assumed as the normal crystalline form of this substance. But two varieties can be artificially obtained, by filtering a warm MICROSCOPIC CHARACTERS. 65 solution of urate of potass or ammonia, into dilute and warm hy- drochloric acid ; perfect rhomboids or square tables, often excava- ted at the sides into an imperfect hour-glass figure, being obtained. These varieties cannot be produced at will, and appear to depend upon the strength of the solution of the urate employed, and tem- perature of the dilute acid. In deposits, the crystalline forms can be examined by merely placing a drop of the turbid urine on a plate of glass, and exam- ining it with a microscope under a good half-inch achromatic object-glass. By far the most satisfactory mode is, however, the following, which, by rendering the crystals distinct, amply repays the trouble it requires. Allow the urine to repose for a short time in a tall vessel, decant the greater proportion, and pour a tea- spoonful of the lowest turbid layer into a watch-glass, gently warm- ing it to dissolve any urate of ammonia, and to aid the deposi- tion of the deposit. Remove the supernatant urine with a pipette, and replace it with a few drops of water; then place the watch- glass under the microscope, and the crystals covered by the water will become most beautifully distinct. They may be examined by transmitted or reflected light, the latter having some advantages when the crystals are large or in masses. All that is then requir- ed is to place on the stage of the microscope, and under the watch-glass, a piece of black velvet; by means of a condensing lens, let a strong light be thrown upon the crystals ; then bring the object-glass into proper adjustment, and the colour, as well as the figure of the crystals, will become beautifully defined on a black-ground. In the following microscopic views, all the larger crystals are thus represented. Fig. 3. Fig. 4. 6* 66 PATHOLOGY OF URIC ACID. 57. In Fig. 3 are represented the common rhomboidal crystals of uric acid ; these are sometimes found so thin, as to be merely pale, lozenge-shaped lamina?; more generally,however, they are thicker, and then by adjusting the light carefully, their sides and true shape become well marked. Many of them appear nucleated, from the presence of certain internal markings, as if one crystal included another. It seldom happens that the angles of these are sharply defined, the two obtuse corners being most generally rounded off; and sometimes the acute angles are blunted, so that the whole crystal appears elliptical. The most perfect specimens of these are found in deposits of yellow sand in the urine of young infants; I have never seen them in red sand, or in deposits pro- duced artificially by the addition of a mineral acid to urine. WTien the deposit has been of long continuance, especially in cases of calculous disease, the rhomboid outline of the crystal is replaced by a square one (Fig. 4). The deposit is then generally high- coloured, and the crystals much thicker than in the former variety. In these an internal marking, like a framework, is visible. Several accidental varieties of these rhomboid and square crystals exist; of these the most curious present a spindle-like figure, the obtuse edges being rounded, and the margin on either side excavated (Fig. 5), so as sometimes to approach a fleur-de-lys outline. Many i:nc deposits appear at first sight to be made up of flattened cylinders, Fig. 5. Fig. 6. presenting a very remarkable appearance (Fig. 6). Upon making them roll over, by adding a few drops of alcohol, or by agitation the fallacy will be detected, they being really very thick lozenges MICROSCOPIC CHARACTERS. 67 lying on their sides ; and hence without causing them to roll over and carefully adjusting the object glass, might be regarded as cylinders, for which indeed they have been erroneously described by M. Vigla and myself. This variety is frequently found mixed with urate of ammonia and oxalate of lime. The addition of hydrochloric acid to urine often causes a precipitation of crystals of this form. 58. The crystals are sometimes found very thin, and longer than broad, so as to represent square tables. These in general have their surfaces quite smooth, especially when they occur in pale urine. When, however, they are met with in very acid urine, or are precipitated by the addition of nitric acid, the sides of the tables are strongly defined, but the extremities are closely serrated, as if made up of a number of closely-packed, irregular needles, crystallized on the body of the crystal. The whole sur- face is sometimes marked with myriads of close dark lines. When carefully examined, the bodies present a very remarkable in- ternal marking, like two crescents placed with their convexities op- posed (Fig. 7). This curious appear- ance is only visible in the non-striated body of the crystal, and is most clearly seen after they have been dried and preserved in Canada balsam. Coarse, and deep orange or red, sand is generally composed of coher- ing crystals, forming, indeed, minute calculi. Two varieties of these are met with, one formed (Fig. 8) of cohering, thick rhomboidal prisms, and the other of aggregated lozenges in spinous masses. The latter are particularly met with where a marked tendency to the formation of calculi exists (Fig. 9). It is not unfrequent to find these masses crystallized on a hair, just as sugar-candy is crystallised on a string or thread. When very hastily deposited by the sudden cooling of the urine, or by the addition of a strong acid, uric acid is sometimes precipitated in irregular masses, re- sembling on microscopic inspection irregular fragments of yellow quartz ; this, however, is unfrequent, and is the only exception 68 PATHOLOGY OF URIC ACID. I am acquainted with to uric acid occurring in well-defined crystals. 59. Diagnosis of deposits of urate of ammonia.—These deposits vary in colour from absolute whiteness to a pale fawn-colour, which is the most frequent tint, brick-red, pink, or purple. All these various-coloured deposits present certain characters in com- mon ; they never appear in the urine until after it has cooled, and disappear with the greatest readiness on the application of heat. The purple deposits require rather a higher temperature for solution than the other. The addition of liquor ammonise, or liquor potassse, immediately dissolves deposits of urate of ammonia. Their chemical constitution is shown in a very interesting manner by examining a drop of the turbid urine with the microscope between two plates of glass ; an amorphous powder will be alone visible, unless uric acid be present; then add a drop of hydro- chloric acid, the turbidity will disappear, and in a short time crystals of uric acid will be seen growing in the fluid, the am- monia having deserted this substance to unite with the acid which had been added. 60. Characters of urine depositing urate of ammonia.—The following modifications are most important. • 1st. A pale urine of low specific gravity (1.012), becoming opaque on cooling from the deposition of nearly white urate of ammonia, which, instead of readily falling, forms rope-like masses in the fluid, and presents on a superficial view so much the ap- pearance of muco-pus, as to have been mistaken for it. Its dis- appearance on the application of heat at once wTill discover the error. URATE OF AMMONIA. 69 2d. A pale amber-coloured urine of moderate density (1.018), which on cooling lets fall a copious fawn-coloured deposit, re- sembling bath-brick grated into the urine, disappearing with the utmost readiness on applying a gentle heat. This deposit is of frequent occurrence, is often very transient, and is so constantly an attendant on the slightest interference with the cutaneous trans- piration, that a " cold" is popularly diagnosticated whenever this state of things exists. 3d. Whenever febrile excitement prevails, the urine becomes concentrated, rises in density (1.025), and deposits on cooling a reddish-brown sediment, constituting the well-known lateritious, or brick-dust sediment. This variety of urine generally becomes turbid on the addition of a drop of nitric acid, not from the coagu- lation of albumen, as has been frequently erroneously supposed, but from the precipitation of uric acid. This is always in minute microscopic crystals, notwithstanding the amorphous appearance it presents to the naked eye. 4th. In well-marked affections of the portal circulation, espe- cially when connected with organic disease of the liver or spleen, or when suppuration, particularly of a strumous character, is going on in the body, the urine is generally found to possess in many instances a deep purple or copper colour, often verging on crimson, so as to have led to the idea of blood being present. These deep tints appear to me to depend upon the presence of an excess of purpurine (47). Whenever a deposit of urate of ammonia occurs in such urine, either spontaneously or by im- mersing it in a freezing mixture, it combines with the pink pig- ment forming a kind of lake, and which is often so abundant as not to entirely disappear by heat, until the urine is diluted by the addition of water. These deposits do not exhibit their delicate tints until after being collected in a filter ; they readily give up their colouring matter to alcohol, which leaves their urate of am- monia nearly unchanged. 61. Microscopic character of urate of ammonia. — When a drop of urine, turbid from the presence of this substance, is placed between two pieces of glass, and examined with the microscope, a mere amorphous precipitate is first seen; but on minute exami- nation, this will be found to be composed of myriads of exces- sively minute globules adhering together, forming little linear 70 PATHOLOGY OF URIC ACID. masses (Fig. 10), often mixed with crystals of uric acid. Sometimes? especially if the urine has been long kept, the minute particles cohere and form small opaque spherical bodies, appearing black by transmitted light, on account of their opacity ; when examined by reflected light, on a black ground, they present a buff or fawn colour. On the application of a slight heat to the drop of urine, the particles of urate of ammonia disappear, again becoming visible on cool- ing. An elegant mode of showing the composition of the de- posit, is to place a drop of the turbid urine in a watch-glass, and gently warm it; as soon as it has become clear, add a drop of almost any acid, the hydrochloric is perhaps the best, and ex- amine it with the microscope. The muddiness previously pro- duced by the urate, will have become replaced by lozenges of uric acid (Fig. 3). Very rarely the urate of ammonia occurs in large globules mixed with crystals of uric acid ; this is occa- sionally observed in albuminous urine (Fig. 11), and from its opacity, is best observed by reflected light. Fig. n. Fig. 12. 62. It has been stated, especially by continental observers, that urate of ammonia occurs in deposits in delicate needles, some- times united so as to form stellse. 1 have never seen this variety in urine. Fig. 12 shows the minute needles and stellse of urate of ammonia, artificially prepared by heating uric acid in the am- URATE OF AMMONIA. 71 monia-phosphate of soda (33). It is difficult to imagine this form ever occurring in urine, as Dr. B. Jones has shown that the presence of saline matter or the colouring matter of urine, inter- feres with the needle-like crystallisation of urate of ammonia, and converts it into minute globular particles. 63. Of the other salts of uric acid, the urate of soda is the only one I have distinctly recognised in deposits. It occurs oc- casionally in gout, but I have more generally met with it in the urine of persons labouring under fever, who wTere treated with carbonate of soda. It then occurs in round yellowish opaque masses provided with projecting, generally curved processes, (Fig. 13,) forming a very remarkable figure. When artificially prepared, by dissolving uric acid in a hot solution of carbonate of soda, it crystallises in needles and tufts (Fig. 14). In chemical characters, the urate of soda resembles the salt of ammonia, but does not disappear quite so readily on heating the urine. Fig. 13. Fig. 14. 64. Pathological changes in the quantity of uric acid and urate of ammonia. — Independently of an alteration in the proportion of uric acid by an excess or deficiency of nitrogen in the food (42), certain pathological states of the system exert a most important influence on the quantity excreted. We have seen that uric acid may be traced to two great sources, viz., the disintegration of tissues, and to nitrogenised food (39). It is obvious, therefore, that whatever increases the rapidity of the former process or in- terferes with the due digestion of assimilation of the latter, will materially affect the amount of uric acid contained in the urine. Experience has shown that in all diseases attended with great 72 PATHOLOGY OF URIC ACID. emaciation, when the wear and tear of the frame is not compen- sated by the supply of food, an increased quantity of uric acid appears in the urine, if the kidneys remain sufficiently healthy to perform their functions. But certain exceptions are pre- sented to this general rule, in cases where the renal function is itself impaired, as in diabetes mellitus, and in the granular dis- eases of the kidneys (Morbus Brightii). In all acute inflamma- tory diseases, in acute inflammation supervening on chronic mis- chief, in rheumatitis, in organic, or even sometimes functional affections of organs materially influencing the circulation, as the heart, liver, and perhaps the spleen; a considerable increase in the quantity of uric acid will occur, and deposits of this sub- tance, either free or combined, will appear in the urine. Taking the average of eleven cases of acute inflammatory diseases, re- ported by M. Becquerel, and twelve of continued fever (on the fifteenth day), by M. L'Heritier, we find that the quantity of uric acid was more that double the healthy average. Acute inflammation. Fever. Health. Specific gravity of the urine 1.0216 1.0229 1.017 Water .... 653.454 591.775 971.935 Uric acid - - - - 1.041 1.312 0.398 In the two allied affections, gout and rheumatism, exclusive of the many neuralgic diseases popularly referred to the latter, a remarkable tendency to the formation of an excess of uric acid, both pure and combined, especially with soda, occurs. The elements of the acid, or its combinations are in these diseases supplied both by the nitrogenised elements of the food, as well as by the changing tissues of the body. In such quantities is urate of soda often generated, that the watery portions of the blood are not sufficient for its solution; and part of it is deposited in the joints, and sheaths of the tendons, producing painful swellings. 65. In all diseases attended with excessive debility, independ- ently of acute disease, especially where an anaemic or chlorotic state exists, and when the circulation is languid, or if excited is owing to irritation rather than inflammation, a deficiency of uric acid occurs, and no deposits ever take place in the urine, unless the quantity of water present is remarkably diminished. The IN SUPPRESSED PERSPIRATION. 73 diminution of uric acid is well observed after losses of blood, in chlorosis, and in many neuralgic and hysteric affections. The average drawn from four cases of chlorosis, observed by Bec- querel, and one of melaena, another of irritable uterus, and a third of spermatorrhaea, examined by myself, is as follows:— Average density - - - - 1.015 ——— water .... .976 Uric acid ..... .184 The quantity of uric acid being less than one-half the normal proportion. 66. As a general rule, whenever the functions of the skin are impaired, where a due amount of secretion is not exhaled from the surface, an excess of nitrogen is retained in the blood, and ultimately separated by the kidney in the form of urate of ammonia, or perhaps urea. A person in apparently good health, experiences from exposure to a current of cold air a slight check to perspira- tion, and the next time he empties his bladder, he voids urine of a deeper colour than is usual with him, and on cooling it becomes turbid from the precipitation of urate of ammonia. The expla- nation of this phenomenon, with which every one is familiar, is found in the kidneys assuming temporarily a kind of compensating function (9) for the skin. It is true that uric acid, or urate of ammonia, is not naturally expelled from the surface of the body, but certain organic matters, rich in nitrogen, certainly are; and if their proper emunctory, the skin, has for a time its function arrested, they are probably filtered from the circulating mass by the kidneys, in the form of urate of ammonia. That nitrogenised products are exhaled from the skin is indubitable. Dr. Faraday calcined pure river sand, and on heating it with hydrate of potass, it yielded no trace of ammonia. On merely passing this sand over his hand, and then treating it in a similar manner, ammonia was evolved. A piece of ignited asbestos, by mere pressure for a short time between the fingers, absorbed enough of some nitro- genised organic matter to evolve ammonia when heated with hydrated potass. 67. From a series of careful observations, Seguin38 ascertained that, on an average, eleven grains of matter were exhaled from the skin in a minute, equal to 15,840 grains, or 33 ounces, in 24 7 74 PATHOLOGY OF URIC ACID. hours. Consequently the amount of perspired matter very nearly equals the urine. The exhaled fluid was afterwards examined by Anselemino,39 who found that it contained on an average "88 per cent, of solids; and 100 grains of this solid extract contained 22-9 grains of saline matter. Hence in the course of 24 hours the skin exhales Organic matter - - - 107.47 grains. Saline matter ... 81.92 Water and volatile matter - - 15650.61 15840. This organic matter contains much nitrogen, and I have more than once detected in it a body resembling urea. Berzelius40 states that osmazome, another nitrogenised substance, is an ingredient in the perspired fluid. It may be safely assumed, that when the skin is unable to perform its functions, the 107-47 grains of organic matter, which then lose their proper outlet, appear wholly or partly in the urine in the state of urate of ammonia. 68. As already stated, this occurs when the kidneys are healthy; but if organically diseased, or even merely in a state of congestion, or at most sub-acute inflammation, as in the dropsy after scarlet fever, they simply pour out albumen, the vital che- mistry of these organs being too far depressed to allow of the conversion of this substance into a body normal to the kidneys; hence, in the disease in question, the disappearance of albumen, and presence of uric acid in the urine, become valuable indications of convalescence. Dr. Marcet41 was the first who suggested that interference with the functions of the skin might in some way account for calculous deposits. 69. Professor Liebig recognises one great cause of the appear- ance of an excess of uric acid in the urine, founded on his theo- retical views of the conversion of this substance into urea (36). It may be thus briefly enunciated, that as normally the insoluble uric acid first produced by the metamorphosis of tissues is, under the influence of oxygen conveyed in the red blood- discs, converted into soluble urea, whatever increases the number of blood-discs, or carriers of oxygen, or quickens the circulation, must cause the more complete conversion of uric acid into urea; and less of the BECQUEREL'S OBSERVATIONS. 75 former and more of the latter will appear in the urine. Con- versely, whatever interferes with the perfection of oxygenation in the body, must necessarily produce an excess of uric acid. From this view,42 it follows that the quantity of uric acid ought to be positively or relatively to urea, decreased in 1. Fever. 2. Acute Phlegmasiae. 3. Phthisis. And conversely it should be increased in 1. Chlorosis. 2. Anaemia. 3. Pulmonary emphysema. The only mode of testing hypotheses of this kind, emanating from a great and respected authority, is by clinical observation ; and so far as recorded facts are concerned, they fail altogether to give the slightest support to the ingenious theory of Professor Liebig. 70. The labours of Edmund Becquerel43 in urinary pathology, furnish us with a mass of carefully recorded observations, which, made with no view of supporting or disputing any preconceived notions, are peculiarly entitled to respect. The numbers in the following table are calculated from some of the analyses alluded to, and point out the actual quantity of uric acid and urea excreted in the twenty-four hours, and the relative proportion they bear to each other, in several diseases. Quantity in 24 hours of Ratio of uric acid to urea. Uric acid. Urea. Grains. Grains. Healthy urine (Becquerel's average) 8.1 255. 1 : 31.48 Chlorosis, minimum of five cases - 1.8 77.5 1 : 43. Chlorosis, maximum of five cases - 6. 172. 1 : 29. Pulmonary emphysema, extreme > dyspnoea - - - - J 4.9 172. 1 : 35.1 Phthisis, tubercles softened - 9.1 66.7 1: 7.33 Phthisis three days before death - 9.8 29.4 1 : 3.3 Morbus cordis, with icterus - 9.82 73.3 1 : 7.6 Acute hepatitis, with icterus - 11.18 61.6 1 : 5.6 Icterus - 17.75 285.6 1 :16.1 Milk fever • 19. 133. 1 1 : 7.47 From this table, we find that in chlorosis, a disease of anaemia, 76 PATHOLOGY OF URIC ACID. in which oxygenation of the blood, on the theory of Liebig, must be most imperfect; theuric acid, instead of being in excess, is posi- tively and relatively below rather than above the healthy average (65). In pulmonary emphysema, again, the same thing is observ- ed, although, from the want of integrity in the function of re- spiration, uric acid ought to abound ; whilst in acute hepatitis, and in phthisis, diseases in which, on Liebig's own showing, exces- sive oxygenisation is going on, the uric acid, both abstractedly and in relation to the urea, is at a minimum instead of a maxi- mum. On this account, as wTell as for the reasons already alluded to (37, 8), the theory of Liebig must, in the present state of know- ledge, be deemed unsatisfactory.* Is it possible in any manner to reconcile these facts, the actual results of clinical observation, with the hypothesis of Liebig ? If we admit that an amount of oxygen, requisite for the destruction of tissue alone, enters the system, uric acid ought to occur in the urine ; in proportion as this amount is exceeded, the acid becomes converted into urea. Therefore, by supposing that in inflamma- tory affections the change of tissue (or emaciation) is so rapid in its progress under the influence of disease, that all the oxygen entering the lungs in a given time is sufficient alone for the pro- duction of uric acid, deposits of this body will occur in the urine. On the other hand, if the disease does not so rapidly emaciate the patient, the metamorphosis of tissue will proceed sufficiently slowly to allow oxygen to react on the uric acid, and but a minimum reaches the urine. By allowing this latitude to the theory, the general absence of uric deposits in chlorosis and anaemia, and * There appears to me to be, however, still a serious objection to the validity of the opinion, that in phthisis excessive oxydation is going on, and therefore uric acid is oxydised and disappears ; (even if it were true that uric acid deposits did not occur in this disease) in the instance of diabetes mellitus. This disease is in the ma- jority of cases complicated with phthisis, indeed so frequently, that some patholo- gists have supposed this complication to be a necessary one. Yet here, while phthisical disorganization is going on, and excessive oxydisation is supposed to be entirely destroying the tissues of the body, an abundance of a highly-carbonized, indeed a readily oxydisable substance, is generated in the body, circulating in the blood, and escapes by the kidneys. By what ingenuity the fact of the (assumed) excessive oxydation going on contemporaneously with the copious formation of an inflammable body, sugar, can be reconciled with this hypothesis, I am at a loss to. determine. CAUSES OF AN EXCESS. 77 their presence in inflammation, is accounted for. Still the great objection regarding phthisis remains, as this disease is especially- mentioned by Professor Liebig in his work as one in which the excess of uric acid does not occur. Even this may be reconcil- ed to his views by an explanation he made to me, that he did not mean by phthisis the disease in any stage in which disorganisa- tion of lung was going on, for here he admitted with all, that uric acid occurred in excess, but intended his remarks to apply when only the early stage of tuberculisation existed, corresponding with what is known in this country of the term tubercular cachexia. 71. Excluding all abstract theories, whenever an excess of uric acid or its combinations with bases occurs in the urine, a normal quantity of water being present (30 to 40 ounces in twenty-four hours), it may safely be inferred that one or other of the follow- ing states exist. a. Waste of tissue more rapid than the ] Fever, acute inflamma- supply of nitrogenised nourishment c tion> rheumatic inflammation, ' phthisis. as in J B. Supply of nitrogen in the food greater ^| Excessive indulgencein ani- than is required for the reparation and I mal food>°* the a^ntity of . [ food remaining the same, with supply of tissue, as in j too ,Utle bo(]Uy ^^ c. Supply of nitrogenised food not being j AU ^ graJeg rf dygp^ in excess, but the digestive functions r sia. unable to assimilate it. J d. The cutaneous outlet for nitrogenised 1 excreta being obstructed, the kidney A» or most sta=es of dis" „ , r ,, . > eases attended with arrest of is called upon to compensate for this . . deficient function. e. Congestions of the kidneys, produced , . °™s an s.rains.°, ° J x K. loins, diseases of genital ap- by local Causes. j partus. 72. It is quite possible for an excess of uric aoid to exist in the urine without forming a deposit, and vice versa, the presence of a deposit does not necessarily indicate the existence of an abnor- mal proportion. Itis, however, easy to discriminate between these cases, for if a deposit of urate of ammonia be present whilst the bulk of the urine in twenty-four hours is not much below the 7* 78 PATHOLOGY OF URIC ACID. average, it is certain that an excess of uric acid exists. But if the bulk of the urine be much below the natural quantity, a de- posit may occur simply from there not being sufficient water to hold it in solution. To determine whether an excess exists, let all the urine passed in twenty-four hours be collected, well shaken, and a given quantity, as about two ounces, mixed in a conical glass vessel with about half a drachm of hydrochloric acid. In six or eight hours crystals of uric acid will be copiously deposited on the sides of the glass ; the urine should be decanted and re- placed by cold water. By means of a thin spatula or feather, the acid can be detached and collected at the bottom of the vessel. All the water except the last few drops can be readily poured off without losing the precipitate, which can then be removed into a watch-glass, dried, and weighed. This little operation is so easily performed, that it can scarcely be deemed troublesome ; and by a simple multiplication sum, the whole amount of uric acid secreted in twenty-four hours can thus be readily ascertained. 73. The copious deposit of urate of ammonia occurring after eating more freely of animal food than is required for the supply of the wants of the body is a well-known phenomenon, and will occur in persons whose digestive organs are in perfect vigour, simply from a greater amount of matter being given them to assi- milate than they are adequate to. In like manner, if a person's digestive powers are impaired, either partially or temporarily, as after a debauch, he will be unable to convert into healthy chyle even a small proportion of food, and hence its albuminous ele- ments imperfectly assimilated enter the circulation, to be evolved by the kidneys and perhaps other emunctories. Particular idio- syncrasies with regard to the action of the stomach on certain articles of diet also exist; thus a single cup of coffee or green tea will, in many persons, determine the formation of a deposit in the urine, as if the caffein present in these two beverages had escaped the digestive powers of the stomach, and become converted into urate of ammonia. 74. The conditions above referred to apply alike to the presence of free or combined uric acid, but certain other circumstances re- quire consideration in connexion with its occurrence in a free or crystalline state. The appearance of a deposit of urate of ammonia, may be caused by a mere exaggeration of a natural condition, a SCIRRHOUS PYLORUS. 79 simple increase in quantity of a salt normal to the urine. When, however, the acid occurs in a free state, it shows that not only may it be in excess, but some change has occurred in the urine, which has separated it from any base with which it has been pre- viously combined. A deposit of free uric acid may depend on one or other of the following conditions : a. An excess of this acid may exist, and be separated by the kidney in too large a quantity to be all converted into urate of ammonia. b. The quantity of acid being normal or nearly so, certain changes have occurred in the urine which have in- duced a separation from its solvent. So long as in the pathological states above enumerated (71), the quantity of uric acid is not too great to combine with the am- monia simultaneously excreted, whether derived from the phos- phate or not (34), the urine will be transparent upon being passed, but on cooling a more or less copious deposit of urate of am- monia takes place. But if the acid exceed this quantity, it is held in solution by phosphate of soda so long as the urine is warm ; on cooling, being partly deposited (32) in the form of a crystalline sand or gravel (35). If, without the amount of this substance being increased, mere traces of a stronger acid reach the urine, it is deprived of its base, and uric acid is precipitated in crystals. 75. Of the first of these conditions the urine frequently pre- sents a good illustration in heart-disease, especially in great hyper- trophy of that organ, in rheumatism, and many phlegmasiae. In these it is common to find one day a deposit of urate of ammo- nia, and perhaps on the next a sediment of crystallised uric acid will occupy the bottom of the glass vessel, and a dense stratum of urate of ammonia will rest upon it. Of the second condition, examples are furnished by cases of irritative dyspepsia with pyrosis; here a large proportion of free acid is generated in the stomach, and being absorbed, finds its way to the kidneys, setting uric acid free, from any soluble urate that may be present. The acid thus generated by the stomach in disease is often considerable, far exceeding the proportion poured out during healthy digestion. In one case of scirrhous pylorus, in which the patient often vomited several pints of fluid 80 PATHOLOGY OF URIC ACID. in twenty-four hours, I found a quantity of free hydrochloric acid, equal in each pint to 22 grains of the pharmaceutical acid,44 in addition to a sufficient quantity of some organic acid (lactic ?) to neutralize near seven grains of pure potass. At another time the hydrochloric acid nearly disappeared, and the quantity of organic acid in each pint required for saturation nearly 17 grains of the alcali. The probability of these acids being absorbed and finding their way to the kidneys, is shown by the well-known fact, that the medicinal employment of the mineral acids will be followed, in the majority of cases, by the appearance of crystal- line grains of uric acid in the urine. 76. If, as has been supposed, an organic acid (lactic or buty- ric) be an element of the perspired fluid, it is quite possible that by being retained when perspiration is obstructed, it may find its way to the urine, and precipitate uric acid. In this way imper- fect action of the skin may cause an uric deposit without increas- ing the amount of nitrogenised matter conveyed to the kidney (73). Seguin, in addition to the facts already stated (67), ob- served that perspiration was lessened during digestion, and con- siderably diminished when this function wTas imperfect. In this way, a bulky meal may be an indirect cause of an uric acid de- posit, besides affording pabulum for the formation of urate of am- monia (73). 77. Uric acid and urates may occur in great abundance in the urine, so as to become serious sources of irritation, and then es- pecially become primary objects of attention as definite diseases. These bodies may be deposited in an insoluble form in the kid- ney or bladder, and aggregating, form a mass, on which, by a kind of imperfect crystallisation, great portions of the acid or its salts may be deposited, giving rise to the formation of a calcu- lus. Uric acid is of more serious importance than most other elements of calculous formations, not only from its constituting a large proportion of all urinary calculi, but even when they are chiefly composed of other ingredients, the nuclei on which they are deposited are, in the great majority of cases, composed of uric acid. In 374 calculi contained in the museum of Guy's Hospi- tal the nuclei were in 269 composed of uric acid or urate of am- monia alone.45 On account of its solubility (32), urate of ammonia is not a CURATIVE INDICATIONS. 81 frequent component of entire calculi, although it often enters with other ingredients into their composition. Indeed calculi wholly composed of this compound are almost peculiar to childhood ; in Guy's museum there are but eight concretions entirely consisting of this substance, although it constitutes the nucleus in eighteen. It is hence very probable that if ever by medical treatment we can succeed in overcoming a calculous diathesis, or dissolving a stone in the act of growth, it will be by means directed to the solution of the uric acid or its combinations. 78. Regarding the medical treatment of the different forms of uric acid gravel (limiting this term to deposits occurring so per- sistently or abundantly as to have become primary sources of irritation or annoyance) much might be said. Discarding alto- gether the existence of any specific agent for a disease which is rather symptomatic of another affection than really idiopathic, the therapeutical agents may be briefly referred to the following heads. 1. Attention to the function of the skin.—The remarks already made on the effect of an arrest of perspiration furnishing a pabu- lum for the formation of a deposit (66-68), or by retaining in the circulation a substance capable of rendering uric acid insoluble (76), show the necessity of attending to this indication. I have repeatedly seen diaphoretics, warm clothing, the use of a flannel, and in winter, even a chamois leather waistcoat, with friction by means of a flesh-brush or hair-glove, repeatedly remove a deposit of uric acid gravel, and in more than one instance, where even an hereditary taint existed from gouty or calculous progenitors. The observations of Dr. Wilson Phillip46 have shown that the proportion of uric acid in the urine is notably diminished by the use of active diaphoretics. It is also probable that the extreme rarity of calculous affections in the navy might be partly explained by the kind of vapour-bath in which sailors sleep, " the lower decks being the part allotted to repose, the ports are for the safety of the ship necessarily closed at night, and the temperature of the surrounding air is thereby so exalted that the place becomes a kind of steam-bath from animal exhalations; the men being literally immersed in their own perspiration." These are the remarks of Mr. Copland Hutchinson,47 who, in allusion to the rarity of calculus among sailors, adds that from 1800 to 1815, 82 PATHOLOGY OF URIC ACID. upwards of 126,000 men were employed in the navy. Of these, nine-tenths had been employed at sea from a very early period of life. But eight were affected with stone. It appears probable that three of these were affected with calculus before entering the service. So that taking all the cases in the navy in the period above mentioned, it cannot be said that more than 1 in 34,000 were the subject of calculus. 79. My own experience induces me to regard the warm, or still better, the vapour-bath, as the most valuable diaphoretic. The latter is readily employed in private practice by means of the very convenient and portable apparatus of M. Duval, which has for a long time superseded other forms of vapour-bath at Guy's Hospital. Actual diaphoresis is by no means necessary in the treatment of all cases of uric gravel; friction to the skin, and when persons are sufficiently robust, immersion in the cold-bath, followed by rubbing the surface of the body with a dry and rough towel, until reaction is produced, is often of great service. 80. Restoring the tone of the organs of digestion.—By effecting this, a double object is attained; the perfection of the primary assimilation of the food by which the entrance of a crude nitro- genised matter, capable of being converted into uric acid, into the blood is prevented (73), and the prevention of the generation of any acid, the product of unhealthy digestion (75), which might be absorbed by the lacteals, and act as a precipitant of uric acid. This part of the treatment of calculous affections must be modified by the peculiarities of the case, and indeed is identical with that of the different forms of dyspepsia. Careful attention to the bowels, avoiding excessive purging, the use of minute doses of mercury, as of a grain of pil. hydrargyri or hydrarg. c. creta, with thrice that quantity of ext. conii, administered two or three times a day, with moderate doses of the carbonates of potassa or soda in the mist, gentianae comp., if constipation exists, or in inf. calumbae, or what is far better, from its action on the skin, inf. serpentariae, will often effect immense relief. Where gastrodynia, with or without pyrosis, exists, the use of half a grain of argenti nitras, or one of argenti oxydum, immediately before a meal, will often check alike the gastric and renal symptoms. But the most important element in the treatment is a rigid attention- to the quality and quantity of the ingesta, taking the utmost care to CURATIVE INDICATIONS, 83 Select those articles of diet which the patient can best digest, it being of far greater importance, in the majority of cases, to regard this, than to choose articles of food according to their chemical composition. A too bulky meal of animal or vegetable food is injurious to persons labouring under calculous dyspepsia, for whilst the former supplies too much nitrogen, both will become sources of mischief by overloading the digestive functions, and preventing the chylopoietic viscera doing their duty (73). In protracted cases, however, much good is derived by actually cutting off part of the supply of nitrogen. In this way I have seen a copious deposit of uric acid gravel disappear, after other measures had failed to give relief. The following case is a good illustration of the mode of treatment. 81. John Lynch, aet. ^37, admitted into Luke ward, Guy's Hospital, under Dr» Addison, on October 2d, 1839. By trade a porter in a warehouse at Spitalfields, and constantly exposed to alternations of temperature. When young he had lived freely, and partaken to excess of spirit and malt liquor, and had eaten meat daily. His health, up to the present illness, had been excellent. No hereditary taint of calculus or gout. On ad- mission, he stated that' nineteen months previously he got very wet, and allowed his clothes to dry on him; this was followed by fever and profuse perspirations. The next day he became the subject of rheumatic pains, from which he has never since been free. He complains of constant pain in the region of the kidneys, increased by pressure and flexing the trunk, and some pain at the extremity of the penis. He passes water thrice in the day and once at night, each time discharging uric acid gravel most copi- ously. The latter symptom has been present a twelvemonth. The urine is not coagulable, contains some mucous flocculi, and the deposit of gravel does not disappear by boiling. The tongue is clean and moist, he complains of habitual heartburn, has occasional bilious vomitings, the bowels are generally relaxed, and he is griped or purged on slight causes, especially by ex- posure to cold. Pulse 78, natural. From October 2 to November 27, his treatment consisted of purgatives, soda ancL uva-ursi, occasional mild mercurials, under which the deposit decidedly increased. He then took dec. alchemillffi with potass without relief. 84 PATHOLOGY OF URIC ACID. Nov. 27 to Dec. 18.—A trial of diaphoretic treatment was made. The warm-bath twice a week, with pulv. ipecacuanha? comp. gr. viij. ex julepo ammon. acet. §j. twice a day. Under this treatment he improved, the skin acted profusely, and the deposit gradually disappeared. January 10, 1840.—The urine up to the present time remained healthy ; he went out of the hospital, took cold, checked the perspiration, and the uric acid deposit appeared as abundantly as before. He was again relieved by the diaphoretic treatment, but soon afterwards relapsed. It was therefore determined to confine his diet to arrow-root, sago, potatoes, and bread, and butter, ex- cluding the four ounces of cooked meat he had previously daily taken. The effect was very remarkable, the deposit almost im- mediately disappeared, and he remained free from it up to Feb. 25th, when he was discharged. On one occasion the urine of this man deposited in twenty-four hours upwards of 30 grains of uric acid. 82. Moderate muscular exertion, and a due amount of exer- cise is quite essential in the treatment of this disease ; for not only do they call into play some very important functions, but often improve the general health. Besides this, when the stomach is imperfectly able to digest nitrogenised food, exercise will often aid its assimilation by making a call upon the chylopoietic organ for supply for the want of tissue it produces. 83. Among the remedies which appear most successful when the food is not converted into healthy chyle, and an unhealthy state of the blood from the presence of imperfectly assimilated matters results, the preparations of iron deserve notice. I have repeatedly seen copious deposits of uric acid in persons of low power completely disappear pari passu with the cure of the pseudo- chlorotic symptoms present, by the use of this important drug. The best mode of administering it, is in combination with a vege- table acid, as the stomach bears it well in this form, and it is probably more likely to enter the circulation. From six to twelve grains of the ammonio-citrate or ammonio-tartrate of iron taken thrice a day immediately after a meal in a glass of water, have been most successful. The solution of the sesqui-acetate of iron is also a very valuable preparation, but is often inconvenient to prescribe, in consequence of its not being of constant strength. CURATIVE INDICATIONS. 85 84. Remedies which act as solvents of uric acid. — These chiefly consist of the alkalies and their carbonates, biborate and phos- phate of soda, benzoic and cinnamic acids. As the alkaline urates are far more soluble than the free acid, the employment of soda and potass with their carbonates has been long used in the treatment of uric gravel. They moreover exert a beneficial effect in neutralizing any free acid in the primae viae, and thus prevent- ing a precipitant of uric acid reaching the kidneys. The liquor potassae may be employed in doses of half a drachm thrice a day ; it is best taken about an hour after a meal, and may be conve- niently administered in a little bitter ale, which conceals much of its disagreeable flavour, or in any bland vehicle. The carbonates of potass and soda are, however, far more agreeable, and perhaps more efficient remedies,—of these the bicarbonate of potass de- serves the preference. It should be given thrice a day in doses of 9j. or 3ss. I think it appears to act best when taken in a glass of warm water. To make it more agreeable, I generally order, what I am accustomed to term to my patients, the artificial Vichy water, made by stirring 3ss. of bicarbonate of potass and gr. v. citric acid into a tumbler of lukewarm water. This mixture evolves enough carbonic acid to be " sparkling," and is generally taken with readiness. 85. A very convenient mode of impregnating the urine with an alkali is to administer the potass or soda in combination with a vegetable acid, especially with the acetic, citric, or tartaric. The mode in which these act is easily explained ; when acetate, citrate, or tartrate of potass are ignited, the acid absorbs oxygen, and is converted into carbonic acid and water, part of the former uniting with the alkali. In a similar manner are these salts decomposed during the process of healthy digestion ; a carbonate finds its way into the circulation, and reaching the kidneys, renders the urine alkaline. If, however, the digestive powers are impaired, the vegetable acid is only partly decomposed, and in some few persons it escapes the influence of digestion altogether. 114 grains of tartrate of potass, 106 of citrate, and 99 of the acetate, absorb respectively 40, 48, and 64 grains of oxygen, to be con- verted into carbonate of potass and water. These salts may be administered by directing the use of the common saline powders made with carbonates of potass or soda and the citric or tartaric 8 86 PATHOLOGY OF URIC ACID. acid, in effervescence. When not contra-indicated, the use of strawberries, currants, and some other fruits containing alkaline citrates and malates, are capable of making the urine alkaline, and may be occasionally employed with advantage. Some persons cannot bear the use of free or carbonated alkalies without suffering severely in their general health, nor is their pro- tracted use altogether without some ill effect. A flabby state of the muscles, and an anaemiated condition of the system, is fre- quently produced by the persistent use of alkaline remedies. Their injudicious employment may, as Dr. Prout has suggested, induce the formation of oxalic acid. 86. Uric acid is soluble in a solution of borax, the biborate of soda, — more so, indeed, than in alkaline carbonates; and this salt may be taken for some time, at least by male patients, without producing any very injurious constitutional effects, and readily « finds its way into the urine. On this account its administration has been suggested in cases of uric acid gravel, but it has not been much employed in this country. In women, this drug cannot be employed with impunity, as it certainly exerts a stimulant action on the uterus, and I have seen it in two instances produce abor- tion. 87. The remarkable solvent action of phosphate of soda on uric acid, to which Liebig has lately directed attention (32), in- spires a hope that its administration might be of use in cases of calculous disease, by impregnating the urine with an active sol- vent. All that is required to ensure this drug reaching the urine is to administer it in solution sufficiently diluted ; 9j. to 3ss. might be administered in any vehicle, as in broth or gruel, as when diluted, the phosphate tastes like common salt, and few persons object to its flavour. I have administered this drug in two very chronic cases of uric acid gravel, and in one with the effect of rapidly causing a disappearance of the deposit. This occurred in the person of a lady about forty years of age, who had, at my wTish, for some weeks used the artificial Vichy water of the German Spa at Brighton without relief. The triple salt, ammonio-phosphate of soda, would perhaps be a more active remedy than the simple phosphate, but its disagreeable flavour constitutes one objection to its employment. 88. Much attention has been lately drawn to the effects of ben- CURATIVE INDICATIONS. 87 zoic acid in preventing the formation of uric acid, by the obser- vations of Mr. Alexander Ure.49 When this acid or its salts are administered, they are acted upon by the stomach in a very dif- ferent manner from the other vegetable acids (85). Instead of becoming oxidized, and being converted into carbonic acid, it combines with those nitrogenised elements which would other- wise have formed urea or uric acid, and is converted into hippuric acid (43). It has been stated that the quantity of uric acid falls, when the benzoic acid is administered, below the average quan- tity, or even disappears from the urine. This has been, however, shown by Dr. Garrod,50 to be an error, and that urea alone dis- appears. Be this as it may, it is certain that the acid does ap- propriate to itself some body rich in nitrogen to form hippuric acid; and experience has shown that, in cases where an excess of uric acid is secreted, the administration of this drug appears to limit it to about the normal quantity. Benzoic acid may be administered in doses of eight or ten grains in syrup, or dissolved in a weak solution of carbonate or phosphate of soda thrice a day. Cinnamon water forms a good vehicle, as cinnamic acid exerts a similar action to the benzoic, becoming converted into hippuric acid. I have found the fol- lowing formula of great service in several cases of chronic uric acid gravel: — R. Sodae Carbonatis, 3jss. Acidi Benzoici, ^ij. Sodae Phosphatis, 3MJ. Aquse Ferventis, f^ iv. solve et adde. Aquae Cinnamomi, f^vjiss. Tincture Hyosciami, f3iv. Fiat mistura, cujus sumet aeger, coch. ij. amp. ter in die. In addition to its chemical action, benzoic acid acts beneficially by secreting diaphoresis, and thus fulfils an important indication in the treatment of calculous affections (78). 89. The conversion of benzoic into hippuric acid, with a cor- responding diminution in the quantity of urea in the urine, can be readily understood, by admitting that these two bodies unite with oxygen, and are converted into hippuric and carbonic acids with water ; thus, PATHOLOGY OF URIC ACID. GNHO CNHO 4 at. benzoic ac. 56+0+20+12^ ^36-f-2-J-16-(-10= 2 at. hip. ac. 1 at. urea 2-t-2+ 44- 2 I | 22 44=44 at. carb. ac. 48 at. oxygen 48 !__ 8 + 8= 8 at. water. 58+2+24+62 j --------J 58+2+24+62 I------------ Cinnamic acid, when taken into the stomach, appears to appro- priate to itself nitrogen and oxygen, in undergoing conversion into hippuric acid, for CNHO 1 atom of cinnamic acid 18+ 8+4 1 atom oxygen and 1 nitrogen= 1 1 Equal 1 atom hippuric acid= 18+1+8+5 90. It is important to bear in mind that by the employment of remedies capable of dissolving a deposit in the urine, we are merely palliating, not curing, the disease. And we must never lose sight of the great importance of endeavouring to remove that pathological state of the whole system, or of any particular organ which may be the exciting cause of the calculous formation. Nothing but a careful investigation of symptoms can put us in possession of the knowledge necessary for this purpose. Still, solvent remedies are not to be despised ; for when the disease is ( chronic, and does not readily yield to treatment, it is of the ut- most importance to prevent the formation of a calculus or lessen the irritation produced by the presence of gravel whilst endea- vouring to remove the primary affection which led to the forma- tion of the deposit. DIAGNOSIS. 89 CHAPTER IV. CHEMICAL PATHOLOGY OF URIC OXIDE. History, 91—Diagnosis of uric oxide, 92, 3—Characters of urine depositing, 94— Microscopic character of, 95—Pathological indications, 96. Uric Oxide. Syn. Xanthic oxide—Urous acid. 91. This substance has not been discovered among the con- stituents of healthy urine, although it is probable that it bears some relation to the yellow colouring matter (46); and hence it may possibly exist in minute quantities, and have escaped the investigations of chemists. But little is known either of the chemical or pathological history of this very rare ingredient of calculous concretions. It was first met with by Dr. Marcet,51 con- stituting the whole of a small calculus weighing but eight grains; the history of the case being unknown. Some years afterwards, some minute pisiform concretions passed by a gentleman with diseased bladder were found by M. Laugier52 to consist of uric oxide. More recently, this substance was discovered in a stone removed by Prof. Langenbeck of Hanover,53 from a boy eight years of age. It weighed 338 grains, and after an examination by Prof. Stromeyer, was submitted to minute chemical investiga- tion by Professors Wohler and Liebig. A fragment of this calculus has been, by the kindness of my friend, Dr. Willis, placed in the museum of Guy's Hospital. A fourth specimen, weighing but seven grains, was lately removed from the urethra of a boy by Prof. Dulk of Konigsberg.54 Uric oxide has been met with in deposits by Berzelius,55 M. Morin, of Geneva,50 and one or two other observers. It has been lately announced by Magnus,11- that this substance exists in the guano of commerce in small proportions. To obtain it, he directs guano to be digested in hydrochloric acid, and the solution carefully neutralised with an alcali. The precipitate, which slowly falls, is boiled with a 8* 90 PATHOLOGY OF URIC OXIDE. solution of potassa, by which the supposed uric oxide is dissolved, and is obtained by a subsequent precipitation by a current of carbonic acid gas. There is, however, room to doubt this sub- stance being really uric oxide, as the latter is insoluble in hydro- chloric acid. 92. Diagnosis of uric oxide.—Concretions composed of this substance closely resemble, and are generally mistaken for, uric acid. They present externally a similar appearance, but their sections are of a well-marked salmon, or rather cinnamon tint, which to a practised eye will distinguish such concretions from uric acid. According to Berzelius, when uric oxide forms an urinary deposit it appears as a grey powder. In one instance, and the only one in which I ever met with a deposit composed of a substance approaching uric oxide in chemical characters, it presented a honey-yellow colour, and under a lens resembled minute irregular fragments of yellow wax. A wax-like lustre is readily assumed by submitting fragments of uric oxide to friction. If a deposit be suspected to consist of or to contain this substance, it should be digested in a weak solution of carbonate of potass which removes the uric acid, and leaves the oxide undissolved. So closely do these two bodies resemble each other, that their diagnostic distinctions will be best observed by contrasting their action towards reagents. Uric oxide. jjric aci& 1. Dissolves slowly in nitric acid 1. Dissolves readily in nitric acid almost without the evolution of bub- with copious effervescence. bles of gas. 2. The nitric solution leaves by 2. The nitric solution leaves by evaporation a yellow residue. evaporation a pink residue. 3. Soluble in strong sulphuric acid, 3. Is precipitated by water from its not precipitated by the addition of solution in concentrated sulphuric acid. water. 4. Its solution in liquor potassae is 4. Hydrochlorate of ammonia pre- not disturbed by hydrochlorate of am- cipitates it combined with ammonia monia. from its solution in liquor potassa:. 5. Precipitated uncombined, when a 5. A current of carbonic acid gas current of carbonic acid traverses its throws down from the alcaline solution solution in potass. an acid urate of potass. 6. Insoluble in solution of carbonate 6. Readily soluble in dilute solution of potass. of carbonate of potass. 7. Ignited in a tube, does not yield ?• When ignited, yields urea as one urea. of its products. DIAGNOSIS. 91 93. Uric oxide has constituted the whole mass of the calculus in all, except in that examined by Prof. Dulk, in which the nucleus consisted of uric acid. According to him, uric oxide furnishes, with nitric acid, some of the same products which uric acid yields, especially alloxantin. 94. Characters of urine depositing uric acids.—Unknown, no observations of the urine of the persons from whom calculi of this substance were removed, having been recorded. 95. Microscopic characters of uric oxide.—This substance does not appear to assume a crystalline form. A careful microscopic examination of the fragment of the calculus removed by Langen- beck, and now in the museum of Guy's Hospital, failed in de- tecting any appearance of crystalline arrangement. I dissolved a portion of this concretion in liquor potassae, and precipitated the oxide very slowly by the cautious addition of acetic acid. Uric oxide fell in a perfectly amorphous state, presenting none of the well-defined crystalline form which uric acid assumes when simi- larly treated. The only instance in which I had reason to believe a deposit was made up of this substance was in the urine of a child, which let fall by cooling a honey-yellow sediment. This, on micro- scopic examination by reflected light, was found to be composed of rather large yellow masses, having much the appearance of yellow wax, and presented no trace of crystalline structure. This substance was replaced in the next specimen I examined, by uric acid. 96. Pathological and therapeutical indications. — Unknown, although from the remarkable similarity of their composition it is highly probable that the majority of the remarks already made on the pathology of uric acid apply to that of the oxide. Uric oxide consists of C5, N2, H.2, 02; if, therefore, we suppose two atoms to be oxidised by combining with two of oxygen, one atom of uric acid will be found. CNHO 2 atoms uric oxide 10+4+4+4 +2 — oxygen 2 = 1 atom uric acid 10+4+4-J-6 It is remarkable that in nearly all the recorded cases, the uric oxide has occurred only in children. One observer stated that he had met with it as a deposit in diabetic urine.57 92 PATHOLOGY OF PURPURINE. CHAPTER V. CHEMICAL PATHOLOGY OF PURPURINE. Diagnosis, 98—Microscopic characters, 99—State of urine containing purpurine, 100 —Pathological indications, 101. 97. The chemical characters of this remarkable colouring mat- ter have been already pointed out (47), but it merits some notice as a pathological product, from the serious lesions its presence frequently indicates. On account of its solubility in water, pur- purine never occurs as a deposit, unless urate of ammonia is pre- sent, this salt having the property of removing the great mass of purpurine from urine, and assuming thereby a more or less deep carmine tint. 98. Diagnosis.—When a deposit of urate of ammonia is coloured by this substance, it presents a tint varying from the palest flesh- colour to the deepest carmine (60). To appreciate the beauty of these tints the'deposit should be collected on a filter, and allowed to dry. The presence of purpurine interferes with the ready solubility of the deposit with which it is combined, on the appli- cation of heat, and free dilution with water is often required to aid its solution. I have never seen purpurine colouring any other deposits except those of urate of ammonia ; even uric acid scarcely appears to have any affinity for it. It is just possible that a very highly coloured deposit of pink urate of ammonia might be mistaken for blood (175), and I have seen this error committed when it occurred in albuminous urine. The appear- ance of the deposit when collected on a filter, and its giving up the purpurine to alcohol, will at once remove any doubt on the subject, and the absence of blood-discs on microscopic examina- tion will aid in demonstrating the real nature of the deposit. There are several calculi in Guy's museum, with layers of urate of ammonia deeply stained with purpurine. Similar calculi have been described by Mr. Taylor,5** as occurring in the museum of St. Bartholomew's Hospital, and Brugnatelli59 has recorded many instances of the same kind. 99. Microscopic characters.—These are always those of the DIAGNOSIS. 93 deposit with which the purpurine is combined. All the sedi- ments I have met with were amorphous. I possess one specimen, however, of a rich pink colour, given me by Dr. Percy of Bir- mingham, in which the deep crimson urate is composed of minute ovoid particles acuminated at both extremities, and possessing a crystalline lustre. 100. Characters of the urine containing purpurine.—It invaria- bly happens that when an excess of urate of ammonia is present, it, on the urine cooling, falls to the bottom of the vessel, carrying down with it great part of the purpurine. If this excess be not present, the urine simply presents a pink or purple colour, and on dissolving white and pure urate of ammonia in it by heat, it is precipitated on cooling deeply coloured by the purpurine. If a small portion of purpurine only is present, it is best detected by adding a little hydrochloric acid to some of the urine previously warmed, a colour varying from lilac to purple, according to the quantity of colouring matter present, immediately occurs. On evaporating urine containing purpurine to the consistence of an extract, and digesting it in alcohol, a fine purple tincture is obtained, the intensity of the tint being rather heightened by acids and diminished by alkalies. The specific gravity of this urine is subject to great variation : when the colour is as deep as brandy, its density varies from about 1.022 to 1.030. The addition of nitric acid generally pro- duces an immediate muddy deposit of uric acid, which has been more than once mistaken for albumen (177). 101. Pathological indications.—The presence of an excess of purpurine is almost invariably connected with some functional or organic mischief of the liver, spleen, or some other organ con- nected with the portal circulation. The appearance of a flesh- coloured deposit in the urine is the commonest accompaniment of even slight derangement of the hepatic function, as every case of dyspepsia occurring in gin-drinkers points out. The intensity of colour of the deposit appears to be nearly in relation with the magnitude of the existing disease. In the malignantly diseased, in the contracted, hobnail, or cirrhosed liver, the pink deposits are almost constantly present in the urine. They also are of fre- quent occurrence in the hypertrophy of the spleen following ague. The most beautifully coloured deposits I have seen have occurred 94 PATHOLOGY OF PURPURINE. in ascites connected with organic disease of the liver; and I think J have received some assistance in the diagnosis between dropsy depending upon hepatic and peritonaeal disease, in the presence of the pink deposits in the former, and their general absence in the latter. I have occasionally seen the deposits in question occur in phthisis, when large quantities of pus were poured out from vomicae, as well as in deep-seated suppuration, as in psoas abscess. But even in these cases, the portal circula- tion is probably more or less influenced. My experience, indeed, leads rne to express a firm belief that an excess of purpurine is almost pathognomonic of disease in the organs in which portal blood circulates. DIAGNOSIS. 95 CHAPTER VI. CHEMICAL PATHOLOGY OF CYSTINE. History, 102—Diagnosis of cystine, 103—Liebig's test, 104—Characters of urine depositing it, 105—Spontaneous changes in cystine, 106—Microscopical cha- racter of, 107, 8—Simulated by chloride of sodium, 109—Pathological origin and indications of cystine, 110, 111—Therapeutical indications, 112. 102. This substance was first discovered by Dr. Wallaston in a calculus given him by Dr. Reeve of Norwich. It does not exist as an ingredient of healthy urine, and rarely occurs as an element in the diseased secretion. Its chemical composition is extremely remarkable, containing no less than 26 per cent, of sulphur. Cystine has been found in urinary sediments by very few observers, and it was not recognised in this form until a long period after its discovery in calculi. 103. Diagnosis of cystine.—This substance, when present in the urine, forms a nearly white or pale fawn-coloured pulverulent deposit, much resembling the pale variety of urate of ammonia(59). It appears to be merely diffused through the urine whilst in the bladder, as at the moment of emission the secretion is always turbid, and very soon deposits a very copious sediment. I have seen a six-ounce bottle full of urine let fall by repose a sediment of cystine of the height of half an inch. On applying heat to the urine, the deposit undergoes no change, and very slowly dissolves on the subsequent addition of hydrochloric or nitric acid. Pure cystine is soluble in the mineral and insoluble in the vegetable acids ; with the former it forms imperfect saline combinations, which generally leave by evaporation gummy masses or acicular crystals. It is readily soluble in ammonia and the fixed alkalies and their carbonates, but insoluble in carbonate of ammonia. Heated on platina foil it burns, evolving a peculiar and disagree- able odour. A deposit of cystine may be distinguished from one of white urate of ammonia, by not disappearing on warming the urine, and from the earthy phosphates, by being insoluble in very dilute 96 PATHOLOGY OF CYSTINE. hydrochloric or strong acetic acid. The best character of cystine is its ready solubility in ammonia, mere agitation of some of the deposit with liquor ammoniae being sufficient to dissolve it, and a few drops of the fluid, when allowed to evaporate spontaneously on a slip of glass, leaves six-sided tables of cystine (107). The ammoniacal solution, when kept for some time in a white glass bottle, stains it black, from the combination of the sulphur of the cystine with the lead in the glass. 104. Another test has been proposed by Liebig,00 founded on the presence of sulphur ; he directs the deposit suspected to con- tain cystine to be dissolved in an alkaline solution of lead, made by adding liquor potassae to a weak solution of acetate of lead until the oxide at first thrown down is re-dissolved. On heating the mixture, a black precipitate of sulphuret of lead appears if cystine be present. All sulphuretted animal matters similarly treated yield black precipitates, and hence this test is useless, if any portions of albuminous or mucous substances are mixed with the deposit to be examined. If cystine exist, mixed with urates or phosphates, in a deposit, it is easily discovered by a few minutes' digestion with ammonia ; and the evaporation of a few drops of the fluid, as already mentioned, leaves the characteristic crystals. This process is not liable to the fallacy of Liebig's test. Cystine has never been artificially formed : some fruitless attempts have been made to effect this by treating albumen with the sul- phuret of potassium. The internal administration of sulphur does not appear to induce its formation, for I have repeatedly examined the urine of patients who were taking sulphur abundantly, without detecting it. 105. Character of urine depositing cystine.—Most of the speci- mens of this variety of urine that I have met with, were pale yellow, presenting more of the honey-yellow than the usual amber tint of urine, not unfrequently possessing a somewhat oily appear- ance, like diabetic urine. The specific gravity of cystic urine is generally below the average (19), and is sometimes passed in larger quantity than natural. In one case (a child), in which Dr. Willis61 met with cystine, the urine was of a specific gravity of 1.030; but this is certainly unusual. It is often neutral, less frequently acid to litmus paper, but soon becomes alkaline by keeping. MICROSCOPIC CHARACTERS. 97 The odour of this form of urine is very peculiar, bearing in general a close resemblance to that of swreet-briar, and is some- times rather powerful; less frequently the odour is foetid, like putrid cabbage, owing, I suspect, to partial decomposition and evolution of sulphuretted hydrogen. In such specimens the colour has usually changed from pale yellow to green. In one case that occurred to me, the urine was actually of a bright apple green ; it presented this tint for a few days, and the specimens subse- quently voided were yellow. Cystic urine, on being kept for a short time, has its surface covered with a greasy-looking pellicle, consisting of a mixture of crystals of cystine, and ammonio-phosphate of magnesia. I have frequently observed it to undergo a kind of imperfect viscous fermentation in warm weather, bubbles of gas being evolved, and the whole becoming ropy and rather viscid (214). 106. A certain portion of cystine exists in solution in the urine, as the addition of acetic acid always precipitates a small quantity. When a case of this disease is carefully watched, and the urine repeatedly examined, the deposit will often be found to vanish for days together; but crystals of cystine are even then generally precipitated by acetic acid. The urea and uric acid are present in very small quantities, and in some specimens the latter is nearly absent. Calculi composed of cystine are generally pale yellow or fawn-coloured, but by long keeping they undergo some change, and assume a greenish grey, and sometimes a fine greenish blue tint. The specimens described by Dr. Marcet in 1817, and ex- isting in the museum of Guy's Hospital, were at that time pale brown; they now possess a colour resembling that of green sul- phate of iron, which hue they have, to my knowledge, presented for the last thirteen years. This change of colour in the concre- tions, as well as in the urine, before alluded to, is probably owing to some change in which the evolution of sulphur is an element. 107. Microscopic characters of cystine.—These are so well marked .and easily recognised, that the microscopic examination of„a sediment composed of cystine, renders the application of tests unnecessary. When an ammoniacal solution of cystine is allowed to evapo- rate spontaneously on a piece of glass (103), it leaves crystals in the form of six-sided laminae (Fig. 15). These are probably ex« 9 98 PATHOLOGY OF CYSTINE. ceedingly short hexagonal prisms. When the evaporation is slowly and carefully performed, these laminae are transparent ; but in general they are crystallised in a confused and irregular manner in the centre, the margins only being perfectly transparent. When examined by polarised light, these crystals, when sufficiently thin, present a beautiful series of tints, which are not observed when thick, on account of the high refracting power of cystine. Fig. 15. Fig. 16. 108. When cystine occurs as a sediment, it is always crystal- lised, never under any circumstances being amorphous. Among the crystals, a few regular six-sided laminae are often seen, but the great mass are composed of a large number of superposed plates, so that the compound crystals thus produced appear mul- tangular, as if sharply crenate at the margin ; and the whole sur- face is traversed by lines, which are really the edges of separate crystals (Fig. 16*). They thus resemble little white rosettes, when viewed by reflected light. These compound crystals always ap- pear darker in the centre than at the circumference, which is some- times quite transparent. Prisms of the triple phosphate (138) are often mixed with the cystine, but on the addition of a few drops of acetic acid, they readily dissolve, leaving the rosettes of cystine unaffected. 109. A fallacy may possibly arise in the detection of cystine under the microscope, by the evaporation of the urine, and crys- tallisation of the chloride of sodium or common salt. This salt naturally crystallises in cubes, but assumes an octohedral figure if urea be present. If, however, a small quantity be allowed to crystallise spontaneously from its solution in urine, it forms mu- riate transparent laminae, which are generally three or six-sided e MICROSCOPIC CHARACTERS. 99 (Fig. 17), and might at first sight be mistaken for plates of cystine. Their solubility in urates, and absence of all colour when examined by polarised light, will prevent these crystals being mistaken for cystine. If urine containing common salt be hastily evaporated on a slip of glass, the regular transparent laminae are not met with, being replaced by a series of elegant crystals, shaped like crosslets and daggers (Fig. 18). The ap- pearance of these, on the evaporation of a fluid containing a little common salt, is a tolerably safe indication of the presence of urea. 110. Pathological origin and indications of cystine. — This curious substance is in all probability a derivative of albumen, or of tissues into which it enters, and appears to be the result of derangement of the secondary assimilative processes (5), es- sentially connected with the excessive elimination of sulphur ; every ounce of cystine containing more than two drams of this element. From an examination of its chemical composition, there appears no difficulty in explaining the origin of cystine, by supposing that it is formed by those elements of our tissues which would normally have been converted into urea and uric acid (8), in consequence of the presence of an excess of sul- phur connected essentially with a scrofulous diathesis. Cystine consists of C6, N, H6, 04, S . CNHOS CNHOS 1 atom urea - 2+2+4+2+0-| f 12+2+12+8+4=2 at. cystine. 1 atom uric acid 10+4+4+6+0 j 4 =4 at. nitron 4 atoms sulphu- '^___J ———--------- retted hydrog. ______4 +4 [~\ 12+6+12+8+4 12+6+12+8+4 j 'L A certain amount of sulphur exists in healthy urine in some 100 PATHOLOGY OF CYSTINE. unknown state of combination, for as Proust long ago proved, when the urine is boiled in a silver basin, a brown crust of sul- phuret of silver is formed. 111. Although but little is known of the pathological condition of the system which induces the formation of cystine, there is suffi- cient evidence before us to justify our expressing strong opinions of its essentially scrofulous and remarkably hereditary character. In one family alone, several members were nearly at the same time affected with cystine ; and one instance exists in which it can be traced with tolerable certainty through three generations. There is probably a remarkable deficiency of the process of oxi- dation in these cases ; Dr. Prout has even seen fattty matter mixed with the urine, and suggests the probability of its connexion with fatty liver. In one well marked case which fell under the care of Mr. Luke, at the London Hospital, extensive disorganisation of the kidneys co-existed with a cystine calculus. 112. Therapeutical indications. — These are unfortunately in the present state of experience not very well understood. The cases have been observed too seldom to allow of any acumula- tion of experience, and most of them having occurred in private practice, have precluded that minute and persistent watching which is so necessary for satisfactory information. The most important indications are to correct the unhealthy condition of the assimilative functions, and if possible to render the cystine, so long as it continues to be formed, soluble in the urine. To effect the latter, the persistent use of nitro-hydrochloric acid has been recommended by Dr. Prout, and in some cases with success. In one, I had an opportunity of watching, it failed in either dis- solving the deposit, or preventing its formation. In this case, however, there was little doubt of the presence of a renal calcu- lus. The genera] health should be most carefully attended to, and everything interfering with it removed as completely as pos- sible. Sea bathing, exercise, nutritious and digestible diet, with attention to the functions of the skin, promise to do much. I feel inclined to place great confidence in the use of iron, espe- cially of the iodide, in tolerably large doses. Unfortunately, as in all ailments demonstrably hereditary, we have an obstinate disease to treat, and the prognosis must be extremely guarded, as in the majority of cases the generation of cystine goes on to the formation of a calculus. DIAGNOSIS. 101 CHAPTER VII. CHEMICAL PATHOLOGY OF OXALATE OF LIME (OXALURIA). History, 114—Diagnosis of oxalate of lime, 115-118—Characters of urine depositing the oxalate, 119—Presence of epithelium and excess of urea, 120—Complication with other deposits, 121, 2—Pathological origin of the oxalate of lime, 123— Absence of sugar in oxaluria, 124—Formation of oxalic acid from urea and uric acid, 125—Symptoms of oxaluria, 126—Exciting causes of, 127—Therapeutical indications, 128—Illustrative cases, 129. 114. The supposed extreme rarity of crystalline deposits of oxalate of lime in the urine has often attracted the notice of writers on calculous affections, and many have expressed their surprise that, although they have repeatedly examined the urine in cases where calculi of oxalate of lime exist, they have never succeeded in detecting a deposit of this substance. To the generally ad- mitted accuracy of this statement all investigators have borne witness ; thus in the third edition of the elegant and elaborate work of Dr. Prout, which must be regarded as giving the most complete account of the present state of our knowledge on these matters, the deposit of oxalate of lime is scarcely described ; and the remarks made on the oxalic diathesis applies to the cases in which the oxalate of lime has existed in a truly calculous form, or to those in which the presence of oxalic acid is rather sus- pected than proved ;62 the whole series of observations inclining to the generally received notion of the almost necessary con- nexion between the presence of saccharine matter and the deve- lopment of oxalic acid. M. Rayer alludes only to the artificial production of crystals of oxalate of lime, effected by adminis- tering to patients alcaline oxalates ;G3 and figures, among his very accurate delineations of urinary deposits, the precipitate pro- duced by the addition of oxalate of ammonia to urine; and the only case of the occurrence of oxalate of lime in the urine that he cites is one which occurred to myself several years ago, the details of which appeared in the Medical Gazette** in a laborious 9* 102 PATHOLOGY OF OXALATE OF LIME. paper on urinary deposits, by Dr. Brett. And this is also the only instance alluded to by Dr. Willis, in his very interesting work on Urinary Diseases. I was first led to question the accuracy of the generally re- ceived opinion of the extreme rarity of the presence of oxalate of lime in a crystalline form, during my examination of urinary deposits preparatory to the publication of an essay in the seventh volume of Guy's Hospital Reports. Since then, I have, in the extensive field of experience in public practice at my command, carried on these researches on a large scale, and have examined microscopically the urine in many hundreds of cases of various diseases.65 The result of this investigation has been the dis- covery of the comparative frequency of oxalate of lime in the urine in fine and well-defined octahedral crystals, and of the connexion between the occurrence of this substance and the ex- istence of certain definite ailments, all characterised by great nervous irritability. The accounts of my researches have been published in the London Medical Gazette for 1842. It will be a matter of great interest to investigate the compara- tive frequency of the oxalate of lime in the urine in different localities, for the purpose of ascertaining how far the formation of this salt is connected with the depressing influences always more or less active in large and densely populated cities ; for, in the cases of disease occurring in this metropolis, I have no hesitation in declaring, as the result of my own experience, that the oxalate is of far more frequent occurrence in urine than the deposits of earthy phosphates. 115. Diagnosis and microscopic characters of oxalate of lime.— To examine urine for the purpose of detecting the existence of the salt under consideration, allow a portion passed a few hours after a meal to repose in a glass vessel; if this be done in winter, or during the prevalence of frequent and rapid alternations of temperature, a more or less dense deposit of urate of ammonia will generally make its appearance, arising either from the sud- den cooling of the urine, or from interference with the functions of the skin prior to its excretion (66). In warm weather, how- ever, or when the functions of the skin are tolerably perfect, the urine, albeit it may be loaded with oxalate of lime, may still appear limpid, or, at furthest, its lower layers only be rendered MICROSCOPIC CHARACTERS. 103 opaque by the deposition of a cloud of vesical mucus. Decant the upper 6-7ths of the urine, pour a portion of the remainder into a watch-glass, and gently warm it over a lamp ; in a few seconds the heat will have rendered the fluid specifically lighter, and in- duced the deposition of the crystals of oxalate, if any were pre- sent : this may be hastened by gently moving the glass, so as to give the fluid a rotatory motion, which will collect the oxalate at the bottom of the capsule. The application of warmth serves, also, to remove the obscurity arising from the presence of urate of ammonia, which is readily dissolved by exposing urine con- taining it, to a gentle heat (59). Having allowed the urine to repose for a minute or two, remove the greater portion of the fluid with a pipette, and replace it by distilled water. A white pow- der, often of a glistening appearance, will now become visible, and this, under a low magnifying power, as by placing the cap- sule under a microscope furnished with a half-inch object-glass, will be found to consist of crystals of oxalate of lime in beautifully formed transparent octohedra, with sharp- ly-defined edges and angles (Fig. 19). It sometimes happens that the oxalate is present in the form of exceedingly minute crystals : it then resembles a series of minute cubes, often adhering together like blood-dies : these, however, are readily and distinctly resolved into oc- tohedra under a higher magnifying power. If the crystals be collected and ignited on platinum foil, oxalic acid is decomposed, and carbonate of lime left ; the subsequent addition of dilute nitric acid dissolves the residue with effervescence. This process is by far the most satisfactory, and, although it requires a little tact, still, after some trials, it can readily be per- formed in a very few minutes. But even this may be avoided, by placing a drop of the lowermost stratum of the urine on a plate of glass, placing over it a fragment of thin glass or mica, and then submitting it to the microscope: the crystals diffused through the fluid becoming very beautifully distinct. In this way, however, it is obvious that very much fewer are submitted to examination than by the former process. 104 PATHOLOGY OF OXALATE OF LIME. 116. It is a very remarkable and interesting circumstance, that this salt, although I have now examined a very large number of specimens of urine containing it, has never subsided to form a distinct deposit; remaining for days diffused through the fluid, even when present in so large a quantity that each drop of the urine, when placed under the microscope, was found loaded with the crystals. If, however, any substance, capable of constituting a nucleus, be present, the oxalate will be deposited around it, although scarcely in cohering masses, and always colourless and beautifully transparent. If, as occasionally occurs, a specimen of oxalic urine happened to contain an excess of triple phosphate, the crystals of this salt are found mixed with those of the oxalate. I have also found the octohedra beautifully crystallised on a hair accidentally present in the urine like sugar-candy on a string. The reason why a large quantity of the oxalate, when present, escapes the eye, arises, I suspect, from its refractive power ap- proaching that of urine (51) ; for whenever we meet with a speci- men in which the salt has partially subsided, and replace the de- canted urine by distilled water, the crystals often become readily perceptible to the unaided eye, resembling so many glistening points in the fluid. 117. The crystals of the oxalate, when collected in the manner above directed in a watch-lass, are unaltered by boiling either in acetic acid or solution of potass. In nitric acid they readily dissolve without effervescence. The solution may be very readily watched under the microscope. When the oxalate is allowed Fig. 20. Fig. 21. to dry on a plate of glass, and then examined, each crystal pre- sents a curious appearance, resembling two concentric cubes with MICROSCOPIC CHARACTERS. 105 their angles and sides opposed, the inner one transparent, and the outer black, so that each resembles a translucent cube set in a black frame (Fig. 20). This is best observed under a half-inch object-glass ; as with a higher power this appearance is lost. 118. In a very few cases the oxalate is met with in very re- markable crystals, shaped like dumb-bells, or rather like two kid- neys with their concavities opposed, and sometimes so closely approximating as to appear circular, the surfaces being finely striated. These crystals are produced, in all probability, by a prolific arrangement of minute acicular crystals (Fig. 21).* I have not met with many cases in which this zeolitic was present. Some of these were under my care for months; and I had repeat- ed opportunities of examining the urine. The remarkable crys- tals now referred to, became in all mixed with, and ultimately re- placed by, the ordinary octohedral variety. The greatest possible variation in the size of these crystals is met with, not only in different specimens of urine, but often in the very same portion. I have often met with octohedra of oxa- late mixed with others four or six times larger in a single drop of urine. The following measurements were made from some speci- mens preserved between plates of glass ; by means of the beauti- ful micrometer of Powell, belonging to the large microscope con- structed by him for Guy's Hospital • — Inch Length of a side of the largest octohedraf --------------------smaller ditto --------------------smallest ditto Long diameter of large " dumb bell" crystals Short diameter of ditto ... Diameter of some nearly circular - Long diameter of the smallest "dumb-bells" Short diameter of ditto 56 3 l 750 l 500 __1 1 4 20 1 3500 119. Characters of urine containing the oxalate of lime. — In the great majority of cases, the urine was of a fine amber hue, * An analogous zeolitic crystallization of the carbonate of lime occurs in the urine of the horse (163). f In the urine of the horse in which I discovered \n abundance of these crystals, their magnitude was considerable, often being —— inch long : they then possessed an amber colour. 106 PATHOLOGY OF OXALATE OF LIME. often darker than in health, but never presenting to my view an approach to the greenish tint described by Dr. Prout as charac- teristic of the secretion during the presence of what he has de- scribed as the oxalic diathesis, unless red particles of blood were present. In a few cases the urine was paler than natural; and then was always of lower specific gravity. This, however, was in most instances but a transient alteration, depending upon ac- cidental causes. In many instances a deposit of urate of am- monia, occasionally tinted pink by purpurine, fell during cooling. This I observed to be infinitely more frequent during the months of January to March than in the three succeeding months of this year: hence it in all probability depended upon the influence of cold upon the cutaneous functions, thus causing a large amount of azote, under the form of the urate, to be excreted by the kid- ney (66). The specific gravity of oxalic urine varies extremely ; in rather more than half the specimens being, however, between 1.015 and 1.025. In eighty-five different specimens of which I have preserved notes, the ratio of the densities was as follows : — In 9 specimens the specific gravity ranged from - - 1.009 : 1.015 In 27 ditto ditto.....1.016:1.020 In 23 ditto ditto.....1.021 : 1-025 In 26 ditto ditto.....1.025 : 1.030 The densities of the specimens of urine passed before going to bed at night, and immediately on rising in the morning, were frequently very different; thus, in twenty-six cases in which the night and morning urine were separately examined:— The night specimen was heaviest in - - - 12 The morning specimen heaviest in - - - 5 Both alike in - ... . 9 And, as a general rule, the heaviest specimens contained most of the oxalate. It seldom happened that the total quantity of urine passed in these cases very much exceeded the average pro- portion ; in a very few only, positive diuresis could be said to exist. Frequently the patients have, from occasional irritability of bladder, mistaken the frequent desire to pass urine for an in- creased quantity; but by positive measurement of the quantity of urine passed in twenty-four hours, the absence of any very con- siderable increase was proved. COMPLICATIONS. 107 120. Many of the specimens of oxalic urine gave a precipitate with salts of lime, insoluble in acetic acid, and consisting of oxalate of lime. This, in some instances at least, depended on the presence of oxalate of ammonia, and delicate acicular crystals of this salt occasionally formed upon the edge of the capsule by spontaneous evaporation. The acidity of these specimens Was always well marked, often far more so than in health, and never being -absent. I have not yet met with a single case in which an alcaline, or even positively neutral, state existed. A greater increase in the quantity of urea, than the density of the urine would have led us to suspect, was frequently found ; indeed, I have scarcely met with a specimen in which, when the density was above 1.015, distinct indications of an excess of urea were not met with. In twenty-four of the eighty-five specimens above referred to, so large a quantity was present, that very rapid, and in some almost immediate, crystallisation ensued on the addition of nitric acid. In general, in cases where the greatest excess of urea Was present, the largest and most abundant crystals of the oxalate were detected. 121. Complication of the oxalate of lime with other deposits.^- In more than half the cases, the oxalate of lime was found un- mixed with any other saline deposit; in a very few, crystals of uric acid were found from the first mixed with the octohedra of oxalate of lime; and in nearly all the successful cases, this acid appeared in the course of the treatment, and ultimately replaced the oxalate altogether, at a period generally contemporary with the convalescence of the patient. In three cases alone, prisms and stellse of the ammoniaco-magnesian phosphate Were found mixed with the oxalate, and occasionally replacing it in the course of the treatment; in two of these the phosphate was observed in the urine some time before the appearance of the oxalate. In several specimens a copious troubling was produced on the application of heat; this generally depended upon the precipitation of the earthy phosphates, as a drop of dilute acid immediately restored the limpidity of the fluid. In one specimen alone did this troubling depend upon the presence of albumen, and then it was transient, appearing but once in the case, and then depending upon some secretions from an irritable vesical mucous membrane 108 PATHOLOGY OF OXALATE OF LIME. becoming mixed with the urine. I have as yet seen no instance of a complication of this oxalic affection with granular degene- ration of the kidneys. Out of the eighty-five cases before referred to Oxalate was present unmixed in * Mixed with urate ammonia in Mixed with uric acid Mixed with triple phosphate Phosphate deposited by heat 85 In one of the specimens containing the triple phosphate, the application of heat produced a deposit of the earthy salts. One very constant phenomenon was observed in the micro- scopic examination of oxalic urine, viz., the presence of a very large quantity of epithelial scales (195); it was, indeed, the exception to the general rule to meet with this form of urine free from such an admixture. So constantly was it found, that repeatedly a white deposit of epithelium has often attracted my attention, and led to the suspicion of the probable presence of oxalate of lime. In general the scales of epithelium are unaltered in form, being oval and marked with a circular spot in the centre ; being, in fact, the variety described by authors under the name of nucleated epithelium. Sometimes irregular lacerated fragments of epithelial structure were met with; and frequently, if not too intense a light were used, a-portion of the urine could, under the microscope, be seen to be full of them. 122. Although I have generally met with the oxalate of lime diffused through the urine, yet, if much mucus were present, so as to form a tolerably dense cloud, the salt might often be seen entangled in its meshes like glistening points; and whenever any other matter was present, which, by repose, became deposited, a great portion of the oxalate would almost invariably fall with it. This was particularly the case when triple phosphate of magnesia and ammonia, or uric acid, existed under the form of a crystalline deposit; for on submitting a portion of this to the microscope, the octohedra of oxalate were always detected with the prisms or stellse of the former, or with the tables or lozenges of the latter. 43 cases 15 „ 15 „ 4 „ 8 „ ORIGIN. 109 123. Pathological origin of oxalate of lime.—This question is one of great interest, and becomes the more important since the discovery of the very frequent existence of this salt in the urine ; so that, instead of being very rare, it really is considerably more frequent than many other deposits (114). It is scarcely possible to avoid being impressed with the very probable physiological relation between oxalic acid and sugar: we know that the latter substance forms a considerable item in our list of ailments; we know that the great majority of farinaceous matters are partially converted into this element during the act of digestion.06 It is indisputable that, under certain circumstances, it finds its way into the blood, and is eliminated by the kidneys; and lastly, we know that, under certain morbid influences, the great proportion of our food may, whilst in the stomach, be converted into sugar, which becoming absorbed, rapidly passes through the circulation, and is thrown out of the system by the kidneys as an effete matter, with the effect of producing more or less rapid emaciation, and in most cases leading to fatal marasmus. Then, recollecting the facility with which sugar and its chemical allies, as starch, gum, and wood fibre, are, under the influence of oxydizing agents, converted into oxalic acid, and having sufficient amount of evi- dence to prove that when oxalic acid is really found in the urine, symptoms bearing no distant relation to those of a diabetic cha- racter are met with, we are almost inevitably led to draw the induction that the oxalate of lime found in the secretion owes its origin to sugar, and to locate the fons et origo malorum in the digestive organs. This appears to be nearly the view adopted by that very excellent authority in these matters, Dr. Prout. From my own observations, however, on this subject, I have arrived at the following conclusions:— 1. That in the urine under consideration oxalate of lime is present, diffused through the fluid, and in a crystalline form. 2. That in rather more than one-third of the cases, uric acid or urates existed in large excess, forming the greater bulk of the existing deposit. 3. That in all, there exists a greater proportion of urea than in natural and healthy urine of the same density; and in nearly 30 per cent, of the cases, so large a quantity of urea was present, that 10 110 PATHOLOGY OF OXALATE OF LIMK. the fluid crystallized into a nearly solid mass on the addition of nitric acid. 4. That the urate of ammonia found in the deposits of oxalic urine is occasionally tinted of a pink hue. 5. That an excess of phosphates frequently accompanies the oxalate. 6. That no evidence of free sugar has occurred in the specimens I have examined. 124. Every one is now tolerably familiar with the composition of the urine in diabetes, and it has been determined, from great observation, that, as a general rule, diabetic urine very seldom contains an excess of urea, uric acid, or urates, especially the pink variety; and that this secretion is remarkably free from saline deposits; the increased specific gravity depending upon the pre- sence of large proportions of sugar. In the oxalic urine under consideration, the density increases with the quantity of urea, which is often present in large excess: deposits of uric and urates are frequent; and, further, no analogy whatever with saccharine urine exists, save in density, which we have already learned depends upon a totally different cause. Thus, so far as the abstract examination of the urine is concerned, not the slightest countenance is given to the idea of there being any relation between oxalic and saccharine urine, however much our precon- ceived and hypothetical views may have led us to expect the existence of such relation. In no instance have I yet found sugar present in oxalic urine; and although I commenced these investigations with a strong bias in favour of the almost necessary connexion between the presence of saccharine matter and oxalic acid, yet, in proportion as I have extended my researches, this idea became less and less supported by experience. In fact, I have never as yet met with oxalate of lime in diabetic urine. I have been twice shown specimens in which a white creamy sedi- ment was considered to be oxalate of lime; but this, by chemical examination, turned out to be a chylous deposit, containing much fatty matter, and yielding butyric acid, or something analogous to it, by distillation. What, then, is the source of the oxalate of lime? and how can its production be explained consistently with the phenomena presented by the urine ? From the symptoms presented in cases of this disease, there is no difficulty in proving CONNECTION WITH AZOTURIA. Ill to a demonstration the positive and constant existence of serious functional derangement of the digestive organs, especially of the stomach, duodenum, and liver; and, further, that the quantity of oxalic acid generated is, to a very considerable extent, under the control of diet; some articles of food quite free from oxalic acid at once causing the excretion of this substance in very large quantities, whilst others appear to have the effect of nearly totally checking it. These circumstances alone, together with the ema- ciation so generally present in the disease under consideration, at once prove, that whatever be the immediate agent which causes the kidneys to secrete the oxalic acid from the blood, that the primary cause must, as Dr. Prout has well and satisfactorily shown, be referred to the digestive and assimilative functions. It must, then, be recollected that an excess of urea, and often of uric acid, in most instances accompanies the development of the oxalic urine. It is, therefore, highly probable that both these unnatural states of the secretion are produced by the same morbid influence; and, further, when the very remarkable chemical re- lation existing between urea, uric acid, and oxalic acid, is borne in mind, as well as the readiness with which the former are con- verted into the latter, is it not a legitimate conclusion to suppose that the disease under consideration ought to be regarded as a form of azoturia (of which an excess of urea is the prevalent indi- cation), in which the vital chemistry of the kidney has converted part of the urea, or of the elements which would in health have formed this substance, into oxalic acid? This view appears to me to be supported by what I have observed of the history, symp- toms, and progress of the cases, as contrasted with the changes presented by the urine during treatment. It may, however, be asked, from whence are the nitrogenised matters derived, whose metamorphoses (3) gave rise to the formation of oxalic acid and ammonia? are they derived from the tissues of the body, like healthy urea and uric acid (8)? Of course it is quite possible that such may be their origin, but as the quantity of oxalate of lime is always the greatest after a full meal, and often absent in the urina sanguinis, or that passed on rising in the morning, and, moreover, disappearing under the influence of a carefully regulated diet, and reappearing on returning to the use of unwholesome food, it is highly probable that the salt is, in the majority, if not in all cases, 112 PATHOLOGY OF OXALATE OF LIME- primarily derived from the mal-assimilated elements of lood, and not, like uric acid generally, .a product of metamorphosed struc- tures. 125. The ready conversion of uric into oxalic acid, under the influence of oxidizing agents, has been satisfactorily shown by Professors Liebig and Wohler ; for when uric acid is heated with water and peroxide of lead, oxalic acid, carbonic acid, and allan- toin, the peculiar ingredient of the allantoic fluid of the cow, are generated. The readiness with which, under certain circum- stances, uric acid is converted into the oxalic, may be well illus- trated by a fact which has been observed in connexion with the guano of South America, a substance now acquiring great cele- brity as a manure. This contains, when recent, a considerable proportion of urate of ammonia, which salt, after a certain length of time, often during the voyage to this country, nearly wholly disappears, and is replaced by oxalate of ammonia. The relation between urea and oxalic acid is readily shown ; for if we conceive urea to exist in the blood, and it be the duty of the kidney to separate it, we have only to suppose the organ to exert a slight deoxidating or decomposing influence to insure the conversion of urea into oxalate of ammonia. We know that under a depressing influence exerted on the nervous system at large, or upon a por- tion of it connected with the functions of the kidney, as during typhus adynamic fever on the one hand (150), and blows over, or a fracture of the spine, on the other (165), such decomposing influence is unquestionable, and the urine becomes loaded with carbonate of ammonia from a re-arrangement of the component elements of the urea ; one atom of urea and two of water being resolved into two atoms of carbonate of ammonia. If, then, a less energetic amount of this morbidly depressing influence be sup- posed to be exerted, we shall have one atom ot urea and two of water, lose an atom of oxygen to become converted into oxalic acid and ammonia. CNHO CJNHO I atom urea —2+2+4+2^ T2 3 2 atoms water = 2+2 2+6 2+2+6+4j [2+2+6+4 Since the first publication of this formula, Prof. Liebig has su g- 1 atom oxalic acid. 2 atoms ammonia. I atom oxygen. RELATION TO UREA. 113 gested that oxalic acid is a derivative of uric acid and not of urea, thus, CNHO CNHO I atom uric acid= 10+4+4+ 6 "\ f 4+4-J-8+ 4=2 atoms urea. 4 atoms water = 44- 4 i j 3----oxygen = 3 I__J 6 9=3----ox acid. 10+4+8+13 | | 10+4+8+13 ---------J l---------- It is, however, a matter of very secondary importance whether the oxalic acid be a derivative of uric acid or urea, considering the relation which exists between these two bodies (35). From whatever source it may arise, the presence of oxalic acid in the urine must necessarily lead to the formation of oxalate of lime, as this acid readily precipitates lime from all its combinations with acids.' 126. Symptoms accompanying the secretion of oxalic acid.—It is difficult, notwithstanding the experience we have had of this ailment, to offer a very satisfactory account of the symptoms at- tending it. As a general rule, however, persons affected with the disease under consideration are generally remarkably depressed in spirits, and their melancholy aspect has often enabled me to suspect the presence of oxalic acid in the urine. I have seldom witnessed the lurid greenish hue of the surface to which Dr. Prout has referred. They are generally much emaciated, excepting in slight cases, extremely nervous, and painfully susceptible to external impressions, often hypochondriacal to an extreme degree, and in the majority of cases labour under the impression that they are about to fall victims to consumption. They complain bitterly of incapability of exerting themselves, the slightest exertion bring- ing on fatigue. In temper they are irritable and excitable ; and in men the sexual power is generally deficient, and often absent. A severe and constant pain, or sense of weight, across the loins, is generally a prominent symptom. The mental faculties are generally but slightly affected, loss of memory being sometimes more or less present. Well-marked dyspeptic feelings are always complained of. Indeed, in most of the cases in which I have been consulted, I have been generally told that the patient was ailing, losing flesh, health, and spirits, daily ; or remaining per^ sistently ill and weak, without any definite or demonstrable cause * Vide Appendix to this chapter. 10* 114 PATHOLOGY OF OXALATE OF LIME. In a few the patients have been suspected to be phthisical. It is, however, remarkable that I have yet met with very few cases in which phthisis was present. In three cases I have seen the cases terminate in the formation of a calculus. In one, the concretion passed spontaneously from the urethra ; in another, it became im- pacted, and was cut out by Mr. Harding; and in a third case the stone was removed by the operation of lithotomy performed by my colleague, Mr. Hilton. 127. Regarding the exciting causes of the secretion of oxalic acid, they were, in the majority of cases at least, generally well marked ; and in nearly all, the predisposing cause was nearly the same, viz., a chronic and persistent derangement of the general health, or the result of previous acute disease, dyspepsia, injury to the constitution by syphilis and mercury, by child-bearing and over-lactation, by venereal excesses or intemperance. The ex- citing cause has generally consisted in some circumstance which has determined the irritation to the urinary organs. Of these, exposure of the lower part of the spine to cold, mechanical vio- lence inflicted over the kidneys, unnatural excitement of the genital organs, as shown by the frequent occurrence of involuntary seminal emissions (210), or irritation from passing a bougie ; have most generally constituted at least the most evident exciting causes. In many cases, however, no other obvious cause existed than great mental anxiety, produced by excessive devotion to business or study. 128. Therapeutical indications.—The treatment, in the majority of cases, is very successful ; a few only resisting all the plans which were adopted. As a general rule, the functions of the body, where obviously imperfect, should be corrected, the general health attended to by the removal of all unnaturally exciting or depressing influences, the skin should be protected from sudden alternations of temperature by a flannel or woollen covering, and the diet carefully regulated. This has generally consisted of well-cooked digestible food, obtained in about equal proportions from the animal and vegetable kingdom ; all things which tend to produce flatulence being carefully avoided. The drink should consist of water, or some bland fluid, beer and wine being ex- cluded, especially the former, unless the patient's depression ren- der such positively necessary. A very small quantity of brandy CURATIVE INDICATIONS. 115 in a glass of water has generally appeared to be the most con- genial beverage at the meals. The administration of nitric acid, as suggested by Dr. Prout; or what appeared to be preferable, the nitro-hydrochloric acid, in small doses, in some bitter infu- sion ; or, laxative mixture, as the mistura gentianae comp., was with minute doses of mercury, generally successful, if continued a sufficient length of time. In cases where these failed, active tonics, especially the sulphate of zinc, and where the patient was anaemiated or chlorotic, the salts of iron in very large doses, appeared to be of great use, by subduing the irritable state of the nervous system. The shower-bath, by acting in a similar manner, has been also of great service. There is one remedy which appears to exercise a marked influence over the characters of the urine, and which, from the small amount of experience 1 have had with it, seems to hold out the probability of its great utility in the disease under consideration : I allude to the col- chicum, which, it is now generally admitted, exerts an immense influence over the organic system of nerves, and the functions under its control. The character of the urine is remarkably in- fluenced by this drug, an excess of uric acid generally being present during its administration; and in two cases, in which oxalate of lime existed in abundance before its employment, uric acid appeared after a few days as a deposit, and nearly en- tirely replaced the oxalate ; a circumstance generally observed during the successful treatment of this disease by other reme- dies. In no case have I seen the disease suddenly yield; it has generally slowly disappeared pari passu with the decrease in number and size of the crystals of the oxalate. 129. I have selected the following cases from those of which I have preserved notes, on account of their illustrating the chief varieties of ailments in wdiich I have met with the oxalate, more than for the sake of pointing out the treatment. I only trust that they will appear of sufficient importance to draw attention to the subject generally, and to impress the profession with the fact of the very frequent, and very generally overlooked, production of oxalic acid in the animal economy. 116 PATHOLOGY OF OXALATE OF LIME. ILLUSTRATIVE CASES. Case I.—Intense hypochondriasis .• emaciation ; copious discharge of crystals of oxalate of lime, -with excess of urea. On Feb. 15th, 1842,1 was consulted by Mr. W. Stone, in the case of a gentleman residing in a densely populated district of this metropolis. He was a remarkably fine man, about thirty years of age, of dark complexion, and whole expression strongly characteristic of deep melancholy ; he was highly educated, and appeared to have painfully susceptible feelings. It appeared from his history that, until within the last four years, his health had been excellent; at that time he contracted a sore, which was regarded as syphilitic, and so treated with, inter alia, abundance of mercury and iodine, which appeared to have aided in bringing on an extremely cachectic condition. Partially recovering from this, he left England on an eastern tour. He visited Malaga, Egypt, and returned to England via Constantinople. At each of these places he underwent treatment for what he regarded as a return of venereal symptoms, apparently only manifested by relaxation of the throat producing hacking cough. At the latter place he fell under the care of Dr. Mac Guffog, who evidently took a very correct view of his case, and he received decided benefit from his treatment. At last, wearied and dispirited, with an irritable throat, bearing about with him what he regarded as a venereal taint, and tired with wandering, he re- turned to England, a prey to the most abject hypochondriasis. When I saw him, his naturally expressive countenance indicated despair: he complained bitterly of the inefficiency of medicine, and seemed only in doubt whether he were doomed to die of syphilis or phthisis. The pulse was quick and irritable; tongue morbidly red at the tip and edges, and covered in the centre with a creamy fur. He had lately lost much flesh ; he was troubled with a constant hacking cough, which evi- dently depended on an enlarged uvula; for on examining the chest I could not succeed in detecting any evidence of disease. There was extreme palpitation, increased by eating and by exercise, much flatulent distension of the colon, the pain between the shoulders, across the loins, and over the region of the stomach ; extreme restless- ness, and nervous excitement, accompanied every action. The bowels were inclined to be constipated; urine copious ; appetite rather voracious, but unsatisfying ; skin acted imperfectly. Feb. 15th.—The urine passed last night was acid, pale, of specific gravity, 1.0295, contained much mucus, with abundance of flesh-coloured urate of ammonia in sus- pension. On warming a portion so as to dissolve the latter, a very copious crystal- line deposit of oxalate of lime, in cuboid crystals, was rendered beautifully visible by the microscope. A large excess of urea was present, the addition of an equal bulk of nitric acid rendering some of the urine placed on a watch-glass nearly solid in ten minutes. The urine passed this morning was precisely similar. R Acid. Nitrici Acid. Hydrochlor. aa, §j.; Inf. Serpentariae, §xj. ; Syr. Zinzib. 3j. M. capt. ^j. ter die. ILLUSTRATIVE CASES. 117 E Ext. Aloes Pur. ij.; Conf. Opii, gr. iij. M. ft. pil. o. n. s. Allowed a bland nutritious diet, with three glasses of old sherry daily : no vegetables, butter or sugar. 27th.—Has continued the treatment up to this date with very marked improve- ment ; his expression is now cheerful ; bowels act freely and healthily; pain much less; skin active ; throat not so troublesome___Pergat. The night urine was now of lower specific gravity, being 1.020, scarcely contain- ing an excess of urea; a slight deposit of urate of ammonia was present, mixed with but a small quantity of oxalate of lime in crystals. The morning urine contained less of the oxalate. He continued this treatment patiently and persistently until March 20, when he was so much better that he desired to take a country trip. I discontinued his me- dicines, and ordered him a mild tonic aperient occasionally. May 1st. I again saw this gentleman. He has gained strength,flesh, and spirits, he only complained of occasional headache, and a dread of a return of his ailment, and is anxious to break through his restrictions of diet. The urine now contained no excess of urea, and was nearly free from oxalate of lime. An occasional aperient was ordered him. June 4th.—He again called upon me : he is free from disease, and his most press- ing evil seems rather to arise from a lurking dread of phthisis than aught else. The urine is natural. Case II.—Intense lumbar pain folio-wing exposure to cold ; diuresis; great hypo- chondriasis ; copious discharge of ox aline of lime folio-wing, and succeeded by uric acid gravel; excess of urea. Mr. F.-------, set. 53, a gentleman residing in the neighbourhood, came under my care May 1st, 1842, complaining of intense pain across the loins, so severe as to interfere materially with his comfort. From his history it appears that the general health had been good ; always had an excellent, indeed often a voracious appetite, and been " a heavy feeder," eating and drinking abundantly, but scarcely ever has been intoxicated. His life has been one of great activity, being daily for several hours out on horseback or in his gig. Ten years ago he became the subject of se- vere irritative dyspepsia, lasting about six months : from this he recovered, and remained tolerably well for four years, when he suffered a relapse, attended with se- vere pain in the left hypochondrium, referred to flatulent distention of the colon, con- sequent on constipation, by the late Mr. Vance, under whose care he then was. This pain has since been always more or less constantly present, and is generally relieved by an escape of flatus. About five years ago he went to Cheltenham on the outside of a coach and got chilled. He soon became the subject of severe lumbar pain, which, although frequently varying much in severity, has now left him. It is greatly increased by all indiscretions in diet, and when absent a hearty meal will at any time bring it on ; when it is present it completely cripples him. By making a powerful effort he can sometimes manage to walk: and this generally gives some amount of relief, although too much exercise will always bring it on. He feels no in- crease of pain when riding on horseback, but a short drive on a coach will bring on a paroxysm of lumbar pain. Neither headache nor sickness have been present during 118 PATHOLOGY OF OXALATE OF LIME. the whole illness. The urine is generally turbid, and occasionally passed in larger quantities than natural. This gentleman has of late become subject to the most distressing hypochondriasis, looking at all occurrences as tinted with a colouring ot melancholy or misfortune. So far as I could learn, the sexual powers had not be- come materially impaired. He has never had pains along the ureters, and inherits no tendency to calculus or gout. The tongue is tolerably clean; having in its centre a mere creamy layer. The bowels act well. May 1st.—The urine passed last night was pale amber-coloured; it contained much mucus, was acid, did not coagulate by heat; it contained in diffusion a large quantity of urate of ammonia, which, on the application of heat, dissolved, and left a copious deposit of lozenges of uric acid, mixed with cohering crystals of that sub- stance in the form of crystalline gravel; in specific gravity was 1.026 : it did not coagulate by heat, but contained an excess of urea : on the addition of nitric acid, it in a few seconds became filled with fine crystals of nitrate of urea. The urine passed this morning was of specific gravity 1.024, and in other respects resembled the night urine. R Hyd. c. Creta, gr. iss.; Ipecac. Pulv. gr. j. ft. pilula o. n. s. Omit all beer and spirits, as well as fatty and indigestible articles of food. Plain diet with animal food once daily. 8th.—Much the same; the bowels had acted with copious bilious discharges ; pain still intense ; depression very great. The urine passed last night was of spe- cific gravity 1.030; it was acid, pale, contained abundance of urate of ammonia, which, by heat, disappeared, leaving, distinctly visible under the microscope, a co- pious deposit of oxalate of lime in minute cubes, mixed with an abundance of nu- cleated epithelium: no uric acid. On the addition of nitric acid, the urine almost immediately solidified from the copious crystallization of nitrate of urea. The morning urine was of a specific gravity 1.027. It contained a great excess of urea, and resembled the night urine in every particular, except that the urate of ammonia was tinted with pink, and the crystals of oxalate of lime were much larger, being fine octahedra. R Acidi Nitrici, mjij.; Acidi Hydrochloric, 1T\/vj. ter in die ex cyatho Inf. lupuli, sumend: 9th.—The urine was sent to me; that passed last night was healthy in colour ; quite limpid ; sp. gr. 1.027. Under the microscope it appeared full of fine octahedra of oxalate of lime. That passed this morning resembled it in everything, save in its lower specific gravity, being 1.021. Both contained excess of urea. 16th.—Very much improved. He has been quite free from pain for several days ; is in excellent spirits. He has taken more exercise, having been out rook-shooting the whole week, and been " living well." Last night's urine was of sp. gr. 1.022. No visible deposit. Under the micro- scope a few small octahedra of oxalate of lime, mixed with cylinders of uric acid, were visible. The specimen passed this morning was of sp. gr. 1.017, and con- tained still few crystals of the oxalate. 23d.—Appears completely well in health and spirits • is now cheerful, and free ILLUSTRATIVE CASES. 119 from pain. The urine passed this morning contained no oxalate ; had a slight de- posit of uric acid in lozenges, but was still rather too high in specific gravity, being 1.024. Case III.—Irritative dyspepsia, gastrorrhcea, great emaciation and depression, voracious appetite, copious deposit of oxalate of lime in large and -well-defined crystals. Mary Wardell, setat. 35, admitted under my care at the Islington Dispensary, April 26, 1842 : a pallid nervous woman ; had one child nineteen months ago ; suckled it during nine months; previous to this had suffered from four miscarriages, losing at each a large quantity of blood ; has no leucorrhcea. Previous to her first pregnancy her health had been excellent. During the last year she has been rapidly losing flesh, and her energies are almost prostrate, the spirits being intensely depressed. She has for a long period, suffered from pain at the scrobiculus cordis, and gastrorrhoea. For several months her most serious evil has been a fixed per- sistent pain across the loins, which becomes much more intense by exertion. No evidence of uterine disease; bowels constipated; appetite craving, and distressing, never being satisfied ; thirst great; flatus considerable. 26th.—Shortly after each meal a gush of limpid fluid rises from the stomach, which, in about an hour after, is followed by the vomiting of the meal in a semi- digested state, mixed with a considerable quantity of black grumous matter; bowels confined. Pil. Cal. c. Hyd. ^ss. o. n. s. 30th.—Bowels freely open ; vomiting considerable and distressing, accompanied with great pain at the epigastrium. Pil. Cal. c. Opii, j.; ante prandium quotidie M.M. c. M.S. 3ss. c.; Acid Hy- drocyan. dil. ITLviij. t. d. May 5th.—Bowels freely open ; vomiting not so frequent; complains of severe pain, referred to the right side of the chest. Rep. Mist. R Bismuth. Trisnitratis, Conii fol. Sodae Carbon, aa. g. iv. t. d. 10th.—Was suddenly seized last night with a fainting, and severe pain in epigas- trium. This was relieved by a little brandy and water. After a short time sleep came on, and she awoke somewhat relieved. The emaciation has rapidly increased during the fortnight. I now requested her to send me a specimen of the urine passed in the evening. It was pale, of sp. gr. 1.030, acid and turbid from the pre- sence of flesh-coloured urate of ammonia. On exposing a portion to heat, the latter dissolved, and a white opaque deposit was left; this, under the microscope, was found to consist of oval epithelial scales, mixed with very fine and large octahedra of oxalate of lime. Perstet in usu pulverum ; Ammonias Sesqui-carbonatis, gr. iv.; ex Inf. Ser- pent. 5j. et Sp. Eth. Sulph. co. 5ss. ter in die. 120 PATHOLOGY OF OXALATE OF LIME. 11th.—Passed a good night; no pain either in back or epigastrium ; much head- ache ; bowels thrice open from a dose of rhubarb she took this morning ; motions offensive; no sickness since yesterday, which followed the eating of a couple of figs ; feels comfortable, but weak ; urine clear ; oxalate of lime not so abundant. Mist. Effervescens c. Syr. Papav. Jj. 4tis horis. 12th.—Vomited yesterday after dinner; passed a good night; complained this morning of pain all over the abdomen, and between the scapulae ; bowels acting freely. Pergat. Fotus Papaveris abdomini. 16th.—Decidedly improving; now can bear on the stomach a slight meal of ani- mal food ; complains bitterly of pain across the abdomen, compared to a cord tightly drawn round it. R Sp. Ammon. Co. nT,xx.; Inf. Serpent. %j.; Syr- Papav. 5j. M. ter in die. 21st.—Improving; is gaining flesh and spirits; complains of gastrodynia daily after dinner. Pergat. Pil. Cal. c. Opii j. bis die. 27th.—Has gained strength enough to walk from Hoxton, where she resides, to my house ; is very much better, but still has great lumbar pain. The urine is still of rather too high a density, contains an excess of urea, and a tolerably copious de- posit of crystals of oxalate of lime. R Inf. Serpent, ^j.; Acid Nitrici dil.; Acid. Hydrochlor. aa. Til,v. M. ter die. Allowed to take some porter. 29th.—Much improved ; urine copious, pale, sp. gr. 1.009. June 7thv—Convalescing; urine 1.019, free from oxalate. 13th.—Has suffered a slight relapse, attended with returns of lumbar pain, fol- lowing her taking a glass of hard porter. This lasted but a few hours ; and she intends leaving town to recruit her strength in the country. Case IV.—Emaciation; extreme melancholy, folio-wing great mental distress; severe lumbar pain ; great excess of urea, and discharge of oxalate of lime; remarkable gelatinization of the urine by heat. Catherine Cutler, aet. 39, a tall thin woman, of fair complexion, presenting the appearance of great emaciation and melancholy, admitted under my care at the Islington Dispensary on May 3, 1842. She has been a widow four years; has had two husbands, and lost both by phthisis; this, with her depressed circum- stances, has caused her to experience great mental and bodily distress. She has had eight children, of which she has lost six. Menstruation still regular, but, to use her own expression, almost drowned in leucorrhcea; bowels habitually consti- pated. She slates that she has for two years been giadually losing flesh ; but lately this has so increased as to amount to rapid emaciation. Her depression and me ILLUSTRATIVE CASES. 121 lancholy are intense, probably, however, partly depending on her being dependent on dress-making as the only means of support. For some months past she has been the subject of almost constant "wearing" pain across the loins, increased by exercise, and so severe at night as often to prevent her lying in the recumbent po- sition. This pain is always increased by exercise. Her nights are usually sleep- less ; and if she does get a little rest, she starts from it with the most frightful dreams. She has frequent palpitations, and pain about the epigastrium after taking food ; no great amount of flatulence; tongue red at the tip and edges, white fur in the centre. Pil. Col. c. Hyd. ij. o. n. s.; Emp. Belladonnas regioni cordis. May 6th.—The urine passed last night was of sp. gr. 1.027, acid, and turbid from holding much urate of ammonia in diffusion. On decanting the clear portion, and gently heating the opaque part, the urate dissolved, and left a copious deposit of microscopic octahedra of oxalate of lime, and numerous scales of nucleate epithelium. No change was produced in this urine by heat. The specimen passed this morning was of sp. gr. 1.011, very pale, and limpid. It became opaque on the application of heat; the troubling not being removed by nitric acid. It scarcely contained ;i trace of oxalate of lime. I ordered all medicines to be omitted, for the purpose of watching the state of the urine for a few days. 8th—Bowels for three days have been confined. She complains of a sense of distension in the abdomen, and has for two days been confined to bed with intense headache, giddiness, and feverish excitement. Morning urine clear, 1.028, acid ; no oxalate. Night urine contained a mucous cloud, 1.022, abundance of oxalate of lime in octahedral crystals. Pil. Cal. c. Hyd. ij. 6tis horis ad catharsin. 9th.—Last night's urine turbid from the presence of urate of ammonia; feels very weak. Mist. Gent. Co. %').; Sp. Ammon. Co. H\,xx. ter in die. 12th.—Much the same ; constipation continues. Pulv. Jalapae Co. 3J- °- ni. s. 15th.—No change for the better; bowels have acted well; she still feels wretch- edly ill, and depressed. The urine passed last night was of a density of 1.028, acid, pale, and contained in suspension the fawn-coloured urates. On warming a portion, the urates dis- solved, and the clear fluid soon let fall a white deposit, which, on decanting the still warm liquor, and examination under the microscope, was found to consist of various- sized octahedra of oxalate of lime, mixed with myriads of oval nucleated epithelial scales. During the application of heat, this urine underwent a remarkable change. It did not become opaque, or coagulate, but assumed a gelatinous consistence, re- taining its transparency. It then required violent agitation to diffuse it through water. The morning urine was of sp. gr. 1.030, contained an abundance of epithelium. 11 T22 PATHOLOGY OF OXALATE OF LIME. hut no oxalates. Both specimens were loaded with urea, and were converted into nearly semi-solid crystalline masses on the addition of nitric acid. I was by no means satisfied upon what this very remarkable gelatinization de- pended. Certainly not upon the presence of albumen, as nitric acid produced no opacity further than that which arose from the rapid production of crystals of nitratr of urea. Nor could I attribute it to the great excess of the latter element, as this change is by no means characteristic of urine containing a large quantity of urea. Rep. medicamenta. 17th.—Improving: bowels act well,and leucorrhcea decreasing; pnlse 24 ; ge- neral health better ; the symptoms of uterine irritation have decreased with the leucorrhcea, but the want of strength, emaciation, depression, and severe lumbar pain, continue; the oxalate of lime still abundant in the night urine. Capiat Acid. Nitric. Dil. rn„xv.; ex. Dec. Cinch, gj. bis die. Ordered nutri- tious diet, avoiding vegetables and beer, weak gin and water at dinner. June 1st.— Has been, during the last week, completely free from lumbar pain ; this morning, apparently owing to an indiscretion in diet last evening, she had a slight return. The urine passed last night just before going to bed was pale, ol specific gravity 1.015, contained abundance of epithelial scales, and no visible oxalate. Rep. omnia. 5th.—The return of lumbar pain has been quite evanescent; she is now quite free ; complains of debility and occasional headache ; still suffers from constipation ; skin acts well; occasional feverish flushes, especially in the evening. The urine passed last night had increased in specific gravity to 1.029; it was loaded with pale urates; it contained no oxalate of lime, and by heat, underwent the remarkable gelatinization before referred to. Rep. Mistura. Sumet. Pil. Col. c. Hyd. ^as. p. r. n. 12th.—By taking the pills on alternate nights, a tolerably healthy action of the bowels has been kept up ; she is much improved ; the flushes are less frequent; no return of lumbar pain ; merely complains now of not feeling quite strong. Inf. Serpentaris §j. t. d. Allowed a little porter. 13th.-*-The urine passed last night was of a density of 1.028, healthy in colour, contained no visible deposit, save a mucous cloud. The microscope, however, de- tected a considerable deposit of octahedral crystals of oxalate of lime, with an im- mense quantity of oval nucleate epithelial scales. Ordered to omit the porter. 20th.—'Feels quite well. The oxalate has again disappeared. Case V.—Rapid emaciation and depression; nervous palpitations; lumbar pains; excess of urea, and discharge of oxalate of lime. John Berry, ?et. 31, admitted under my care at the Finsbury Dispensary, June 3,1S42, ILLUSTRATIVE CASES. 123 A tall and remarkably fine man, extremely emaciated, his cheeks hollow, and his whole appearance resembling that of a diabetic patient. He is a currier, and is exposed to extreme alternations of temperature, working in a half-bent position, without coat or waistcoat, in a shop through which are constant currents of air. He is unmarried, and has been very irregular with regard to women; for two years he has been gradually losing flesh, strength, and spirits; his sexual powers have also rapidly declined, and now scarcely exist; he has frequent seminal emissions in his sleep, which leave him weak, exhausted, and melancholy, during the ensuing day. Regarding his previous habits, he considers he has been temperate, rarely getting intoxicated more than twice a week, and then on porter or ale. During two months his decline has been rapid,—a facilis descensus. He has now an almost constant headache, a constant aching pain across the loins, a sense of sinking at the stomach, as if, to use his own expression, he had no inside, frequent chills, with cold and clammy sweats, succeeded by feverish flushes ; tongue red at the tip and edges, with a white central fur; frequent giddiness; his memory has been for some time failing. His nights are wretchedly restless, generally tossing all night from side to side, in vain endeavouring to sleep, and if he does slumber, he awakes as fatigued as when he retired to rest; appetite bad; no thirst; frequent palpitation, and flatulence ; pulse small and irritable; no chest disease. Sumat. Pulv. Rhaei Salin. %'y, eras mane. 5th.—Bowels acted once yesterday from the powder; hands tremulous. The urine passed last night was deep amber-coloured, acid, of a density of 1.030, no visi- ble deposit: by microscopic examination, however, myriads of splendid octahedral crystals of oxalate of lime became visible. On the addition of nitric acid to the urine, a copious formation of crystals of nitrate of urea occurred. The urine passed this morning was paler, acid, of a density of 1.025, and con- tained less oxalate and urea. Pil. Col. c. Hyd. ij. o. n. s.; Acid Nitric, dilut. ffLxv. ter die, ex Dec. Cin- chonas, gj. Nutritious diet, light pudding daily, no beer, weak brandy and water at dinner. i 15th.—Bowels act thrice daily; motions offensive and dark-coloured ; complains greatly of palpitation of the heart. Rep. Mist. c. Inf. Serpentariae. instar. Dec. Cinchonas. The urine passed last night was deep amber-coloured, of specific gravity 1.028 : the microscope detected myriads of smaller octahedra than before. The morning urine was of a density of 1.018. 28th. Very much improved ; rests better at night; no lumbar pain ; great sense of sinking at the scrobiculis cordis. Night urine, 1.026, deposited phosphates by heat, and contained numerous minute crystals of oxalate of lime. Morning urine 1.026, like the night specimen, but did not become opaque by heat. M. Ferri Co. £j.; c. Tr. Lyttae, Tl^x. b. d. July 2d.—Improving ; seminal emissions ceased. Still copious octahedra in the night urine, which is of the density 1.025, 124 PATHOLOGY OF OXALATE OF LIME. Sumat. Vin. Sem. Colch. n\xx. ex Mist. Gent. Co. 5J. b. d. 10th.—So much better that he is anxious to leave London on along journey ; the urir.c is now free from oxalate. Case VI.—Discharge of dumb-bell oxalates,apparently succeeding to mechanical injury. David Maneford, set. 58, admitted under my care at the Finsbury Dispensary, May 25, 1842; a pallid-looking man, with a face, although not remarkab/y atten- uated, presenting a gaunt hollow aspect, with a slight hectic flush over each cheek- bone ; engaged up to the age of 32 as a ship's carpenter, in vessels chiefly in the Mediterranean, and once in a privateer on the American coast; during this time his life was one of great intemperance, drinking rum abundantly. Since he left the navy he has worked as a cabinet-maker. In 1831, whilst lifting a heavy weight, he experienced a " wrench" across the loins, the effects of which.injury, although ap- parently not severe at the time, have ever since, more or less, annoyed him; although his general health, up to the last year, has been tolerably perfect. His'chief ailment now consists in a gradual, but persistent, loss of strength and health during the last twelve months, during which period he has lived more regu- larly than previously. He is very low-spirited; his memory has of late become defective ; perspires freely on the slightest exertion ; has frequent nausea at the sight of food; appetite bad ; no pain in the stomach after the meals; no acid or bitter eructations: great and frequent flatulent distension. His nights are wretched and restless. During the last year, a fixed and constant pain across the loins has dis- tressed him ; this he can succeed in -walking off for a time, but fatigue will even- tually increase it; the bowels have of late been relaxed, acting three or four times a day, the motions being dark and fluid; his sexual appetite and powers have of late rapidly declined ; frequent involuntary seminal emissions appear at night; the tongue is clean, vividly red, and polished at the tip and edges ; pulse full and hard but jerking. The urine passed on the night of May 25th was clear, amber-coloured, acid, of specific gravity 1.017, and contained no visible deposit; a drop of the lower stratum of the urine, after repose, was full of oxalate of lime in dumb-bell crystals, which were hard and somewhat gritty, unaltered by boiling acetic acid, but readily soluble in nitric and hydrochloric acids. The specimen passed in the morning re- sembled the last; was of the density of 1.012 ; it let fall a slightly cloudy deposit by repose, which, under the microscope, was found to be made up of myriads of minute cuboid crystals of oxalate, mixed with a very few dumb-bells. R. Acidi Hydrochlorici, Jiij.; Acidi Nitrici, 3j.; Mist. Camphorse, Jiiiss.. M. capt. cochl. j. Min.; ex Inf. Anthemidis, giss. ter die; Sumat. Pil' Hydr. Chlor. Co. gr. v. o. n. He was ordered to wear a flannel bandage round the loins, to keep to a bland nutritious diet, omitting all fermented liquors. 27th.—Night urine clear, amber-coloured, no visible deposit. 1.016, very acid, no opacity by heat; some white pearly granules became visible by repose, which con- sisted of cohering dumb-bell crystals of oxalate. Morning specimen pale, contained mucous clouds, with some flakes of uric acid mixed with cohering dumb-bells. ILLUSTRATIVE CASES. 125 June 2d.—Notwithstanding the warm weather, he has not perspired so much as usual; bowels act once daily; motions dark, and tolerably healthy; urine less in quantity; that passed at night, 1.019, pale, and had a copious deposit of cylinders of uric acid, mixed with lozenges and rosettes, nearly free from oxalate of lime. The morning specimen was 1.018 in density, and perfectly resembled that passed at night. He gets better nights' rest; lumbar pain still severe, but altogether feels stronger. 9th—Tongue not so vividly red; gums slightly affected. Has been drinking cider, which not appearing to disagree, I have permitted him to continue. The night urine is of density 1-024, and contained a copious deposit of uric acid. Rep. mist: omitte pil. 23d —Improving manifestly in general health ; no sickness ; bowels act well. Night urine 1.018; morning 1.015; no visible deposit; feels only weak and nervous. Zinci Sulph. gr. iij. c. Conf. Opii. gr. ss. forma, pilul. ter die. 30th.—Convalescing; has now only a pain in the back, chiefly confined to the spine, from the first lumbar vertebra to the sacrum ; this is not constant, but now comes on after fatigue in the evening; still complains of frequent involuntary seminal emissions at night. He was ordered to continue his zinc, and to have cold water copiously applied in a stream from a kettle over the genitals and loins twice a week. Case VII— Copious excretion of oxalate of lime ; over-lactation ; probable exist- ence of caladus in the right kidney. Mary Rootham, set. 37, came under my care at Guy's Hospital, Dec 14, 1843; a pallid thin woman, the mother of two children; has been for years ailing from vague pains connected with irritable uterus. Eighteen years ago, whilst in service, received a violent blow in the right hypochondrium, and has never since been free from more or less persistent pains in that region, extending to the right kidney. From the period when she received the blow, she has, at each return of the cata- menia, been jaundiced, and is generally relieved by spontaneous bilious vomiting. Every two or three months she suffers severe paroxysms of pain in the region of the right kidney, lasting three or four days, and relieved by a copious discharge of very turbid urine, attended with great irritability of the stomach, no haematuria. After one of these attacks she brought me the urine. JYight urine—pale, acid, specific gravity 1.025, with a copious deposit of urate of ammonia, which vanished on the application of heat, and left undissolved an im- mense number of the largest dumb-bell crystals of oxalate of lime I ever saw. Morning urine—clear; by heat a scanty deposit of phosphates fell; much epi- thelial debris ; no oxalates. Ordered her a generous diet, and to wean her infant, who is thirteen months old; no medicine. Dec. 18.—Has suffered much from sickness; pains over the Tight kidney less defined ; bowels act well; feels extremely weak and depressed ; probably owing to first pointed out by the excellent chemist to whom I have just referred, of be- coming opaque by ebullition, from a deposition of a portion of the earthy salt. The very same phenomenon often occurs in urine which contains an excess of phosphates. Indeed, it is not unfrequent to meet with urine which does not contain any visible deposit, and yet on the application of heat appears to coagulate, not from the presence of albumen, but from the deposition oi earthy phosphates. The addition of a drop of nitric acid imme- diately dissolves this deposit, and distinguishes it from albumen (177). A different explanation to this phenomenon has been offered by Dr. Hargrave Brett,117 and undoubtedly is ^perfectly true in some cases. Dr. Brett's explanation is founded on the solubility of phosphates in water impregnated with carbonic acid. It has been long known that carbonic acid frequently exists in a free state in the urine, and in a large number of specimens ex- amined by Dr. Brett and myself we succeeded in readily isolating it. These experiments were made several years ago, in conse- quence of our having noticed some curious phenomena presented by the urine of a student of Guy's Hospital (since dead), a pupil of the late Mr. Bryant, of Kennington. This gentleman, in en- deavouring to raise a heavy sack of Epsom salts, strained his back, and soon after he fell into a state of marasmus, with occa- sional hectic, which ultimately exhausted him. During the last six months of his life he passed a very large quantity of pale acid urine, which by keeping soon became alcaline. This urine was limpid when first passed, but became opaque as soon as it had cooled, still, however, retaining its acidity, so that the deposition of the phosphates did not necessarily depend upon the develop- ment of an alcali. On warming the fresh urine an evolution of carbonic acid gas took place, accompanied by a deposition of phosphates. When two portions of the fresh urine were placed as soon as passed in separate bottles, and one left open, the other being closely corked, the urine contained in the latter remained transparent, and that in the former became opaque. 137. The urine, in cases where an excess of phosphates of either kind exists, varies very materially in its physical character. Certainly no general rule can be assigned for the colour, density or quantity of the urine secreted in these cases, taking them in a MICROSCOPIC CHARACTERS. 133 mass; although I think there are certain facts connected with the presence of the phosphatic deposits which serve to connect the colour and quantity of the urine with the pathological conditions producing, or at least co-existing with them. As a general rule, where phosphatic deposits, whether magne- sian, calcareous, or both, exist for a considerable time, the urine is pale, often whey-like, generally secreted in very large quanti- ties, and of low specific gravity (1.005—1.014). This is espe- cially the case where organic lesion of the kidneys exists. On the other hand, when the deposits are of occasional occurrence, often disappearing and recurring in the course of a few days, the urine generally presents a deep amber colour, and is not only of high specific gravity (1.020—1.030), but often contains an excess of urea, and presents an iridescent pellicle on its surface by re- pose. This is especially the character of the phosphatic urine se- creted under the influence of some forms of irritative dyspepsia, and where the phosphates themselves may be traced to mal-assi- milation. Again, phosphatic urine may be met with varying from a pale whey-like hue to deep brown or greenish brown, ex- ceedingly foetid, generally but not constantly alkaline, and loaded with dense ropy mucus, often tinged with blood, and in which large crystals of the triple phosphate and amorphous masses of phosphate of lime are entangled. This variety is almost always met with, either under the irritation of a calculus or even of a catheter worn in the bladder (147), or where actual disease of its mucous lining exists. The phosphates are occasionally found mixed in a deposit with urate of ammonia ; in this case the latter is always of the pale variety, and nearly white. It has indeed been stated that when urine deposits pale urate of ammonia, it indicates a ten- dency to the deposition of phosphates. This remark is so far true, that as phosphatic urine is usually very pale, it would follow as a necessary consequence that any urate of ammonia deposited from it, would be nearly white from the absence of colouring matter to tint it of any other hue. Beyond the fact, then, that white urates are deposited by pale urine, and that phosphatic urine is often scarcely coloured, I am not aware of any necessary connexion between them. 138. Microscopic characters of earthy phosphates.—A. Prisms 12 134 PATHOLOGY OF EARTHY SALTS. of neutral triple phosphate.—These are always exceedingly well defined, the angles and edges of the crystals being remark- ably sharp and perfect (Fig. 22). The triangular prism is the form most frequently met with, but it presents every variety in its terminations. These are sometimes merely truncated, often bevelled off, and not unfrequently the terminal edges are replaced by facets. Fig. 22. Fig. 23. I scarcely know a more beautiful microscopic object than is afforded by a well-marked deposit of this salt. The different de- grees of transparency presented by these crystals is very remark- able ; sometimes they are so transparent as to resemble prisms oi glass or crystal ; at others presenting an enamel-like opacity, so that they can only be viewed as opaque objects. When preserved in balsam, they depolarise light, exhibiting a beautiful series of tints, when the axes of the tourmalines or calc-spars are crossed in the polarising microscope. B. Simple stella of the neutral salt.—These are in fact minute calculous concretions, and are generally composed of acicular prisms cohering at one end, so as to represent simple stellae (Fig. 23). Not unfrequently they adhere so closely and are so crowded as to resemble rosettes. I have repeatedly seen small prisms crystallized like uric acid on one of the fine transparent hairs which are of frequent occurrence in urine. The crystals of the phosphatic magnesian salt are invariably colourless, never pre- senting the yellow or orange hue of uric acid. C. Penniform crystals of neutral salt.—This very elegant va- riety of the neutral magnesian phosphate has only lately fallen under my notice, and has occurred in a very few cases. It pre- MICROSCOPIC CHARACTERS. 135 sents the appearance of striated feather-like crystals, two being generally connected so as to cause them to resemble a pair of wings (Fig. 24). I cannot give any satisfactory explanation of the causes of this curious and elegant variety, or whether they differ in any way chemically from the prismatic form. The few- specimens I have met with occurred in acid urine. Fig. 24. Fig. 25. D. Stellar and foliaceous crystals of basic salt.—This variety, as I have already stated, cannot generally be regarded in any other light than as a secondary product taking place out of the body. When rapidly formed, this salt generally appears in the form of six-rayed stars, each ray being serrated, or irregularly crenate, often renuncinated, like the leaf of the taraxacum. This, how- ever, presents several subordinate varieties, depending, in all pro- bability, upon accidental circumstances. WThen this salt is more slowly formed, as on the surface of the urine in pregnancy, it pre- sents large and broad foliaceous laminae, often so thin and trans- parent as to escape notice altogether, especially if viewed in too strong a light. I have, indeed, often overlooked them until I illuminated the specimen under the microscope with polarised light, when they started into view elegantly tinted with colours in which pink and green are the most prominent. E. Phosphate of lime.—I have never seen this salt in a crys- talline form, but it has been said to occur in irregularly crystallised masses.67 In all the specimens I have examined, no appearance of structure could be detected; the phosphate either resembling an amorphous powder, or collected in roundish particles often adhering to prisms of triple phosphate. The sediments of this substance are remarkably opaque, so that when even a minute 136 PATHOLOGY OF EARTHY SALTS. portion is examined between plates of glass, the layer, however thin, and white by reflected, always appeared yellow or brown- ish by transmitted, light. 139. Pathological indications of the phosphates.—The occur- rence of deposits of the earthy phosphates in the urine, must be regarded as of serious importance, always indicating the existence of important functional, and too frequently, even of organic mis- chief. One general law appears to govern the pathological development of these deposits, viz., that they always exist simul- taneously with a depressed state of nervous energy, often general, rarely more local, in its seat. Of the former the result of wear and tear of body and mind in old people, and of the latter the effects of local injury to the spine, will serve as examples. It is true, that in the majority of these cases there is much irritability present, there is often an excited pulse, a tongue white on the surface and red at the margin and tip, with a dry, often imper- spirable, occasionally hot skin. Still its irritability with depres- sion, a kind of erythism of the nervous system, if the expression be permitted, like that observed after considerable losses of blood. The pathological state of the system accompanying the appearance of deposits of phosphate of lime, are analogous to those occurring with the triple salt; indeed, as has been already observed (134), they often, and in alcaline urine always, occur simultaneously. So far as my own experience has extended, when the deposit has consisted chiefly of the calcareous salt, the patients have ap- peared to present more marked evidence of exhaustion, and of the previous existence of some drain on the nervous system, than when the triple salt alone existed. 140. When the triple salt occurs in small quantities, nearly or entirely free from phosphate of lime, the urine being acidulous or neutral at the moment of emission, and not restoring the colour of reddened litmus paper until some time after; we have the sim- plest cases, or those in which the amount of organic or functional lesion is at a minimum. These patients are generally regarded as labouring under severe dyspepsia. The most prominent symp- toms they present, are great irritability of temper, extreme rest- lessness, mal-performance of the digestive functions, with such imperfect assimilation of the ingesta, that a certain and often ex- treme amount of emaciation is a constant attendant. The appetite DIAGNOSIS. 137 is uncertain, occasionally being voracious; fatigue is induced by the slightest exercise; there is a remarkable inaptitude to any mental or bodily exertion, and the patient is often, from the exhaustion thus produced, unfitted for his ordinary duties. In acute cases these symptoms become aggravated by an exces- sive elimination of urea, which aids considerably in depressing the patient's strength. Where the presence of triple phosphate is only occasional, its connexion may be traced with some cause which has rendered the system morbidly irritable, at the same time that its tone or vigour has become depressed. The simplest examples of this kind that have occurred to me, have been in the cases of individuals of nervous temperament, who have periodi- cal duties to perform requiring extreme mental tension and bodily exertion. I have witnessed this state of things several times in clergymen, especially in those who, from the nature of their secu- lar engagements, have been compelled to lead sedentary lives during the week, and to perform full duties on Sundays. The best illustration of this I ever met with, was in the person of a well-known and deservedly popular clergyman, who, from his connexion with a public school, scarcely used any exercise during the week, whilst on Sunday he performed duty thrice in his church. This gentlemen was a tall, thin person, of dark com- plexion, lustrous eyes, and almost phthisical aspect. He was the subject of constant dyspepsia. The urine passed on Saturday evening, as well as on Sunday morning, although repeatedly ex- amined, was healthy, except in depositing urate of ammonia, and being of high specific gravity. Before his Sunday duties were completed, he almost invariably became the subject of ex- treme fatigue, with a painful aching sensation across the loins, in addition to the flatulence and epigastric uneasiness under which he always laboured. The urine voided before retiring to rest after the severe exertions of the day was almost constantly of a deep amber hue, high specific gravity, and deposited the triple phosphate in abundance. The urine of Monday would contain less of this salt, which generally disappeared on the following day, and once more reappeared on the following Sunday even- ing. I had an opportunity of observing this state of things for several weeks, and it ultimately disappeared by the patient relax- 12* 138 PATHOLOGY OF EARTHY SALTS. ing from his duties and enjoying the amusement of travelling for a few weeks. 141. In mild cases of indigestion, especially in gouty dyspep- sia, it is not uncommon to find the iridescent pellicle (135) of triple salt, the urine being rich in urea. This condition must be regarded as an attempt made to get rid of an excess of a salt deri- ved either directly from the food, or by a freer disorganisation of tissue by secondary assimilation, than exists in health. This state does not generally terminate in decided gravel or the forma- tion of a stone ; it is rather to be regarded as an index of the state of the assimilative functions than as leading to the ulterior deposit of calculous matter. The most valuable diagnostic mark of these cases, in contradistinction to those where organic mischief is to be apprehended, is founded on the fact that the phosphates are chiefly confined to the urine passed at night. (See Table, next page.) 142. Deposits of the triple salt frequently occur in very old people, in whom the state of decrepitude depending on senility has either become extreme, or been aggravated by low living and a want of the ordinary comforts of life. In several cases of this kind occurring in octogenarian dependants on parochial relief the urine has been very pale, of low specific gravity (1.008 — 1.0012), subacid or neutral, and extremely foetid. This foetor, not unlike that of stale fish, did not appear to depend so much upon the pre- sence of free ammonia as from the occurrence of a slow decom- position of the organic constituents of the urine. Crystals of triple phosphate have been observed in the urine of persons who have been the subject of acute diseases, and in whom convalescence has barely commenced. This has been observed by Dr. Franz Simon in pleurisy and pneumonia, and I have met with a similar condition of the urine in cases of acute rheuma- tism. Here, also, the presence of the salt must be regarded as indicative of irritability with exhaustion. 143. When the deposit is copious, either readily falling to the bottom of the vessel, or remaining suspended in the urine like mucus, the two phosphates are generally found mixed. In these cases an alcaline condition of the urine almost invariably occurs, a piece of turmeric paper being readily stained brown on being immersed in it. The odour also is very disagreeable, and is URINE DEPOSITING PHOSPHATES INDEPENDENTLY OF ORGANIC DISEASE. Evening urine. Morning Urine. Case. Colour. Density. Action on litmus. Deposit. Colour. Density. Action on litmus. Deposit. Pale amber. Normal. Pale. Pale. Normal. Amber. Amber. 1.029 1.028 1.020 1.022 1.028 1.025 1.025 Neutral. Alcaline. Neutral. Neutral. Barely alcaline. Acid. Acid. Prisms of triple phosphates. Ditto. Ditto with phosphate of lime. Nearly all phosphate of lime. Prisms and stellar of phos-phate. Prisms of phosphate. Fine stellae of triple salt. Dark amber. Normal Pale. Normal. Ditto. Ditto. Ditto. 1.031 1.025 1.025 1.025 1.031 1.020 1.020 Neutral. Acid. Ditto. Ditto. Neutral. Acid. Ditto. Red urates. Ditto. Uric acid. Ditto. Ditto and scanty prisms of phosphate. None. Ditto. Gouty dys-pepsia. Ditto. Ditto. Ditto. Dyspepsia of intemperance. Dyspepsia following fatigue. Dysmenor-rhcea. / 140 PATHOLOGY OF EARTHY SALTS. generally said to be ammoniacal, although in very many instan- ces the term foetid would be more appropriate, as ammonia is by no means necessarily evolved. This kind of urine, if not depend- ing upon organic disease of the urinary apparatus, is always con- nected with some serious affection of the spinal marrow. In a mild form this is observed after slight violence inflicted on the spine or over the region of the kidneys, and generally disappears in a few days. I have seen a copious deposit of phosphates with alcaline urine occur for a few days in the case of a young gentle- man who had exerted himself too much in a riding-school. The fact of alcaline urine resulting from strains or blows on the back was first noticed by Dr. Prout,68 and injuries to the loins have been long enumerated among the existing causes of renal calculi. This alcaline state of the urine and deposition of phosphate, is a pretty constant result of anything which depresses the nervous energy of the spinal marrow, whether the result of insidious dis- ease of the spine, or the effect of sudden mechanical violence. Further, as observed by Sir B. Brodie, this condition of the urine, whenever it follows spinal injuries, appears not to be connected with the particular locality of the injury, but to occur equally in accidents to the lumbar, dorsal, or cervical regions. 144. It is well known that all the hollow organs of the body are endued with a sufficient amount of nervous energy, or vital power, to preserve the fluids they contain from change for a long time. Thus the blood in a vessel, even when its motion is preven- ted by ligature, does not putrefy in a space of time sufficient to convert it, if removed from the vessel into a putrescent mass. The bile in the gall-bladder, the urine in the kidneys and bladder, the fasces in the intestines, are examples of the same fact. This law even obtains in disease; for a serous or purulent effusion, the result of morbid action, will be preserved in the living cavities of the body unchanged, while a few hours would be sufficient to render them foetid and putrid, if exposed out of the body to the influence of a similar heat. It is, therefore, evident that in so complex a fluid as the urine, the vital endowments of the liv- ing cavities containing it, alone preserves it from undergoing the change which so readily occurs out of the body. The power thus possessed by the bladder of preserving its contents unchanged is indisputably dependent upon the integrity of the spinal nerves ALCALINE URINE. 141 and branches from the organic system, supplying it. If there- fore, any injury, even of an indirect character, be inflicted upon them, the result must of necessity be the diminution to a certain extent of the vital power of the organ, and the fluid it contains will become susceptible of changes analogous to those which occur in it when removed from the body. One of these changes is the union of the urea with the elements of water, and the formation of carbonate of ammonia (30). This salt, by uniting with the normal acid of the urine, will precipitate the earthy phosphates with some carbonate of lime ; the latter being the result of the de- composing influence of the carbonate of ammonia on the phosphate of lime. Whether the decomposition of urea be the primary che- mical change, or is the result of some antecedent one, is unknown. Prof. Dumas 118 has ingeniously suggested that the vesical mucus may undergo a putrescent change ; and this, acting as a ferment, may induce the metamorphoses of urea into carbonate of ammonia, just as yeast aids the conversion of sugar into alcohol. 145. The urine thus rendered ammoniacal, acts as an irritant on the mucous membrane of the bladder, exciting a form of in- flammatory action ; and the result of this is the secretion of a large quantity of mucus of a more viscid character than usual. By persis- tence of the irritation, puriform mucus is at length poured out, and this, from the chemical influence of the carbonate of ammonia, becomes changed into a viscid, almost gelatinous mass, which greatly adds to the patient's sufferings by preventing the ready es- cape of the urine even when the contractile power of the bladder is not quite paralysed. On this view the production of alcaline urine is looked upon as the exciting cause of the excessive secre- tion of unhealthy mucus, and the result of changes in the bladder, the urine being supposed to be acid at the time of secretion by the kidneys. In the case of a woman in Guy's Hospital, labour- ing under complete paraplegia, and passing, with the acid of a catheter, foetid, alcaline, and phosphatic urine, I washed out the bladder with warm water, and allowing the secretion of urine to go on for half an hour, the catheter was again introduced, and an ounce of pale acid urine escaped ; proving that the alcaline con. dition of the urine previously removed was owing to changes it underwent subsequent to secretion. 146. A somewhat different view of the cause of calculous urine 142 PATHOLOGY OF EARTHY SALTS. has been published by Mr. Blizard Curling ;71 this gentleman be- lieves that the immediate result of spinal lesion, is the loss of the natural sensibility of the bladder ; the result is the secretion of unhealthy alcalescent mucus, and this acting chemically upon the urine, renders it alcaline, and leads to the deposition of the earthy phosphates. Subsequently the urine may be actually secreted in an alcaline state by the extension of irritation from the bladder to the kidneys, or by the latter sympathising with the debilitated yet irritable state of the system. The opinion that alcaline urine may eventually be secreted by an extension of irritation to the kidney, receives consider- able support from an interesting case which occurred at Guy's Hospital in the early part of this year. A man was admitted under the care of my colleague, Mr. Bransby Cooper, for injury to the spine, resulting from accident. He was paraplegic ; the urine soon became alcaline, and he died. On a post-mortem ex- amination, the contents of the bladder restored the colour of red- dened litmus paper, and on making a section of the kidneys, the papilla? were found encrusted with prismatic crystals of the triple phosphate. 147. Mr. Curling considers that the mere continuance of urine in the bladder is not sufficient to allow it to become alcaline, but that a diseased condition of the mucous lining is a necessary con- dition in effecting this change. Hence in enlarged prostrate, when the bladder is often distended for a long time, the urine is gene- rally acid, even when only emptied by the catheter twice in the day. But when, on the other hand, a catheter is worn in the bladder, so that no accumulation can take place, the urine is often alcaline ; a circumstance admitting only of explanation by the secre- tion of unhealthy mucus, excited by the irritation of the instrument. 148. The urine may be alcaline, and loaded with phosphates, simply from diseases limited to the bladder. In all cases in which disease of the mucous membrane, especially of a chronic character, exists, more particularly where retention of urine occurs ; the urine is almost always phosphatic, and abounds in viscid mucus. This is seen in cases of old stricture of the urethra, chronic cystitis, and many of the affections included under the generic term of irri- table bladder. I have witnessed more than one instance in which the state of the urine alluded to has resulted, in women, from ALCALINE URINE. 143 secretion of unhealthy mucus, by the propagation of irritation from an irritable uterus, or even inflamed vagina. In all these cases the patient's suffering is much increased by the formation of soft pseudo-calculous masses of mucous phosphates, blocking up the urethra. These cases ought to be regarded as quite distinct from those already alluded to, in which the presence of the phosphatic deposit is indicative of, and produced by general irritability and depression, or spinal lesion. 149. Cases occasionally present themselves in which the urine is very copious, pale, and freely deposits the phosphates, indepen- dent of any local disease in the genito-urinary organs, and in which the general symptoms are those of marasmus; the appear- ance of the patient, and his most prominent ailments, much re- sembling a case of diabetes. It is in these that the formation of a calculus is more especially to be dreaded ; and even if these evils be arrested, the patient too generally goes on from bad to worse, and dies worn out with irritation. An instance of this kind has been alluded to (136), and I shall have occasion to refer to another when speaking of the treatment (159) of the disease. Even in these, a careful investigation of the case will generally lead to a detection of some antecedent causes of spinal mischief; and in many, abuse of the sexual organs have constituted the most prominent exciting cause. I have seen some in which no other antecedent morbid influence could be discovered, than the cachexia produced by the abuse of mercury. 150. It has been frequently stated, that in the course of con- tinued fever, the urine at a certain period becomes alcaline, and deposits phosphates. It is well known that early in fever the urine is high-coloured, acid, and loaded with uric acid or urates (71) ; and it is distinctly stated by Dr. Simon,72 from observations made under the sanction of Professor Schonlein of Berlin, that the acidity vanishes, and is replaced by an alcaline state, at a period of the disease varying with the powers of the patient, but generally about the end of the second week. Simon states that in cases of severe typhoid fever, in which the urine is acid and deep coloured, it, just at the period when comatose symptoms set in, becomes alca- line and pale. On examination he found carbonate of ammonia in solution, resulting of course from the re-arrangement of the elements of urea. That this alteration of acid to alcaline urine may and does occasionally occur in the course of a case of fever, 144 PATHOLOGY OF EARTHY SALTS. is certain, but that it is the general rule, as assumed by Schon- lein a.nd Simon, is certainly opposed to all the experience I have had in the disease in question. M. Edmund Becquerel73 has made a similar remark, and adds that out of thirty-eight cases of typhus, where urine was constantly examined; he found it alca- line in one case only, and in this pus was present. Dr. Graves,74 of Dublin, some time ago drew attention to the fact that the urine in fever was occasionally ammoniacal, and deposited the earthy phosphates ; in the two cases related by him, extreme exhaustion existed, in one anasarca, and in the other petechias, accompanied the fever. In the epidemic of maculated fever, which occurred in London four years ago, I often found the urine alcaline in the second week; but this appeared to be almost peculiar to that epidemic. On submitting the urine to analysis, a marked defi- ciency, and after a time, a total absence, of urea was detected. Hence it appeared, that owing to the state of enervation which existed, the kidneys in separating C2, N2, H6, 04, from the blood, instead of resolving these elements into C2, N2, H4, 02,= urea and 2 H 0=water, allowed them to become obedient to ordinary chemical laws, and they then arranged themselves into 2C02+ 2 N H3= two atoms of carbonate of ammonia. 151. The deposits of phosphates, where no organic disease exists, are often absent, not only for hours (141), but for days together; and this fact will often enable us to predict with tolera- ble confidence the happy or unsuccessful termination of the case. From all the experience which I have had of phosphatic deposits, I feel confidence in offering the following as a safe indication from clinical observation, and one of great service in practice. That,^ where the presence of a deposit of phosphates is independent of the irritation of a calculus, or of organic disease, it is most abundant in the urine passed in the evening (urine of digestion), and absent or replaced by uric acid, or urates, in the morning (urine of the blood), the urine being always of tolerably natural colour, never below, and often above the mean density. Where the presence of phosphatic salts depends on the irritation of a calculus, or of organic mischief in the urinary passages, the urine is pale and whey-like, of a density below the average, often considerably so, and the earthy deposit is nearly equally abundant in the night and morning urine. 152. Some curious cases are occasionally met with, in which enormous quantities of phosphate of lime have come away for a CURATIVE INDICATIONS. 145 long time in the urine without apparently doing much mischief. A very remarkable instance of this kind occurred some years ago among the out-patients of Guy's Hospital, in the person of John Jenkins, an old man under the care of my colleague, Dr. Hughes. This patient was an habitual dyspeptic, and had laboured under pyrosis from boyhood. He had during many years been in the habit of passing almost milky urine, which by repose deposited such an extraordinary quantity of phosphate of lime, that he brought to me at one time more than an ounce of the salt. He had been for this disease under the treatment of half the hospital physicians and surgeons in London. He stated, that fifty-five years previously he was a patient at Guy's Hospital under Dr. Saunders, and subsequently under Dr. Fordyce at St. Thomas's; but his urine had never at any time exhibited any signs of im- provement. Indeed, all the remedies tried appeared quite use- less; at the same time this man's general health was so good, that there was scarcely an excuse for submitting him to any course of treatment, beyond the apprehension of the possible formation of a calculus. In cases of this kind, it is very possible that the phos- phate of lime is secreted from the mucous membrane of the bladder, and not derived from the urine. All mucous secretions contain phosphoric acid, combined with earthy bases; and hence, if an excess of the latter is secreted with the vesical mucus, it may be washed away by the urine, and form a deposit. This is by no means very unfrequent in the irritable bladder, depending on the irritation of prostatic diseases, &c: we have a perfect analogy to this in the calculous concretions found in the ducts of glands furnishing mucous secretions. These are all prone to secrete phosphates in too great an excess to be washed away with the secretion; they are, therefore, retained, and form a calculus. These, from whatever part of the body they are obtained, present nearly the same composition. Composition of phosphatic concretions. Species. Prostatic. Bronchial. Seminal. Salivary. Pancreatic. Phos. of lime. Carb. of lime. Animal matter. 84.5 .5 15.0 80. 2.3 7.7 90. 2. 10. 75. 2. 23. 80. 3. 7. Authority. Lassaigne. Brandes. Peschier. G. B. G. B. 13 146 PATHOLOGY OF EARTHV SALTS. 153. Therapeutical indications.—In considering the indications for treatment in cases where the phosphates appear in the urine in excess, it will be necessary to regard at least four different pathological conditions, the existence of one or other of which must be deduced from the symptoms presented by the patient. a. Cases in which dyspepsia, with some febrile and nervous irritation, exists independently of any evidence of ante- cedent injury to the spine (140). b. Cases characterised by high nervous irritability, with a varying amount of marasmus, following a blow or other violence inflicted on the spine, but without paralysis (143). c. Cases in which the phosphatic urine co-exists with para- plegia, the results of spinal lesion (145). d. Cases of diseased mucous membrane of the bladder (148.) Of these it will be only necessary to direct attention to the first, second, and fourth series of cases, as the third includes cases in which the deposition of phosphates constitutes a mere symptom of a grave and serious lesion, which, whether the result of acci- dental violence or insidious disease, must be treated according to the particular disease existing. 154. The first class of cases, or those in which a particular form of irritative dyspepsia is the characteristic feature, is by no means uncommon. Every now and then cases occur in practice, in which the most prominent symptoms are a capricious appetite, sense of weight and fulness at the prsecordia, especially after meals, irregular bowels, severe lancinating pains darting between the scapulas from the pit of the stomach; much flatulence, tongue white, often with injected marginal papillae; pulse quick and irritable, dull heavy aching pain across the loins, excessive de- pression of spirits, despondency so intense as often to excite the most painful ideas. In a merchant surrounded by affluence, visions of impending beggary often embitter the moments that are free from the excitement of business; in the mechanic, unfounded ideas of immediate loss of employ, and the interior of a work- house, are generally present. On examining the urine, its specific gravity is often above the average; the deposition of crystalline or amorphous phosphates, and often excess of urea, will refer the case to its proper class, as one of irritative dyspepsia, in which CURATIVE INDICATIONS. 147 the excess of phosphates indicates the "drain" on the nervous energies. 155. The treatment of these cases must be rather directed by general principles, than limited to the solution of the phosphatic deposits. It is true that by the persistent administration of acids the deposit may disappear for a time, but the ailment goes on; all that is effected by such treatment is to mask a symptom, and an important one, of the progress of the malady. After having attended to the morale of the case, as far as possible rousing the patient from any morbid influence excited in his mind, whether real or imaginary; the next thing is to attend to the general health. The bowels should be freed from any unhealthy accumu- lation by a mild mercurial laxative, as a few grains of pil. hydrarg., followed by a dose of rhubarb or castor-oil; but all active purging should be avoided, as it generally aggravates the distress of the patient, and decidedly interferes with the success of the treatment. A combination of a tonic-laxative with a sedative may then be administered, as tinct. hyoscyami et sp. ammon. aromatici aa nxxx —jss. ex mist, gentianse co. gj. ter in die. If the bowels be irritable, the inf. cascarillse, or inf. serpentarise, maybe substituted for the mist, gentianse comp. Should gastrodynia exist, great relief will be obtained by the administration of half a grain of oxide of silver, made into a pill with confection of opium, before a meal. The diet should be very carefully regulated, all bland nutritious articles of food being preferred; vegetables should be avoided, and in general a small quantity of good sherry may be allowed. By a plan of treatment of this kind, the patients gene- rally do well, and the phosphates and excess of urea vanish from the urine. As the patient approaches convalescence, much good is often effected by the use of sulphate of zinc in gradually in- creasing doses, beginning with a grain thrice a day, made into a pill with a little ext. hyoscyami, or ext. gentianse, and increasing the quantity every three or four days, until five grains or more are taken at a dose. Under the use of the zinc, I have seen many cases do well, whose symptoms approached in severity and cha- racter those of mild delirium tremens. I need hardly say that change of scene and occupation are important adjuvants to our medical treatment. 156. Sometimes, although rarely, the phosphates will disappear 148 PATHOLOGY OF EARTHY SALTS. from the urine, and be replaced by the oxalate of lime; a change that should excite serious apprehensions for the patient's ultimate welfare. This generally occurs in persons who by imprudence have drawn some time previously a heavy bill upon their health. The following is one of the few cases of this kind I have wit- nessed. Case. Irritable bladder following repeated gonorrhoea; dyspepsia; severe lumbar pain; triple phosphates followed by crystals of oxalate of lime. I was requested by my friend, Mr. Complin, of Charter-House Square, to see a patient of his, where, from his symptoms, he suspected renal disease existed. He was a fine florid person, setat. 25, who, from his own confession, had been most irregular in his habits; he owns to having laboured under twenty-five dif- ferent attacks of gonorrhoea. Eight years ago he had cystitis, following the injection of some fluid into the urethra for the cure of gonorrhoea ; he at the same time drinking a bottle of port daily. During this attack he passed a large quantity of bloody mucus, which continued pretty constantly for five months; nor did it entirely cease for fifteen months. He was then treated by Dr. Budd, of Plymouth. He spent the year 1837, and part of the succeeding one in yatching to the West Indies, and Southern Africa. He then re- turned to England, and got married. Since then his habits have been more regular, occasionally only indulging in wine. His appetite, however, continued to be, as it ever was, most vora- cious, often eating, as he, at least, declares, three pounds of meat and bread for dinner. In January, 1842, he fancied he had some obstruction in the urethra, and passed a bougie: this produced much irritation, and was followed by intense pain over the left kidney, darting to the sacro-sciatic notch; this has continued up to the time I saw him (April the 23d), occasionally only being absent for a day or two, always being reproduced after partaking of a hearty or indiges- tible meal. Walking does not appear to increase the pain ; on the contrary, although its severity often cripples him, yet if he can succeed in walking for a few yards, he generally becomes relieved. CURATIVE INDICATIONS. 149 When the severe pain is absent, there is always a considerable amount of tenderness on pressure over the left kidney. To add to his annoyances, he suffers considerably from irritability of the sexual organs, attributed to his rarely being able to indulge in intercourse, in consequence of his wife suffering from profuse menorrhagia. April 23d.—The urine passed last evening was faintly alca- line, of specific gravity 1.028, of natural colour, and appeared to contain a dense mucous deposit, which, under the microscope, was found to consist of large prisms of triple phosphate, mixed with stellse, formed by a number of finer prisms cohering toge- ther ; the whole presenting a magnificent appearance, when viewed as an opaque object. By repose an iridescent film of crystals of the triple salt formed on the surface of the urine: on the applica- tion of heat, an amorphous deposit of the phosphate of lime. On the addition of acetic acid to the turbid urine under the micro- scope, the whole deposit dissolved, the prisms vanishing much more rapidly than the stellse. 24th.—The urine passed this morning was neutral, of a deep amber colour; its specific gravity was 1.031; it contained a mu- cous cloud, entangling a few prisms; on the application of heat, a thick deposit of phosphate fell. A large excess of urea was present: the addition of nitric acid producing a rapid growth of crystals of the nitrate of urea in a few seconds. 25th.__His symptoms continued the same. The urine was again examined; that passed last night was acid, of deep amber colour, and of a density of 1.030 ; it contained merely a delicate mucous cloud in suspension, there being no distinct deposit; on the application of heat, a deposit of phosphates, soluble in acetic acid, occurred. A large excess of urea was present. On placing a drop of the urine under the microscope, it was found abun- dantly loaded with very large octohedral crystals of oxalate of lime, unmixed with phosphates or urates. 26th;__The urine passed this morning much resembled the night specimens,.save that it was quite free from oxalate; its spe- cific gravity was 1.030, and was loaded with urea; it did not become turbid by heat. May 2d.—I again saw my patient: up to this time he had taken no medicine, except a brisk purgative, as I was anxious to 13* 150 PATHOLOGY OF EARTHY SALTS. watch the urine. He now stated that since its action the lumbar pain had become much diminished. He boasted to me that two evenings previous he had drank a bottle and a half of port at dinner, and felt better for it. He begged to be allowed to avoid physic, unless he became worse ; and it was with some difficulty that I procured a specimen of urine. 3d.—The urine passed last evening was acid, of deep amber, specific gravity 1.030, contained no visible deposit, but the micro- scope detected an abundant deposit of octohedral crystals of oxa- late of lime diffused through it; it deposited phosphates by heat, and contained a large excess of urea. 4th.—The urine passed this morning resembled the last de- scribed specimen: both were remarkable for the oily appearance they presented when poured from one vessel to another—a cir- cumstance probably depending upon the great excess of urea they contained. 157.—The second class of cases, characterised by a much higher amount of nervous irritability, and of a rapidly progressing emaciation, are much less frequent than those just alluded to, and are far less amenable to treatment. In these, the phosphatic deposit is often copious and sometimes consists nearly exclusively of phosphate of lime ; the lumbar pain and weight are considerable, the skin often dry and scarcely per- spirable ; in some cases, indeed, I have seen it look as if var- nished ; the tongue sometimes white, is often red ; the thirst often great; indeed, the general appearance of the case closely resem- bles one of diabetes. The urine is generally more copious than natural, frequently pale, and of a specific gravity below the ave- rage. On investigating the patient's history, some evidence of a previous strain or wrench of the back, or a blow over the spine, is always elicited. These patients are seldom hypochondriacal ; but intense irritability of temper, and a painfully anxious expres- sion of countenance and manner, are almost invariably present. In the treatment of these cases, the great end and aim must be to subdue the morbidly irritable state of the brain and nervous system ; and subsequently, by a generous diet and persistent use of those tonics which appear especially to exert their influence on the organic nerves, as silver, bismuth, zinc, &c, to endeavour CURATIVE INDICATIONS. 151 to restore the assimilative functions to their due vigour. Besides the general indications to be fulfilled by regulated diet, amuse- ments, exercise, &c, the use of narcotics, especially of opium, or the preparations of morphia, should be regarded as of the highest value ; and we are indebted to Dr. Prout for first direct- ing the attention of the profession to their use. 158. The case of this affection recorded by Dr. Prout75 was one of peculiar severity, and I have never had but one case be- fore me in practice which at all equalled it. I can, however, add my testimony to the efficacy of narcotics in the cases I have seen. Morphia appears to me to be somewhat preferable to crude opium, and under the persistent use for seven weeks of one third or one half a grain of the acetate, three or four times in the twenty-four hours, the deposit has vanished from the urine, and the patient done well. In these, as in the preceding class of cases, the shower-bath, and cold douche over the loins, followed by fric- tion with horse-hair gloves, have been of essential service. To succeed in these cases, the treatment must be persistent, for they are essentially chronic in their character ; and if remedies be in- termitted too soon, may end in fatal marasmus, and in some the formation of a calculus. 159. Cases occasionally occur in which the symptoms are of a much milder character, but which insidiously go on to the for- mation of a calculus. It is in these in particular that the use of acids is called for, to hold the phosphatic salts in solution, and prevent their being moulded into a concretion in the pelvis of a kidney. Unfortunately there is a great uncertainty attending their use; sometimes the mineral acids appear to reach the urine and destroy its alcaline character ; often, however, even their continued employment appears to be utterly ineffectual in ren- dering the urine acid. So far as I have watched cases of this kind, the nitric acid has appeared to produce the smallest amount of gastric derangement, and to render the urine acid, or at least diminish its alcaline reaction. In one case lately, in which the nitric acid could not be borne, the phosphoric appeared to suc- ceed. Mr. Ure76 has recommended the employment of benzoic acid, under the idea of its reaching the urine as hippuric acid (88); and he has recorded the history of a case thus treated. I confess that in my hands this drug has not appeared to succeed, 152 PATHOLOGY OF EARTHY SALTS. and when it is recollected that hippuric acid requires about four hundred parts of water for solution, and that it reaches the urine combined with bases, and not in a free state, we can, I think, hardly place much confidence in it as a solvent for the earthy phosphates. 160. The following case will illustrate the general progress of an excess of phosphates, ending in the formation of a calculus. Case. Phosphatic urine and formation of calculi, following in- jury to the kidney ; gradually increasing diuresis ; persistence of the deposit of phosphates. George W----, set. 39, came under my care, Feb. 24, 1843; he had been engaged at the distillery of Messrs. Booth during the preceding five years, during which period he had partaken pretty freely of gin. Four years ago he fell down a trap-door, and frac- tured two ribs on the left side. Since then he has had almost constant pains in the region of the right kidney, with occasional, although slight hsematuria, to which, as he states, he has been more or less subject from childhood. About six months after his accident he suffered from intense pain in the course of the right ureter, followed by retention of urine, which was relieved by the passage of an oval calculus. He remained tolerably wTell until a year ago, when after another similar attack, a second calculus escaped. From this time he remained free from complaint, ex- cept the occasional discharge of white sand in his urine, until Sunday, Feb. 19. On the evening of that day he was attacked with what he regarded as colic, attended with excessive vomit- ing ; this continued until Feb. 21st, wrhen he was relieved by the bowels acting. For six months before the man came under my care he had been subject to profuse nocturnal perspiration, and his skin acted copiously on slight exertion during the day. The desire to pass urine, which has been very frequent since the passage of the first calculus, has of late much increased, so that he is called upon to empty the bladder a dozen times a day. He is much emaciated, his countenance pale and haggard, his manner anxious; pulse 100 soft; tongue clean ; complains of heavy aching pains across the loins. The calculi were brought to me, and on analysis I CURATIVE INDICATIONS. 153 found them to consist of the triple-phosphate, with a small quan- tity of phosphate of lime. Urine 35 ounces in twenty-four hours. Feb. 25. Urine passed at night.—Spec. grav. 1,020, neutral to litmus-paper, deep brandy coloured, with a copious white crys- talline sediment of the triple phosphate mixed with mucus. A deposit of phosphate of lime occurred on the application of heat. Morning urine.—Same as the night specimen, but the sediment more copious. Feb. 26. Urine of twenty-four hours only 22£ ounces, faintly alcaline and brandy-coloured. Spec. grav. 1.022, no deposition by heat. Sediment copious, and as before consisted of triple salt. The small bulk, and high colour of the urine of the last two days is attributable to rather copious purging from an aloetic aperient he had been taking. A nutritious diet was ordered, and a flannel bandage to the loins. Faintly alcaline to litmus, and loaded with phosphatic deposits. R Acidi Nitrici diluti,n\,xx. ter die ex dec. sarsae. co. cyatho Feb. 28. Urine 35 oz. Mar. 1. — 42 oz. 2. _ 40 oz. 3. — 57 oz. sp. gr. 1.015 Mar. 3. The dose of acid has been gradually increased to half a dram. The urine, in increasing in quantity, has become paler and whey-like; the morning and evening specimens exactly cor- respond, and both contain a copious sediment, which to the naked eye resembled pus. It, however, consisted of large prisms of phosphate mixed with very little mucus. The night specimen only deposited phosphate of lime on applying heat. All the urine contained a small quantity of albumen. The patient says he feels better, and is nearly free from a se- vere lumbar pain, which had been distressing a week before. Rep. omnia. Mar. 5. Perspiration at night less intense. Mar. 4. Urine, 47 ounces ) Sp. gr. 1.019 neutral, deposit co- ----5. — 45 ounces S pious. ----6. — 60 ounces ) Sp. gr. 1.016 neutral, deposit ----7. — 70 ounces \ still copious. 154 PATHOLOGY OF EARTHY SALTS. 10. Sufficiently relieved to enter business; he thinks the urine continues increasing, but he has not measured it. Sp. gr. 1.015 neutral, April 7. Improving slowly in health, urine still profuse and pale, still copiously depositing phosphates. Complains of return of lumbar pain. Applic. emp. opii regioni renum. Acidi benzoici, gr. vj. bis die. 14. Urine certainly improved ; a mere mucous cloud in the morning specimen, sp. gr. 1.014; night specimen, 1.014: both slightly acid for the first time. He passes 80 ounces in twenty- four hours. P. 21. Much the same in health ; urine the same in quantity and density, but a rather copious deposition of phosphates has oc- curred. He looks as emaciated as ever, but declares he feels fit for all his duties. He wishes to leave off his medical treatment. Oct. 29. I again saw him; his general health is improved, and he is stouter; has had but one attack of pain in the kidney since I saw him. He stiil passes a very large quantity of urine containing a small quantity of phosphates in diffusion, quite neu- tral to test-paper. Sp. gr. 1.015. His only complaint now is a want of power on contracting the bladder, being often obliged to use powerful efforts to expel the urine. There is no stricture, but he has found great relief to this symptom by emptying the blad- der with an elastic catheter every night. He effects this himself, and is then enabled to get a good night's rest. Nov. 5. Much the same ; urine 50 ounces in twenty-four hours. Aug. 2, 1844. Tolerably comfortable in health; urine still pale, copious, and neutral, without sediment, but soon by heat lets fall a deposit of phosphate of lime. 161. The third class of cases, or those in which the phosphates are probably entirely secreted with unhealthy mucus by a dis- eased lining membrane of the bladder, are familiar to every practitioner. Chronic cystitis or cystorrhoea, and retention of urine from stricture of the urethra or enlarged prostate, may, and often do, lead to this state of things. Here, of course, the primary affection, and not its effect, the deposit of phosphates, must be the great object of treatment. The urine is often very foetid and CURATIVE INDICATIONS. 155 pale, sometimes green, and almost viscid from the abundance of mucus. On placing some of the latter between plates of glass under the microscope abundant crystals of the triple phosphate are seen entangled in it. One point of great practical conse- quence must be borne in mind in forming a prognosis from the state of the urine, viz., not to regard it as ammoniacal, because the odour is offensive; and not to consider the deposit as puru- lent, because it looks so. A piece of litmus paper will often show the urine to be really acid, and microscopic inspection often proves that the puriform appearance of the urine is owing to abundance of phosphates with mucus. For want of these precau- tions I have seen one or two cases regarded as almost hopeless, which afterwards yielded to judicious treatment. It is quite cer- tain that the mucous membrane of the bladder may, under the influence of chronic inflammation, secrete so much of the earthy phosphates and unhealthy mucus as to render the urine puriform and offensive without having necessarily undergone any struc- tural change. 162. A few cases have occurred to me in practice, in which the kind of urine just referred to was secreted for a long time, and yet yielded readily to treatment. In these, the greatest good has arisen from freeing the bladder from the phosphates which appear almost to incrust it, by acid injections. In this way cases have occasionally yielded which have quite defied all other treat- ment. The following case is a good illustration of this, and I record it in the hope of drawing particular attention to this form of phosphatic cystitis, if a name be required for the disease. Case. Phosphatic cystitis co-existing with pregnancy and vagini- tis'?—Discharge of phosphatic calculi—Cure by injection. Mrs. K----, a fair and delicate looking lady, 34 years of age, residing in Essex, was married in 1832, and had nine children in the succeeding ten years, being pregnant of a tenth when she came under my notice in May, 1842. She appears to have en- joyed good health up to Dec. 1841, when without any assignable cause she had severe scalding in micturition, with considerable irritability of bladder. These symptoms rapidly increased in severity, and soon afterwards the urine became loaded with 156 PATHOLOGY OF EARTHY SALTS. mucus, occasionally streaked with blood. She continued getting worse until March, 1842, when her sufferings became intense ; she had frequent desire to pass water every few minutes, with most distressing straining, especially after each attempt at empty- ing the bladder; this almost entirely deprived her of sleep. The urine was thick, foetid, and let fall a copious deposit, which was considered as purulent; although acid when first passed, it soon became ammoniacal. About this time, as a calculus was sus- pected, a sound wras passed ; this gave rise to the most excru- ciating pain, but no stone was detected. She suffered severely from hsemorrhoids, and sexual intercourse was attended with positive torture, so that from her own account her life became a miserable burden of woes. From the report of the very expe- rienced surgeon under whose care this lady was, (Mr. May, of Maiden,) it appears that the bladder was decidedly thickened. In May, 1842, I was consulted by letter, the patient being then three months pregnant, and two specimens of urine, which were described as being purulent and bloody, were sent up. On examination I found the specific gravity of the urine to be only 1.009 ; it was opaque and rather green; odour extremely foetid, although faintly acid to litmus paper. A thick creamy de- posit, equal in volume to one-fourth of the whole, occupied the bottom of the bottle. The deposit, which bore the closest re- semblance to pus I ever saw, was examined by placing a portion between two slips of glass under the microscope. It consisted of mucous particles, with a few blood-discs and myriads of large prismatic crystals of the triple phosphate, mixed with amorphous phosphate of lime. On pouring the lower layers of the urine containing the deposit from one vessel to another, it formed a nearly continuous rope and entangled some small coagula of blood. But mere traces of albumen were found in the urine. I suggested a nutritious diet, and Pil. Saponis comp. gr. v. pro suppositorio omni nocte. Acidi Hydrochlorici diluti n\x. gradatim augens dosin ad n\,xxx. ter die ex Dec. Sarsas. co. In a fortnight (May 20) I received a report from Mr. May, with another specimen of the urine, and some irregular calculous masses the size of peas, consisting of crystals of triple phosphate CARBONATE OF LIME. 157 with mucus. " The poor lady tells me that manual aid was re- quired to remove them from the orifice of the meatus, some haemorrhage followed, and continued for a few days. The de- posit bears a less proportion to the urine than it did, and the intervals between the attempts made to empty the bladder are longer. The recumbent position increases her uneasiness, and renders micturition more frequent (about twice in an hour). An aggravated condition of habitual haemorrhoids has rendered it ne- cessary to substitute an anodyne draught for the suppositories. She has continued the use of the acid, and she has certainly not lost ground: on the contrary, she appears stronger. Within the last few days the legs have become oedematous ; this has been the case in previous pregnancies, but not at so early a period." I then suggested the daily careful injection into the bladder of acidi hydrochlorici ^x. vini opii "Ixx. in barley-water, in the hope of dissolving and bringing away some of the phosphatic masses which I suspected to be in the bladder, and thus remove one source of irritation. A poultice of conium leaves was di- rected to be placed over the pubes, and a recumbent position enjoined. In a few weeks, I received a letter from my friend, Dr. Baker, of Maiden, who had seen the patient in consultation with Mr. May; he states, " I am happy to say that Mrs. K---- has de- rived infinite benefit from the use of the injection into the blad- der. She could not, previously to her injection, retain her urine for twenty minutes, and then the pain and straining was most dis- tressing; she can now retain it four hours without pain, and there is no appearance of deposit." I had an opportunity of seeing this patient with Dr. Baker on June 19th, on being called to Maiden to see another case: she was well, and progressing comfortably with her pregnancy. It is rather a curious circumstance that I was consulted in the spring of the present year, by the son of this lady, for a calcu- lous affection, the urine being loaded with triple phosphate. Deposits of Carbonate of Lime. 163. It has been already stated that carbonate of lime often oc- curs in small proportions in deposits of earthy phosphates (144), when the urine is decidedly alcaline. Its origin may then be 14 158 PATHOLOGY OF EARTHY SALTS. explained by a decomposition of phosphate of lime by the carbo- nate of ammonia which replaces the urea. In this state, the car- bonate of lime simply appears as an amorphous powder, and its presence may easily be recognised by the addition of any dilute acid, which dissolves it with effervescence. Care must, however, be taken to wash the deposit with water before adding the acid, for unless all traces of adherent carbonate of ammonia are re- moved, an effervescence will be excited by the acid, whether the calcareous salt be present or not. 163.* Deposits of carbonate of lime are, as is well known, of constant occurrence in the urine of herbivora. These may be readily collected for examination from the urine of the horse, in which they occur spontaneously. When examin- ed by the microscope, after being washed with water, the particles of the carbonate are observed to be small transparent spheres, like glo- bules of glass, and strongly refracting light. Allowed to dry, and examin- ed after immersion in Canada balsam, their structure is beautifully distinct. Each sphere being made up of myriads of minute needles radiat- ing from a common centre (Fig. 26). With polarised light, these interesting objects present a series of concentric coloured rings traversed by a black cross. Some few cases are recorded, in which little concretions and gravel of carbonate of lime have been passed in the urine, as if an excess of lime had been eliminated without its usual adjunct, phosphoric acid. I have, however, never met with any exam- ples of this kind, although I have detected carbonate of lime in phosphatic calculi, both mixed with the mass of the concretion, or more rarely forming a distinct stratum. Carbonate of magnesia is said to occur occasionally in phos- phatic deposits, its presence being in all probability due to the decomposition of phosphate of magnesia by carbonate of ammo- nia (metamorphosed urea). Deposits of Silicic Acid. 164. Silicic acid exists in infinitessimally small quantities in SILICIC ACID. 159 some of the animal fluids, and therefore may possibly be met with as a urinary deposit. It was found in crystals forming part of a calculous concretion by Dr. Yellowley,77 and some other instances of its occurrence hate been recorded. Lassaigne78 found a calculus consisting of pure silicic acid in the urethra of a lamb, and WTurzer79 has given the analysis of one removed from an ox, in which silicic acid existed to the amount of thirty-eight per cent. It is, however, very necessary to be on one's guard respecting silicious concretions; for as there is a popular notion that calcu- lous matter is bondjide gravel, whenever an imposition is intended, a silicious pebble is usually chosen to deceive the medical attendant. I have met with repeated instances of this, in which common rolled pebbles of quartz have been placed in my hands, with the asser- tion that they were actually passed from the bladder. This has usually occurred in hysterical girls, who laboured under that most unintelligibly morbid desire of deceiving the doctor, by repre- senting themselves as afflicted with some disease of the genito- urinary organs. I have heard of instances in which such pebbles have actually been thrust by a girl into her own urethra, and thus have reached the bladder. In a case mentioned to me by Dr. Christison a piece of chlorite slate was found forming part of the supposed calculus, thus attesting its true origin. A case occurred many years ago in St. Thomas's Hospital, in which the late Mr. Cline operated, and removed a quantity of common coals from the bladder of a patient. As silicic acid has been found in calculi by such excellent ob- servers as the late Dr. Yellowley and Dr. Venables, and as the ox and lamb mentioned by Wurser and Lassaigne could hardly have been supposed to have put the silicious matter into their own bladders, the occasional possible occurrence of silicic acid in urinary deposits and concretions must be conceded. Still, that it is extremely rare all experience has proved, as indeed might be anticipated from the chemical relations of this very refractory substance. 160 PATHOLOGY OF ABNORMAL PIGMENTS. CHAPTER IX. DEPOSITS OF ABNORMAL BLUE OR BLACK COLOURING MATTERS. Blue and black deposits, 165—Braconnot's Cyanourine, 166—Diagnosis of, 167— Indigo, 168—Diagnosis of, 169—Percyanide of iron, 170—Diagnosis of, 171— Black deposits described by Braconnot, Marcet, and Dulk, 172. 165. In addition to the various tints communicated to urine by bile and blood (20, 178), certain peculiar colouring matters, strictly the products of diseased action, are occasionally, although very rarely, met with. These generally communicate to the urine a blue or black colour. Three different blue pigments, at least, have been met with, viz., cyanourine, indigo, and percyanide of iron, and probably two black ones, melanourine and melanic acid. Blue, green, and black urine has been described by the ancients, but it is probable that the varieties of tint so often mentioned by all physicians since Hippocrates, were produced by blood or bile modified by the state of the urine. 166. Cyanourine was first discovered by Braconnot,80 and has since been observed by Spangenberg, Gamier, Delens, and others. Urine containing it possesses a deep blue colour, and by repose lets it fall as a blue deposit capable of being readily separated by the filter. It may be freed from adhering mucus, uric acid, phos- phates, &c, by washing with water, and digesting it in hot diluted sulphuric acid. The cyanourine may be precipitated from the acid solution by the careful addition of magnesia. It may also be obtained by boiling the blue deposit from the urine in alcohol, and evaporating the solution to dryness. 167. Diagnostic characters.—Cyanourine is a tasteless and in- odorous dark blue powder, scarcely soluble in water, merely at a boiling heat communicating to it a brown colour, which on the addition of an acid becomes red. Moderately soluble in boiling alcohol, being partly deposited on cooling. Diluted acids dis- solve it, the solution being brown or red, according to the pro- portion of acid present. The solution in sulphuric acid leaves by evaporation a carmine-red extract, which dissolves in water, INDIGO. 161 forming a brown fluid. Ammonia, lime-water, and magnesia, precipitate it unchanged from its acid solution. Hot solutions of alcaline carbonates dissolve cyanourine, forming a red, whilst the pure alcalies yield a brown solution. Nitric acid converts this substance, like indigo, into nitro-picric acid. Heated in a glass tube, it forms an oily fluid which burns to a bulky ash. Cyanourine is distinguished from indigo by not subliming when t heated in a tube, and from percyanide of iron by not yielding sesqui-oxide of iron when digested with carbonate of potass. The pathological indications of this substance are quite un- known. 168. Indigo.—This pigment, when taken into the stomach, as is occasionally done in the empirical treatment of epilepsy, finds its way into the urine, forming a blue deposit. It, however, ap- pears probable that indigo has occasionally been generated in the animal economy, and instances of this kind have occurred to Drs. Prout81 and Simon.82 When this substance is present, the urine acquires a dark blue colour, and by repose a deposit of the same hue falls. This, when collected on a filter, presents all the well- known chemical characters of indigo. The composition of this substance (C16, N,H5, 02), approaches sufficiently close to that of some animal products to render its occasional development in the organism a matter of high pro- bability. 169. Diagnostic characters of indigo.—This substance dis- solves in strong sulphuric acid forming a purple solution. Nitric acid converts it into nitro-picric acid. Carefully heated in a tube, it sublimes in purplish-red crystals. By de-oxidising agents it is bleached, and white indigo produced; this, by exposure tq the air, loses an atom of hydrogen by oxidation, and becomes blue. Simon83 gives the following as the best mode of detecting in- digo in a blue deposit. Heat the deposit with a little grape-sugar in a mixture of alcoT hoi and liquor potassse, the blue colour disappears and a yellow solution is obtained, By agitation and exposure to the air the fluid assumes a red, and eventually a green colour, from the rer production of blue indigo. The pathological indications of deposits of indigo are unknown. 14* 162 PATHOLOGY OF ABNORMAL PIGMENTS. Whenever they are met with, care should be taken to investigate the patient's history, so as to discover whether this substance had been previously medicinally administered. 170. Percyanide of iron, or Prussian blue.—This substance was first found by M. Julia-Fontanelle84 in the urine of a boy re- siding at Mont-Louis in the Pyrenees. He was labouring under severe colic, attributed to his having swallowed a quantity of ink. The blue deposit continued for a day or two after the attack, leaving the urine of its natural colour, but containing some solu- ble cyanide, as a blue precipitate was produced on the addition of a salt of iron. Several other instances of Prussian blue de- posits have occurred, and it is remarkable that in most of them iron has been accidentally or intentionally taken. These deposits can be artificially produced by giving to a patient who has been taking some preparations of iron, a few doses of ferrocyanide of potassium. The origin of the cyanogen of the blue deposit can be readily explained from the known composition of urea. We have seen that this substance may be regarded as a carbonate of ammonia (30), but it may also be considered as a cyanate of that base ; thus, CNHO , . ,, ( 1 atom cyanogen = 2-4-1 1 atom cyanic acid = •? , £ 1----oxygen = 1 1----ammonia = *+3 1----water = 1+1 Composition of an atom of urea = 2-+r2-r-4-J-2 Prussian blue consists of seven atoms of iron, united with nine of cyanogen. If, then, any cause determines the resolution of urea into the above proximate element, and iron be present, a precipitate of the percyanide must be the necessary result. 171. Diagnostic characters of Prussian blue. — A blue powder insoluble in water and alcohol. By digestion with liquor potassse its colour is destroyed, sesqui-oxide of iron being set free, and a yellow solution of ferrocyanide of potassium formed. This solu- tion is precipitated blue by sesqui-salts of iron, and hair-brown by sulphate of copper. The pathological indications of these deposits are unknown. MELANOURINE. 163 172. Melanourine and melanic acid. — Under these names have been described some black pigments which have been met with in urine. Their chemical properties are very ill-defined, and their origin and pathology alike obscure. It is more than probable that in some instances, at least, these pigments ought to be regard- ed rather as altered colouring matter of blood than any thing else. a. Braconnot85 describes a black matter which he regarded as a weak salifiable base ; it occurred in the blue urine (166,) and remained in solution after the cyanourine fell. It was obtained after the latter had fallen, by merely boiling the clear urine, when the black matter coagulated and became insoluble. It in all pro- bability was merely modified hsematosine. b. The late Dr. Marcet86 met with a black matter in the urine of a child, unaccompanied by the ordinary constituents of the secretion. To this substance the name of melanic acid was ap- plied by Dr. Prout. The urine in which it occurred was like ink ; it slowly deposited black flocculi after the addition of an acid. The black matter was insoluble in water and alcohol; nitric and sulphuric acids dissolved it, forming a black solution, which by dilution deposited the pigment unchanged. Alcalies and their carbonates dissolved it, and acids precipitated it from its solution. Its alcaline .solution produced brown precipitates on the addition of metallic salts. c. Prof. Dulk, of Konigsberg, has described a curious kind of urine of a blackish grey colour passed by a patient affected with hepatic disease. On filtering it, a yellow fluid, which was merely diluted urine, passed through, and a black matter was collected on the paper. This was slightly soluble in nitric and hydrochlo- ric acids : the solution being precipitated by tincture of galls. Prof. Dulk suggests that this pigment was merely a highly car- bonised hsematosine, arising from the imperfect performance of the hepatic functions. 164 NON-CRYSTALLINE ORGANIC DEPOSITS. CHAPTER X. NON-CRYSTALLINE ORGANIC DEPOSITS. Use of the microscope, 173—Elements of blood in urine, 174—Diagnosis, 175— Albumen, 176—Tests for, 177—Haematosine, 178—Microscopic characters of blood-discs, 179—Pathological indications, 180—Therapeutical indications, 181-2 —Of albumen, 183—Purulent urine, 184—Diagnosis, 185—Microscopic charac- ters, 186—Pathological indications, 187—Mucous urine, 188—Tests for, 189— Microscopic characters, 190—Pathological indications, 191—Therapeutical indi- cations, 192—Large organic globules, 193—Small globules, 194—Epithelial debris, 195—Milky urine, 196—Kiestein, 197-199—Diagnosis, 200, 201—Con- nexion with pregnancy, 202, 203—Fatly and oily urine, 204—Diagnosis, 205— Microscopic characters of, 206—Pathological indications, 207—Spermatic urine, 208—Microscopic characters, 209—Connexion with oxalate of lime, 210—Pa- thological indications, 211—Treatment, 212—Growth of torula in urine, 213— Microscopic characters, 214—Presence of sugar in urine, 215—Tests for, 216 — Development of vibiio laneola, 217. 173. The elements of the urinary deposits already examined, are capable of being easily recognised by their crystalline form, or chemical properties. Those which we have now to investigate are secreted organic substances, often possessing organisation, and sometimes enjoying an independent vitality. In the detection of these in deposits, microscopical examination is in almost every in- stance quite indispensable, and in many, furnishes the only means for discovering their true nature. The best mode of examining these deposits microscopically, is to allow the urine to repose in a glass cylindrical vessel for a short time, decant the upper nine-tenths of the fluid, and then place a drop of the residue on a plate of glass. Gently drop on it a piece of mica, or what is better, very thin glass, and submit it to the microscope. A good achromatic objective of a quarter inch focus is generally sufficient for all these investigations, but it is some. times necessary to use one of one-seventh or one-eighth inch, when the object is very minute; but to a person familiar with these ob- servations a good half-inch glass is sufficient for almost all cases, BLOODY URINE. 165 ELEMENTS OF BLOOD. 174. All, or any, of the elements of the blood, may find their way into the urine, either as the result of mechanical violence to the kidney or any part of the genito-urinary tract, of the irritation of a calculus, of organic disease, or any breach of surface of the mucous membrane of the kidneys or bladder ; or of sufficient pres- sure on the renal veins to prevent the return of blood from the kidneys to the cavse (180). We may find in the urine, serum of blood alone or accompanied by red particles ; sometimes the liquor sanguinis is alone effused, and containing but a small proportion of colouring matter; or more frequently, all the elements of blood may be poured out together. Of the first of these, the urine of morbus Brightii, and of cases of anasarca resulting from scarlatina, are good examples ; in these the urine is characterised by the pre- sence of albumen, and in acute cases presents the dingy hue characteristic of the presence of colouring matter of blood, or of entire blood-corpuscles. Of the second condition, urine in fungus hsematodes of the kidney often furnishes a good example ; this is often observed to be of the colour of infusion of roses whilst warm, and on cooling solidifies into a red transparent mass, like red-cur- rant jelly, retaining the figure of the vessel. Every case of idiopa- thic or sympathetic hsematuria affords examples of the presence of all the elements of blood in the secretion. 175. Diagnosis of urine containing blood. — When blood is effused in any quantity in the urine, it coagulates into blackish masses like pieces of black-currant jelly; and when it partly coagu- lates in the bladder, linear masses of clot of nearly the shape of leeches are passed from the urethra often to the great distress of the patient, by producing temporary suppression of urine. Even after this coagulation, the urine retains a port-wine colour, and the microscope detects an abundance of entire blood-corpuscles; although in a great quantity of them, the investing membrane has given way, and the coloured contents been diffused through the urine. If too small a quantity of blood has been effused to give a decided red colour to the urine, it will be frequently found pos- sessing merely a dirty dingy hue ; less frequently being pinkish, like the washings of flesh. In either case a sufficient number of 166 NON-CRYSTALLINE ORGANIC DEPOSITS. blood-corpuscles will subside by repose to allow of their being readily identified by the microscope (179). The spontaneous coagulation of urine will readily indicate the presence of the liquor sanguinis, as the fibrin it contains is the only spontaneously coagulating substance in the body. This element is very rarely effused of itself, being generally mixed with blood-corpuscles, giving the coagulum a red colour; or with a fatty matter, which causes the coagulum to assume the appearance of blanc-mange (204). The red-corpuscles, or the hsematosine contained in them, and the albumen of serum, do not present characters always sufficiently satisfactory to be able to identify them without the application of re-agents. 176. Albumen may readily be detected in urine containing it, by the production of an opacity by application of heat. This experiment, where any amount of accuracy is required, should always be performed in a clean test-tube, heated over a spirit- lamp. The clumsy mode of heating it in a metallic spoon over a candle, although answering the purpose very tolerably when a glass tube cannot be procured, is infinitely inferior in the delicacy of its indications. If a large quantity of albumen be present, the urine will become quite solid on the application of heat, and will vary from this state to the production of a mere opalescence, ac- cording to the quantity existing in the urine. It is a curious fact, that the greatest amount of coagulation by heat, is often found in urine either free from, or containing but a small quantity of the colouring matter of blood. The dingy-red urine in granular disease of the kidneys, generally deposits less albumen by heat than when it is straw-coloured, and nearly free from hsematosine. Albumen does not require actual ebullition for its coagulation by neat; if any be present in urine, the latter becomes opaque long before a bubble of vapour is evolved. The addition of a drop of nitric acid to albuminous urine im- mediately produces a copious coagulation of the albumen; but if any mere traces of the latter be present, the opacity first produced will disappear by agitation, and will re-appear by the addition of a second drop of the acid. 177. As a general rule, if urine becomes opaque by heat, and on the addition of nitric acid, albumen is present. It is important to bear in mind that certain sources of fallacy exist when one only of these tests is used. ALBUMINOUS URINE. 167 1. Heat will produce a white precipitate in urine contain- ing an excess of earthy phosphates (136). Distinguished from albumen by disappearing on the addition of a drop of any acid. 2. Heat being applied to urine containing deposites of urate of ammonia, will sometimes, if actual ebullition be pro- longed, produce a deposit of an animal matter, insoluble in nitric acid. This is rare, but is distinguished from albumen by being deposited only after protracted ebullition. 3. Nitric acid will often produce white deposits in the urine of patients under the influence of copaiba, cubebs,83 and perhaps some other resinous diuretics. Distinguished from albumen by not being produced by heat. 4. Albumen may be present in urine and not be precipi- tated by heat, provided the secretion be alcaline. If, there- fore, urine suspected to be albuminous, is capable of restoring the blue colour of reddened litmus paper, nitric acid must be used as the test, as albumen, when combined with alcalies, does not coagulate by heat. 5. It may occasionally happen that albumen may be present in the same incipient or hydrated state in which, according to Dr. Prout, it occurs in chyle.84 Heat scarcely affects this variety of albumen, except by protracted ebullition; but nitric acid immediately coagulates it. This form of albumen must be regarded as rather possibly than probably occurring in urine. I have never met with it. 178. Haematosine is the colouring matter of the blood, normally contained within the delicate sac of the corpuscles, particles, discs, or globules of blood; all these terms being synonymous. When hsematosine exists, the urine is always more or less coloured by it, and a few entire corpuscles are always present floating in the fluid. It never occurs unaccompanied by albumen, and being acted upon by tests in a similar manner, the remarks already made on the latter substance (177) apply equally to hsematosine, except- ing that the deposits produced by heat or nitric acid, are always brown instead of white. M. Pariset105 has proposed the following process for the detection of blood in urine, as least liable to fallacy. Boil the urine and filter it. Brown coagula of hsemato- sine and albumen will be left in the filter; pour on these liquor 168 NON-CRYSTALLINE ORGANIC DEPOSITS. potassse, and if hsematosine be present, a greenish solution will pass through, from which hydrochloric acid will precipitate white coagula of protein. The following, in addition to those mentioned as affecting albumen, are the most serious sources of fallacy in the detection of hsematosine. 1. Purpurine, when present in the urine (97), will often communicate to it so intense a colour, as to cause the patient to report his urine to be bloody. Distinguished by not being affected in colour or transparency by a boiling heat. 2. Uric acid, when present in concentrated urine, as in the first week of fever, is often immediately precipitable by nitric acid, brown coagula, much resembling those of hsema- tosine, falling; but really composed of extremely minute crystals of uric acid. Distinguished by not being affected by heat, and by the microscopic character of the deposit (60). 3. Bile, or at least its colouring ingredient, often tints the urine of a deep brown colour, and may lean to an unfounded suspicion of the presence of blood. One or other of the following tests, will at once detect bile or its colouring matter in a fluid. a. Pour oA r<\ white plate a small quantity of the urine or other fluid, so as to form an exceedingly thin layer, and carefully allow a drop or two of nitric acid to fall upon it. An immediate play of colours, in which green and pink pre- dominate, will, if bile be present, appear around the spot where the acid fell. b. Add to a few drops of the suspected fluid on a white plate, a little strong sulphuric acid; when the mixture be- comes hot, add a drop of saturated solution of sugar. The mixture will immediately assume a fine purple colour if bile exist. (Pettinkoffer). 4. Hcematoxylon, administered as a medicine, will often, by the red colour it communicates to the urine, lead to an unfounded suspicion of the existence of hsematosine. Dis- tinguished by the dark precipitate produced by sulphate of iron, and by absence of coagulation by heat. 5. Pareira and Chimaphila will both sometimes communi- cate a dark brown tint to the urine; but the absence of all the characteristics of albumen and hsematosine will distinguish it from the colour produced by blood. BLOOD-CORPUSCLES. 169 179. Microscopic characters of blood-corpuscles.—These furnish the readiest and most infallible mode of detecting blood in the urine. To detect them, if the urine possess a red or brown colour, a drop taken from it after agitation will be sufficient to allow their ready detection. But if the urine be barely coloured, it is better to allow it to repose for some hours, and examine a drop from the bottom of the vessel, to which the corpuscles gene rally sink with readiness. If blood be recently effused into the bladder from some me- chanical injury, the components are observed not only unaltered in figure, but even adhering in rouleaus (Fig. 27), as when a drop of fresh blood unmixed with urine is examined. If the blood is present in smaller quantity, or even if copious, but its effusion has been slower, all traces of the linear arrange- ment of the corpuscles is lost, and they are found pure and floating in the fluid (Fig. 28). On first examining the object, the cor- puscles resemble little rings; an optical illusion arising from their being nearly emptied of their contents by exosmosis. The cor- puscle thus becoming a doubly concave disc, a change which Fig. 27. Fig. 28. receives a ready explanation by the very interesting demonstration of the real structure of the corpuscles by Dr. Rees.90 Sometimes an appearance of a spiral fibre, like that described by Dr. Martin Barry,91 is observed. This appearance of the supposed fibre has always appeared to me to arise, from the delicate investing mem- brane of the nearly empty corpuscle collapsing in circular folds round the nucleus, as a centre. By longer repose in urine, the corpuscles alter still further in figure, becoming irregular at their margins, as is shown in part of Fig. 28. 15 170 NON-CRYSTALLINE ORGANIC DEPOSITS. Whatever are the modifications presented by the blood-cor- puscles in urine, their non-granular surface, uniform size, and yellow colour under the microscope, will always be sufficient to identify them. 180. Pathological indications. — Whenever the elements of blood appear in the urine, there is ample proof of the existence of active or passive hsemorrhage. If, however, the quantity of hsematosine be so minute as barely to tint the urine, it is probable that the albumen present maybe really secreted (i. e., without breach of surface) by the kidney assuming an abnormal function. This is probably the case in the peculiar disease of the kidney so laboriously and successfully elucidated by Dr. Bright, the effusion of albumen being in the first stage of the disease an attempt to relieve a congested condition of the kidney, and must be regarded as an effort of diseased function; whilst the structural changes which afterwards occur, unfit the kidneys for eliminating the normal azotised elements of urine, and the chief relict of its se- creting power is found in the separation of water and albumen from the blood. On the recession of some affections, in which the cutaneous function is temporarily impaired or suspended, especially in scarlatina, a congested kidney occurs as an almost necessary result, and albuminous urine occurs as in the first stage of morbus Brightii. During the existence of pregnancy, and per- haps of some pelvic tumours, the urine is occasionally and tempo- rarily albuminous; a fact first noticed by my friend Dr. Lever,9- and meeting with a ready explanation from the probable existence of pressure on the emulgent veins, a condition which the late researches of Mr. Robinson93 have shown to be capable of pro- ducing congestion of the kidney, and serous urine. Where blood is present in large quantity, or coagula are mixed with the urine, hsemorrhage from some breach of surface is indi- cated; and the immediate cause of this, whether a ruptured vessel from excessive congestion only in any part of the urinary organs, the irritation of a calculus, mechanical violence, or ma- lignant disease, as fungoid degeneration, can alone be made out by a careful examination of the existing symptoms. 181. Therapeutical indications. — These will vary according to the immediate cause producing the sanguineous or albuminous effasion. Of course, where active hsemorrhage exists, the treat- CURATIVE INDICATION'S. 171 ment will be directed by the view taken by the practitioner of its immediate exciting causes. Absolute rest, the local application of cold to the hips and loins, the relief of congestion of the kidneys by local or general blood-letting, free action on the bowels by saline (sedative) purgatives, with dilute acids, will constitute the essential part of the therapeutic agents. The administration of the acetate of lead is frequently of great service, but it should be administered boldly, and in tolerably large doses, for a short time ; a plan far more effectual than that generally followed, of giving small doses for a longer period. In doses of three or four grains, with one-fourth of a grain of opium in a pill, repeated every two hours until six or eight doses are taken, this remedy is very suc- cessful. I, however, prefer administering the lead in solution ; in this form it is readily taken by the patient, and seems to act most efficiently, as in the following formula. R Plumbi acetatis, gr. xxiv. Aceti destillati, fjj- Syrupi papaveris, f^j. Aqufe rosae f^iij. ----- destillata, f^iv. M. fiat mistura. Cujus sumat aeger coch. ij. magna omni seeunda. hora. If care be taken to keep the bowels acting by a saline purga- tive, no fear of any unpleasant consequences from the lead need be apprehended, during the period required to give it a fair trial. The gums should, however, be watched, and if the blue edge described by Dr. Burton94 be seen, the medicine should be at once given up. 182. No remedy has, however, appeared to me to be of such extraordinary value in the treatment of hsematuria as gallic acid. I have seen this drug arrest for many weeks bleeding from an enlarged (and fungoid?) kidney, after all other remedies had failed. It should be given in doses of five grains in a draught, with mucilage, and a little tinct. hyoscyami, and repeated at short intervals. This drug really acts as a direct astringent, reaching the capillaries of the kidney, and finding its way into the urine, which soon becomes so impregnated with it, as to be changed into ink on the addition of a few drops of tinctura ferri sesqui- chloridum. 172 NON-CRYSTALLINE ORGANIC DEPOSITS. 183. When the only constituent of blood present in the urine is albumen, the treatment will vaiy according to whether the kidney is merely congested or structurally affected. The treat- ment of the latter class of cases has been fully detailed else- where,95 so that it is unnecessary for me to give any account of it. The treatment of the acute stage of congested kidney, oc- curring in children in the dropsy after scarlet fever, when the urine is albuminous, and dingy from the presence of red particles, is in the great majority of cases so successful and uncomplicated, that it is important to allude to it. I may remark as a prophylactic remedy, that the warm-bath is invaluable ; I scarcely recollect, even in a large experience, a case of dropsy after scarlet fever occurring, when the warm-bath was daily used as soon as the skin began to exfoliate, and con- tinued until a perspiring healthy surface was obtained. When anasarca has occurred, strict confinement to bed, or at least to a warm room, must be enjoined, the warm-bath used twice a week, and a free action on the skin encouraged. The bowels should be kept acting by the pulvis jalapse compositus, and the antimonii potassio-tartras administered in doses varying from one-twelfth to one-eighth of a grain, four or nve times in the twenty-four hours, according to the age and strength of the patient. A bland and nearly fluid, but moderately nutritious, diet should be enjoined. This plan must be continued until all anasarca has vanished, a supple and perspiring surface obtained, and urine free from albu- men. The remedies may then be gradually left off, a more nutri- tious diet allowed, and the ammonio-citrate of iron administered thrice daily, in doses of three to five grains, to remove the anse- niated state of the patient. On leaving the bed-room, a flannel waistcoat, extending to the loins, should be worn for some time. This treatment has been almost invariably successful in every case I have employed it, and 1 may remark that I have never in these cases witnessed the excessive prostration, said by some to be the almost necessary result of the employment of antimony in the diseases of children. PURULENT DEPOSITS. 184. Pus is not unfrequently met with in the urine, as the re- PURULENT URINE. 173 suit of suppuration of the kidney, or of some portion of the genito- urinary mucous membrane, or of abscesses from adjoining viscera or abnormal growths, bursting into the urinary cavities. There is said also to be occasionally another source of purulent matter in the urine, viz. when a vicarious discharge of pus occurs from the kidneys. Many pathologists, especially in Germany, have advo- cated the frequent occurrence of this phenomenon, and cases have been recorded of empyema disappearing contemporaneously with the discharge of purulent urine. The subject is, however, still obscure, and any opinion must in the present state of our know- ledge be given with caution (187.) 185. Characters of urine containing pus.—Generally acid or neutral, unless long kept, and slow to assume putrefactive change. By repose, pus falls to the bottom, forming a dense homogeneous layer of a pale greenish cream colour, seldom hanging in ropes in the fluid like mucus, and becoming by agitation uniformly diffused through it. The addition of acetic acid neither prevents this diffusion, nor dissolves the deposits. If a portion of the deposited pus be agitated with an equal quantity of liquor potassse, it forms a dense translucent gelatinous or mucous mass, often so solid that the tube can be inverted without any escaping ;96 this character constitutes the best test for the presence of pus. On decanting some urine from the deposited pus, the presence of albumen can be detected by heat and nitric acid (177). When pus is agitated with ether, a quantity of fat is dissolved, which is left in the form of yellow butter-like globules, when the ether is allowed to evaporate in a watch-glass. If the urine containing pus happens to be alkaline and to con- tain free ammonia, the character of the deposit is completely altered, becoming viscid, not readily diffused by agitation through the fluid, and resembles in appearance some varieties of mucous deposits. The detection of albumen in the supernatant fluid by the addition of nitric acid, and the conversion of theVleposstfipto a white granular mass, destitute of its previous viscidity, by the addition of acetic acid, will generally enable a safe opinion as to the nature of the deposit to be arrived at. A source of fallacy may occur in the urine of women, which may be supposed to contain pus, merely from an admixture of leucorrhceal or other vaginal discharges. In such specimens traces of albumen can 174 NON-CRYSTALLINE ORGANIC DEPOSITS. generally be detected in the urine, whilst the deposit, instead of presenting the dense homogeneous layer so characteristic of pus, is flocculent and granular ; although often extremely copious, and readily gelatinize with liquor potassse. 186. Microscopic characters of pus.— This substance consists essentially of roundish granules, or particles father larger than blood-corpuscles, floating in an albuminous fluid, or liquor puris, differing essentially from liquor sanguinis, in the absence of a spontaneously coagulating power. When a drop of a purulent fluid is placed under the microscope, the particles become visible; they are white, roughly granular exteriorly, and are much more opaque than blood-corpuscles (Fig. 29). On the addition of a drop of ..cetic acid, the interior of the particle becomes visible, and is found to be filled with several transparent bodies or nuclei, as shown in the figure. Hence it is usually considered as a egularly organised body, consisting of a granular membrane enveloping transparent nuclei; being in fact a nucleated cell. The microscopic exami- nation of a suspected purulent deposit is essential, for, as we have seen, phosphatic sediments will sometimes so closely resemble pus, as to deceive a most practised eye (135). 187. Pathological indications. — Whenever pus occurs in urine, it generally indicates the existence of suppurative inflammation in some part of the urinary apparatus. It must, however, never be forgotten that an abscess from any adjoining viscus, may dis- charge its contents by an ulcerated opening into the pelvis of a kidney or into the bladder. Suppuration in a more distant organ will often, by burrowing under the peritoneum or through mus- cles, be discharged by the urinary apparatus. An empyema has thus been known to find its way to the kidney, emptying itself through an ulcerated opening, and be discharged with the urine. This is in all probability the mode in which the purulent con- tents of a diseased pleura have escaped, in the supposed cases of metastatic discharges of pus from the kidney, which have lately- been published on the continent (184). MUCUS. 175 The therapeutical indications of purulent urine will of course strictly depend upon the nature of the disease under which the patient labours, and the source of the suppuration. MUCUS. 188. The quantity of mucus present in healthy urine is very small, being merely sufficient to form a just visible cloud. When collected on a filter it dries, forming a thin varnish-like layer. Characters of urine containing an abnormal proportion of mucus. —The quantity of mucus in urine may vary under the influence of different degrees of irritation or inflammation, from a mere floc- culent cloud to the production of a fluid so viscid and tenacious, as to be capable of being poured from one vessel to another in a continuous rope. Urine containing a deposit of mucus is generally alkaline, and soon undergoes a putrefactive change, becoming ammoniacal even in the bladder, if long retained. If the urine itself be acid when first voided, the mucus it deposits will always restore the blue colour of reddened litmus. Thus a specimen of urine will fre- quently redden litmus-paper, and the blue colour will be restored by allowing it to sink into the mucous deposit at the bottom of the vessel. Providing the urine is even slightly acid, a deposit of pus and mucus may be readily distinguished, as the former will appear as a homogeneous opaque layer, readily miscible by agitation with the urine : whilst the latter will appear gelatinous and hang in irregular masses, often entangling large air-bubbles, and no agita- tion, however violent, can completely mix it with the urine. There can never be any difficulty in distinguishing between puru- lent and mucous deposits by simple inspection, unless the urine be alkaline (144); or a large quantity of earthy phosphates (137) be mixed with the mucus, which thus acquires great opacity, and may be readily mistaken for pus without microscopic examina- tion. 189. The action of acetic acid on mucus is very characteristic, and is of great value in discriminating between that fluid and pus. When a fluid containing the former is mixed with acetic acid, the fluid part of the mucus in which the particles float, coagulates into a 176 NON-CRYSTALLINE ORGANIC DEPOSITS. thin semi-opaque corrugated membrane, presenting an appearance so peculiar, that once seen it can never be mistaken. Mucus contains no albumen in a state allowing of coagulation by heat or nitric acid (177); hence mucous urine can never be albuminous like pus (185) unless the albumen be derived from some other source. Agitated with ether, mucus gives up but mere traces of fat, and in this respect also differs from pus. 190. Microscopic characters of mucus. — Mucus, like pus, is composed of granular round particles, floating in a fluid, which is viscid and glairy, and does not contain uncombine'd albumen. Under the microscope, it is nearly, if not quite, impossible to distinguish between the pus and mucous particles — in fact, it may be questioned whether they are not identical. Where mucus and pus essentially differ is not in the nature of the particles, but in the fluid secreted with them, and in which they float; the liquor puris being albuminous and coagulable by heat (185), the liquor mud not being affected by it. Treated with acetic acid, the mucous particle exhibits the internal-nuclei just as pus does (186). The particles are by no means so numerous as in the latter, and are perhaps not quite so distinctly granular ; a rather higher magnifying power being required to show satisfactorily the granular surface of the mucus, than of the pus particle. Even this slight distinction may depend rather upon the greater refractive power of the fluid part of the mucus, concealing the irregularities on the surface of the mucous particle from ready observation, than upon any real difference between them. 191. Pathological indications of mucous deposits. — Their gene- ral indication is an irritated or inflamed state of the genito urinary mucous membrane, which may be excited by a variety of causes. Independently of idiopathic acute or chronic cystitis, certainly rare affections, the mucus may be the result of the disease termed cys- torrhoea, probably a low form of chronic inflammatory action, in which a large quantity is poured out from the mucous membrane of the bladder, and gives great distress by producing much irri- tability of the viscus, and interfering with the free flow of urine. Mucous deposits are more generally symptomatic of some me- chanical cause irritating the vesical mucous membrane, as the presence of a calculus, or the existence of a stricture in the CURATIVE INDICATIONS. 177 urethra, or of some other mechanical obstruction to the free escape of urine. Cysterrhoea, accompanied by a copious secretion of phosphates by the vesical mucous membrane, has been already alluded to (161). 192. The treatment of mucous urine must strictly depend upon the nature of the exciting cause. It can never be treated as a special affection, except perhaps in cases of cystorrhoea or chronic cystitis, when much advantage is gained by the employ- ment of certain remedies which are supposed to exert a specific action over the secreting function of the mucous membrane of the bladder. This specific action, after all, generally depends upon the astringent element of the drug reaching the urine, and thus acting nearly as directly, as an injection of alum into the vagina does in leucorrhcea. Most of the vegetable astrin- gents containing tannin and gallic acid are here available, but some have obtained a more especial reputation, from their con- taining some elements which enables them to fulfil more than one indication, and hence become applicable in particular cases. Among these, the leaves of the arctostaphylos uva ursi, barosma* crenata, chimaphila umbellata, and the root of the pareira brava, are the most celebrated. Although these are often prescribed, as if they all acted in the same manner, in checking the exces- sive mucous secretion, yet each fulfils a second indication which should never be lost sight of. Thus we find in the — Uva ursi, a simple astringent, but slightly diuretic. Chimaphila, a less active astringent, but freely simulating the kidneys. Barosma, a stimulating tonic, diuretic, and diaphoretic ; whose active principle (volatile oil; is excreted by the kid- neys. Pareira, a narcotic ? tonic diuretic. When microscopic examination of the mucus has shown that an excessive elimination of phosphates does not exist, the irrita- bility of bladder and crystorrhcea are remarkably relieved by the administration of alcalies, especially of the bicarbonate of potass * Diosma of the Pharmacopoeia. 1*78 NON-CRYSTALLINE ORGANIC DEPOSITS. (9j.) or liquor potassse (^xxv.) with a sedative, as tinct. hyos- ciami (5ss.), in an infusion or decoction of one or other of the a'bove drugs. When the earthy salts are copiously excreted, the dilute phosphoric acid (3ss.) may be advantageously substituted for the alcalies. In mild cases, where the normal character of the mucus is scarcely changed, we may employ the uva ursi; the chimaphila being preferred if the kidneys are inactive. The barosma, from its free action on the skin, being of most ser- vice where a highly irritable state of kidney or bladder exists ; whilst the pareira, as remarked by a high authority, Sir Benja- min Brodie,97 is of the greatest use, where the mucus is copious and opaque, and the distress of the patient, from a constant de- sire to empty the bladder, considerable. 193. There are two other forms of globules allied to mucus occasionally found in urine, which, for want of a better name, and until their true pathological relations are better understood, I have proposed to name organic globules. The large organic globule much resembles the mucous particle or globule, being composed of a granular membrane investing a series of trans- parent nuclei which become visible on the addition of acetic acid. In some, two nuclei of a crescentic shape, with their con- cavities opposed, are alone seen. I know of no character by which these bodies can be distinguished from pus or mucus, ex- cepting that they are unaccompanied by the characteristic albu- minous (185) or glairy fluids (190) in which the pus and mucous particles respectively float. The large organic globules seldom form a visible deposit, being free and floating in the urine, and are generally so scattered that not more than a dozen or two are visible at one time in the field of the microscope. They are abundant in the urine of pregnant women, especially in the latter months, and when there is a frequent desire to empty the blad- der. They have existed in every case of ardor urinse I have examined, although irritability of bladder was not necessarily present. In the latter disease, however, they abound. The glo- bule under consideration occurs in the greatest abundance in the albuminous urine of confirmed morbus Brightii. I have seen them so abundant as to cause a drop of urine to resemble, when microscopically examined, diluted pus, a resemblance rendered ORGANIC GLOBULES. 179 more close by the albuminous character of the urine. Is it possible that these globules may here be indicative of subacute inflammatory action going on in the structure of the kidney ? The marginal figure, copied from one by Simon in his Beytrage, accurately shows the common microscopic appear- ance of deposits in the urine of morbus Brightii. The large dark bodies are organic globules; mixed with them are seen altered blood-discs and epithelial scales, whilst a large cylindric mass of coagulated albumen entangling epithelium and blood-discs occupies the centre of the figure. 194. The small organic globules are very beautiful microscopic objects. These little bodies are very much smaller than the pus or mucous particles, and are essentially distinguished from them by the absolute smoothness of their exterior, no trace of granulation being visible even with a high magnifying power. I have never been able to detect a nucleus, or any other sign of definite structure, except their well-defined figure. In hot acetic- acid they are quite unchanged. On the slightest agitation they roll over each other with the utmost facility, which their per- fectly spherical figure readily permits. These globules form a visible white deposit, resembling to the naked eye a sediment of oxalate of lime. So rare are these curious little bodies, that but three examples of them have occurred to me ; in two, the urine was passed by women during menstruation. It is just possible that they may really be nuclei of some larger nucleated cell, as pus or mucus, and have escaped by the bursting of the investing membrane, or sac of the cell. EPITHELIUM. 195. The epithelial covering of the genito-urinary mucous membrane is, like the external skin, constantly experiencing the effects of wear and tear, causing a more or less rapid exfoliation of epithelial cells. These are sometimes partly broken up so as to appear like patches of membrane-like mucus, and often are Fig. 30. 180 NON-CRYSTALLINE ORGANIC DEPOSITS. irregularly lacerated. Most generally, however, a certain num- ber are entire, and can be readily recognised by their microscopic characters, being either regularly oval, or irregularly angular flattened cells; containing a well-marked central nu- cleus, often appearing, if the focus be not properly adjusted, to project like the central boss of a shield (Fig. 31). The exfoliation of epithelium sometimes is very considerable, so as to give rise to a copious deposit in the urine which to the naked eye resembles mucus; but may be readily distinguished by the absence of all viscid quali- ties. When oxalate of lime exists in the urioe, an abundance of epithelium is generally found, and indeed has often, from its pre- sence, induced me to examine specially for that substance (120). MILK. 196. No satisfactory case is recorded by any observer of credit, in which milk has been discovered in the urine ; although there are few who have devoted themselves to investigations connected with the pathology of the urine, but have met with urine rendered opaque by the fraudulent admixture of milk,—a piece of decep- tion occasionally practised by persons who labour under the un- intelligible delusion of wishing to appear the subjects of some marvellous disease. All the cases of milk-like urine where no fraud has existed, are instances of phosphatic (130), purulent (185), or fatty (204) urine. Although milk itself does not occur in urine, yet there can be little doubt but that some of its ele- ments may be met with in it, by a kind of vicarious action of the kidneys, in the same manner as bile is. It must be remem- bered that milk consists of globules of fatty or oily matter float- ing in a fluid or serum in which a peculiar protein-compound, casein, is dissolved. This substance is distinguished from other protein-principles by the action of acetic acid, which immediately coagulates it, producing the well-known curd, the basis of cheese. The most interesting subject connected with the supposed pre- sence of this substance in the urine, is its apparent connexion URINE OF PREGNANCY. 181 With utero-gestation ; and its temporary occurrence when an ob- struction occurs to the ready escape of milk from the breast. 197. An account of the supposed discovery of a peculiar mu- cilaginous principle in the urine of pregnant women appeared a few years ago in several of the British and Foreign Medical Jour- nals," and attracted much notice as a diagnostic sign of preg- nancy. This new constituent of the renal secretion, to which the name of Kiestein was applied, was stated to exist in the urine of the human female during utero-gestation, and to become visible when the secretion is allowed to repose in a cylindrical vessel, in the form of a cotton-like cloud, which in a lapse of time, vary- ing from the second to the sixth day of exposure, becomes re- solved into a number of minute opaque bodies, which rise to the surface, forming a fat-like scum, remaining permanent for three or four days. The urine then becomes turbid, and minute flocculi detach themselves from the crust, and sink to the bottom of the vessel: this action continues until the whole pellicle disappears. This crust of Kiestein was stated to be distinguishable from ana- logous pellicles which occasionally form on the surface of urine, from its never becoming mouldy, or remaining on the surface be- yond three or four days from the time of its complete formation. 198. This subject appeared of sufficient importance to justify a minute investigation, the results of which were published in the Guy's Hospital Reports for 1840. As nothing has appeared since, to induce me to modify the opinions I then made public, I now republish the most important part of these remarks. The first specimen of urine submitted to examination was some voided by Catherine Shaw, aged 28, a married woman in the sixth month of pregnancy, admitted under my care at the Finsbury Dispensary, on October 17th, 1839, for a slight attack of bronchitis. The urine was passed immediately on rising from her bed : it was tolerably copious, pale, acid, and rather opaque, of sp. gr. 1.020. About half-a-pint of it was placed in a glass cylinder, covered with paper. After two days' repose, it became very much troubled : numerous globules, presenting a fatty or greasy aspect, appeared on its surface : in two days more the urine became completely covered with a pellicle, very closely resembling that which forms on the surface of mutton-broth in the act of cooling: on the sixth day of exposure, this crust broke 16 182 NON-CRYSTALLINE ORGANIC DEPOSITS. up, and fell to the bottom of the vessel. On the 26th of Octo- ber, this patient, then convalescing from her bronchial affection, again sent me a specimen of the urine, voided as before, imme- diately after awaking from sleep ; and the very same results were obtained ; the pellicle of fat-like matter being, however, much thicker. On November 30th, the urine was again exposed, with precisely identical results.—Although in this woman the pheno- mena presented by the urine were tolerably constant, yet it be- came an important matter to determine whether such appearances were not to be met with in the urine of women who were not pregnant, and whether they were constant in every case of utero- gestation. To determine the latter question was, within certain limits, somewhat easier than the former: for this purpose, every pregnant woman who came under my care at the Finsbury Dis- pensary, or among my out-patients at Guy's Hospital, was desired to furnish specimens of urine, passed after awaking from sleep : this request was not in every instance complied with ; but during the months of November and December, specimens from about thirty Women, in the third to the last month of pregnancy, were obtained ; and in every case, with but three exceptions (to which I shall hereafter allude), copious fat-like pellicles were observed, after two or three days' exposure. The three women, whose cases thus appeared to be exceptions to the general rule, were all affected with inflammatory fever accompanying severe catarrh. The urine was turbid with urate of ammonia. On the disap- pearance of the latter by the convalescence of the patients, the phenomena characteristic of pregnancy appeared. 199. Whilst collecting these specimens of the urine of preg- nant women, I directed several young women, who presented themselves to be treated for amenorrhoea, to bring specimens of their urine ; which were exposed simultaneously with those fur- nished by the pregnant women ;—and in two instances only, was any evidence of the presence of the peculiar matter manifested. In one, a servant-girl of 18 years of age, I strongly suspected pregnancy, from the appearance of the areola around the nipple; but she was so much annoyed at my questioning her on this point, that she ceased to attend. The second case was more satisfactory : it Was that of Martha Chamberlain, aged 33, a stout, tall, unmarried servant, who came under my care, November 7th, URINE OF PREGNANCY. 183 1839, suffering from cough, apparently depending upon deranged digestive functions, and relaxed uvula : she had not menstruated since the preceding May, and attributed the disappearance of the catamenia to exposure to cold. She had morning sickness, and the veins of her lower extremities were varicose. On examining the abdomen, no evident enlargement of the uterus could be ob- served, in consequence of the parietes being loaded with fat; and on looking at the breasts, the nipples were found surrounded by a large purplish-brown areola. On being charged with preg- nancy, she obstinately denied it: but admitted having been the mother of an illegitimate child eleven years previously. She de- clared that she had preserved absolute chastity since that period, and wept bitterly at my (as she termed them) unjust suspicions. I procured a specimen of her urine, and exposed it in a lightly- covered glass cylinder : in two days, a dense pellicle of fat-like matter formed on its surface : this increased in thickness during three days, and then evolved so powerful an odour of putrefying cheese, that I was obliged to throw it away. Five months later this woman was delivered of a male child.. The odour of putrescent cheese, remarked in this case, is by no means unfrequent in those specimens of urine in which the pel- licle is very thick. 200. None of the specimens of urine voided by pregnant women, that I examined, were coagulable by heat, nitric acid, or, with but two or three exceptions, by acetic acid, and there- fore could not contain any considerable portion of albuminous or caseous matter. The addition of ammonia almost invariably pro- duced a dense deposit of earthy phosphates; and, with the ex- ception of this proof of the existence of an excess of earthy phosphates in the secretion, no appreciable portion of any anor- mal ingredients could be detected. Some of the fat-like pellicle was removed from the surface of some urine on which it had formed, by plunging a plate of glass perpendicularly into the fluid, and withdrawing it adroitly, in a nearly horizontal position : an equable layer of the substance was thus procured ; and, when carefully covered with another plate of glass, it could be very conveniently submitted to exami- nation. The pellicle thus procured, appeared glistening with a lustre 184 NON-CRYSTALLINE ORGANIC DEPOSITS. like that of spermaceti: when placed under a microscope, and examined with an object-glass of a quarter-inch focal length, myriads of triangular prisms of triple phosphate (174) were seen imbedded in a mass of granular matter, mixed with which, might here and there be seen patches of tolerably regular globu- lar bodies. The prisms of triple phosphate were so beautifully distinct, and their angles so sharply defined, that the whole be- came a most interesting microscopic object: some of the crystals were placed on end, and thus appeared like triangular plates. When the urine is kept so long that the pellicle begins to break up, it falls, in the form of a deposit, to the bottom of the vessel. If the supernatant fluid be decanted, and the deposit collected on a slip of glass, it is found to present the same appearance as the pellicle; excepting that the crystals are much more numerous, and all the animal matter present is entirely composed of amor- phous granules ; all trace of any thing like a regular structure being lost. 201. A slip of glass, on which a portion of the pellicle had been collected, was placed under the microscope, and covered with a few drops of acetic acid: the whole became opaque, the crystals were rapidly dissolved, and a white pultaceous mass re- sulted. On washing the whole with a few drops of water, and carefully drying the residue, the animal matter was left upon the glass in a white opaque layer, in which no trace of crystalline matter was perceptible, upon very minute microscopic investi- gation. Another portion of the pellicle, also collected on a glass plate, was placed under the microscope, and a few drops of strong liquid ammonia were added : the crystals underwent no change, but became much more distinct from the opaque matter, in which they were imbedded, undergoing solution. In the course of half- an-hour, the glass was carefully washed with a little water, and again examined ; when every trace of animal matter was found to have disappeared, and the crystals of the triple phosphate were alone left. From these investigations, it is evident that the greasy aspect of the pellicle of the so called Kiestein arises not so much from the presence of fat, but from the numerous crystals of triple phosphate, which, from their brilliancy, produce this glistening # URINE OF PREGNANCY. 185 appearance. Some fatty matter is, however, present, and Leh- mann,100 in repeating these observations, discovered that on di- gesting the pellicle in ether and allowing the ethereal solution to evaporate, a fat was obtained which closely resembled butter, and when saponified with potass, yielded butyric acid on the addition of sulphuric acid. With regard to the nature of the animal matter soluble in ammonia, mixed with these crystals, it is difficult, in the present state of physiological chemistry, to give a positive opinion. It is not mere albumen of casein, although much closer allied to the latter than to any other product of or- ganization I am acquainted with, especially when we connect with its chemical characters, the powerful cheese-like odour so frequently evolved, during its development in the urine, in the form of a pellicle. To this view may be objected the circum- stance, that the urine yielding it does not coagulate on the addi- tion of acetic acid: this, however, is by no means an important objection, as milk, when very much diluted with a saline solu- tion, or even water, is not perceptibly troubled by acids. The pellicle may be regarded as possibly constituted of an imperfect caseous matter, mixed with traces of butter and crystals of the ammoniacal phosphate of magnesia. It has been proposed by Dr. Stark to dignify the animal matter present in this mixture with the name of gravidine, but we are not justified in consider- ing it as constituting a new organic principle. There are few products formed during repose in urine which can be readily confounded with this caseous pellicle, if it be borne in mind, that the secretion remains faintly acid up to the moment of the crust breaking up. Which phenomenon seems to depend upon the development of ammonia in the urine, as at that time it acquires distinct alkaline properties. The crust of earthy phos- phate, which forms on the surface of all urine by long repose, cannot be mistaken for the pellicle under consideration ; as that which destroys the latter, viz., putrefaction, causes the produc- tion of the former. 202. If it be granted that we possess sufficient evidence of the presence of certain ingredients of the milk, as an imperfect caseous matter, and abundance of earthy phosphates, in the urine of pregnant women; it might be suggested as a probable expla- nation opposed to no physiological views that I am acquainted 16* 186 NON-CRYSTALLINE ORGANIC DEPOSITS. with, that during utero-gestation certain ingredients of the milk are eliminated from the blood by the mammary glands, and, as is very well known, often accumulate in the breasts, in sufficient abundance, to escape from the nipple on pressing it between the fingers. This imperfectly-formed secretion, not having a ready exit by the mammse, is taken up into the circulating mass, is separated by the kidneys, and, eventually, escapes from the body by the urine. This view is certainly sanctioned by the state- ments of a high authority, Prof. Burdach,101 of Konigsberg, and although not quite consonant with the opinion of M. Rayer,102 yet is quite in accordance with what we find occurring, under certain circumstances, in the bile, in the cases of obstruction of the biliary ducts; and more rarely in the urine, when, from the presence of calculi or other causes, the ureters are completely obstructed. 203. Although it is extremely probable that similar pellicles, which I have assumed to be characteristic of the presence of cer- tain elements of milk in the urine, may be met with in the renal secretion of nurses whilst suckling, yet I have never met with an instance of this kind : indeed, the following interesting case appears rather opposed to this view : Oct. 26, 1839. I was consulted by Mrs. T----, then in the third month of utero-gestation, on the case of her child, a boy sixteen months old, whom, notwithstanding her pregnancy, she was then suckling. This little patient had a severe attack of pneumonia following measles ; from which he was recovering, when, a few days before I was called in, from imprudent expo- sure to cold, he contracted bronchitis ; and when I saw him he was evidently dying: his face was pale, lips livid, and extre- mities cold: he had, however, sufficient strength to take the breast. As it was evident that the child would in all probability expire in a few hours, I was anxious to ascertain whether the urine of the mother contained any of the supposed caseous mat- ter ; and if not, how long after the death of the boy it would appear. Some of her urine was accordingly collected ; and after six days' repose, it underwent no particular change: putrefac- tive decomposition then commenced, and it was thrown away. She continued to suckle her child until within a few hours of its death, which took place forty-eight hours after my first visit; and URINE OF PREGNANCY. 187 on the following day I procured another specimen of the mother's urine: this, after two days' repose, had a thin caseous pellicle on its surface. In the course of a week, a third specimen was pro- cured ; and this in three days became covered with a complete creamy layer, evolving a strong cheese-like odour. This case certainly appears to justify the idea, that, whilst suckling, the milk being got rid of almost as quickly as it is secreted, none of its elements find their way into the urine; but as soon as the milk ceases to be removed in this way, indi- cations of it are to be met with in the urine, providing preg- nancy exists. The following case appears to support the position I have assumed :— Emma Cox, aged 24, suckling her first child, five months old, admitted under my care at the Finsbury Dispensary, in December 1839, complaining of symptoms generally referrible to asthenia lactantium. She was a tall, thin, delicate looking woman, and had lost a mother and some collateral relations from consump- tion : she had little or no cough : on examining her chest, I de- tected tubercular deposit at the apices of both lungs, with evi- dence of commencing softening on the left side: her urine was pale, and free from any appearance of caseous pellicle. I desired her to wean her infant; but this she did not do until January 27th, 1840. When she sent her child away, her breasts became painful and hard. She was compelled to have them drawn ; and in a week they became flaccid, and the secretion of milk stopped. On January 30th, the breasts being still turgid, and three days after the cessation of suckling, some of her urine was collected, and exposed in a glass cylinder: in the course of four days, a cream-like pellicle, evolving a cheese-lide odour, wss observed: on collecting some of it on a slip of glass, and ex- amining it under the microscope, it was found to resemble the usual pellicle which forms, by repose, on the urine of pregnant women, in every respect, except in the extreme paucity of the crystals of triple phosphate; the entire portion of the pellicle examined, being nearly entirely composed of the animal matter, insoluble in acetic acid. A few days afterwards the urine was again examined, but with negative results : no evidence of case- ous matter, as indicated by the formation of a pellicle, could be detected. 188 NON-CRYSTALLINE ORGANIC DEPOSITS. It is not known how soon after conception the urine assumes the properties characteristic of pregnancy. In one case, that of a woman who considered herself to be at the end of the second month of her pregnancy, the urine yielded a well-marked pelli- cle : but I do not place much confidence in this observation, as the woman might very likely err in calculating how far she was advanced in utero-gestation. As a test for the existence of pregnancy, the formation of the caseous pellicle, especially if accompanied by a cheese-like odour, will be an extremely valuable corroborative indication : but it would be unsafe to found on it alone any positive opinion, be- cause, as a sufficient number of observations have not yet been made on this subject, we have no right to assume, however pro- bable it may be, that a caseous pellicle can appear only when pregnancy exists. FATTY MATTER. 204. A very minute trace of fatty matter is not unfrequently present in urine, and in some rare instances it increases in quan- tity, so as to become an important element of the secretion. The majority of cases of this kind hitherto recorded have not been very satisfactory, in consequence of the general dearth of detail respecting both the chemical and microscopical characters of the supposed fatty fluid. In some cases oil has been said to have beeuiseen floating on the surface of the urine in large drops, even to the extent of ounces ;103 but no instance of this kind has ever occurred to me, and I suspect that certainly, in most of such cases, a fraud has been practised by the patient. An oil-like pellicle, often observed on the surface of urine, from the forma- tion of a pellicle of earthy phosphates (135), may have been mistaken for true fat. It has been lately shown, that during pregnancy a portion of butter-like fat may form part of the pelli- cle which forms on the urine by repose (201). All genuine specimens of fatty urine that have occurred to me have been opaque, like diluted milk, and in the majority of instances have spontaneously gelatinised, like so much blanc-mange, on cooling. To these the term of chylous urine has been applied by Dr. Prout.104 FATTY URINE. 189 205. Chemical characters of fatty urine.—On agitating the fresh urine with an equal bulk of ether in a tube, the fat is dis- solved, and by repose a yellow ethereal solution of it will float on the top of the urine, which, by thus losing the fat, becomes nearly transparent. On decanting the solution, and allowing it to evaporate in a watch-glass, the fat is left in little yellow globules, like butter, and having a rancid odour. This fat readily melts by a gentle heat into a yellow oil, and slowly solidifies on cooling. Albumen exists in the urine generally in its spontaneously coagulable form, so that on cooling it readily assumes the figure of the vessel. In this fespect the urine often remarkably varies, sometimes losing its power of spontaneous coagulation for days together. Albumen is, however, even then present, and readily coagulates on the application of heat and nitric acid (177). In some cases wdiich occurred to Dr. Prout, the albumen did not coagulate by heat, although it did by nitric acid; he hence con- sidered it to be an imperfect or hydrated state, like the albumen of the chyle. If a large proportion of fat exists, the fibrin, if present, is often prevented by its presence from coagulating; in this case, after agitation with ether, so as to dissolve out the fat, a delicate tremulous transparent coagulum of fibrin will form on the surface of the urine, and beneath the ethereal solution of fat. 206. Microscopic characters.—Cases have been reported in which globules of fat, like those existing in milk, were detected by the microscope. In all the specimens I have examined, the fat appeared to form a most intimate mixture or emulsion with the albumen, so that under the microscope nothing could be detected except myriads of infinitely minute particles floating in the fluid, unmixed with the slightest appearance of a globule of oil. 207. Pathological indications.—These can scarcely be said to be accurately known. In the few instances I have witnessed of fatty urine,the patients have shown a remarkable disposition to obesity. The continual presence of albumen must, however, excite our alarm, for fear of the probable termination of the ailment in dis- eased kidney and resulting dropsy. In these cases there can be no question, notwithstanding the occasionally repeated assertion that albuminous urine is not always connected with renal mis- 190 NON-CRYSTALLINE ORGANIC DEPOSITS. chief, that our most serious apprehensions must be entertained for the welfare of our patient. The more extended our experience becomes, the more correct does the law laid down by Dr. Bright, of the almost necessary connexion between persistently albumi- nous urine and diseased kidney, appear. I am indebted for the opportunity of investigating a well- marked case of this affection to the kindness of Mr. Montague Gossett, in whose practice it occurred. This case was peculiarly interesting on account of several curious anomalies it presented, as well as from its affording an opportunity of correcting the account generally given of the microscopic characters of urine containing fat. 4 The first specimens of the urine from the patient to which I have referred were given to me on April 14th of this year, with an inquiry as to their nature ; one specimen was of specific gravity 1.018, somewhat paler than usual, and was perfectly transparent, with the exception of a slight mucous cloud. The other speci- men stated to have been passed some hours before the former, resembled milk in colour and general appearance, and was quite free from any urinous odour: it was faintly acid, of specific gravity 1.020; the addition of either nitric or hydrochloric acid produced a considerable curdling. By repose, a cream formed on the sur- face of the urine, forming a layer one-tenth the thickness of the whole volume of fluid. When a drop of this milky urine was placed under the microscope, no oily globules could be seen when examined with an excellent object-glass of one-eighth of an inch focus, by Powell: the turbidity appears to depend upon an immense number of particles, so minute, that under a mag- nifying power of 800 diameters they resembled mere points. I confess that I could not help suspecting that some addition had been made to the urine by the patient after its being passed; an idea that at first gained some support from the fact, that when the bladder was emptied by means of the catheter, the urine removed was found to be quite transparent and healthy. On April 22d, I saw Mrs. T----in bed : she was an ex- tremely fat, flabby woman, about 35 years of age, the mother of several children. She expressed herself as quite well with regard to her general health, and only complained of the occasional milky state of the urine as possibly indicative of some threatening ail- FATTY URINE. 191 ment. She stated to me that for several years she had been ac- customed to pass milk urine, especially during part of her pregnan- cies. On several occasions the urine, although not milky, had gelatinised on cooling so as to assume the form of the receiving vessel like so much ordinary jelly. The appearance of the milky urine was exceedingly capricious, sometimes being constant for weeks together, and then disappearing for some time. She could trace no apparent connexion between its appearance and any obvious exciting cause; it bore no evident relation to the quality, quantity, or hours of her meals, nor to the periods of men- struation. The only general rule she had observed regarding its appearance was that it most frequently appeared when she first voided urine on rising from bed, and hence she fancied it was pro- duced by lying on her back all night. It had become most fre- quent in its appearance since she had begun to grow fat. My visit was made about 2 p. M.; Mrs. T.----had not risen except to pass water since the preceding evening. Three speci- mens of urine were shown me as having been passed since an early hour in the morning. The first specimen was like ordinary urine ; contained an abun- dance of pinkish urate of ammonia, which disappeared by heat; it was acid, and not coagulable ; contained no albumen. The second specimen was as water, subacid, and on heating it clouds formed in it from the coagulation of albumen. The third specimen was of a healthy amber colour ; it appeared natural, and was free from albumen. The examination of these specimens certainly gave no satisfac- tory explanation of the nature of the milky urine she had pre- viously passed, and she declared that this was the first occasion on which she had failed to pass that kind of urine for some weeks. I introduced a catheter into the bladder, and a pint of fluid escape ed, possessing the odour, colour, and general appearance of hot milk and water ; in fact, having none of the physical characters of urine. The specimen thus obtained was of specific gravity 1.010, slightly acid ; by repose a cream-like layer formed on its surface, leaving the lower portion of the fluid nearly transparent. I may remark that Mrs. T----had not partaken of any food since breakfast. This milk-like urine presented the following chemical characters. 192 NON-CRYSTALLINE ORGANIC DEPOSITS. A. When exposed to heat, a large and tremulous coagulum of albumen formed, becoming firmer and more solid on raising the temperature of ebullition. B. About four ounces of the urine were agitated with half an ounce of pure ether, and the mixture set aside in a carefully closed bottle. On the following day the mixture had lost all its opacity, and presented three well-defined layers. The lowest, forming the great bulk of the urine, was transparent, and consisted of urine de- prived of the ingredients which had produced its previous opacity. On the surface of this, rested a perfectly transparent and tolerably firm coagulum of fibrin, about a quarter of an inch thick, of a pale yellowish colour. The superior layer consisted of an ethereal solution of fatty matter; this fluid was of a fine golden yellow colour. C. The ethereal solution was decanted and allowed to evaporate spontaneously : a large proportion of yellow fat, closely resembling butter in colour and odour, was left. It differed from some speci- mens of fatty matter obtained by an analogous process from milky serum of blood, in not presenting any tendency to crystallise. This yellow fat readily fused by heat into a perfectly transparent oil, which slowly solidified by cooling, and it has undergone no change by keeping up to the present period. D. A portion of the urine left to itself for some time underwent no further change than the formation of a thin creamy layer on its surface : not the slightest tendency to the formation of a fibrous coagulum appeared. E. A portion of the milky fluid was evaporated at a boiling temperature to dryness, and digested with hot water. The fluid was filtered, and after concentration, treated with nitric acid, when crystals of nitrate of urea slowly formed. I carefully examined the urine under the microscope, but not the slightest appearance of oil-globules, blood-discs, or pus-gra- nules, could be detected; the opacity appearing, as in the first specimen given me by Mr. Gossett, to depend upon the presence of particles so minute as to present no defined form ; appearing like mere irregular points when examined with a linear power of 800 under an excellent achromatic microscope. The result of this examination is completely opposed to the few statements recorded by continental observers on the optical characters of fatty urine, FATTY URINE. 193 Thus M. L'Heritier has stated that oily globules can always be detected in fatty urine ; and a similar remark is made by Franz Simon of Berlin. The latter has, indeed, stated that he has met with three varieties of fatty urine ; one in which the fat is merely diffused through it, and collects on its surface by repose, as in the cases recorded by Dr. Elliotson: the other in which the fat com- bined with albumen ; and a third in which the fatty matter existed with casein as an emulsion, forming in fact true milky urine. In all these Simon states that fat-globules could be seen by the mi- croscope. So far as my own observations have extended, I have never met with true milky urine, but I may remark that when milk is added to urine, the oil-globules are easily seen by the microscope, even for a long period, quite unchanged. In the urine passed by Mrs. T-------, there can be no question but that the fat existed with the fibrin as an emulsion, so minutely broken up, and perhaps combined with the latter, as to lose its characteristic microscopic characters. The analytic power dis- played by the ether was peculiarly interesting: by merely dissolving out the fat it left the albuminous matter in a position capable of concreting into a transparent fibrous clot by repose, and by render- ing the urine transparent, at once demonstrated the cause- of its previous opacity. The presence of the fat probably mechanically prevented the formation of a coagulum of fibrin until it was re- moved by the solvent power of the ether. A case somewhat similar to the present has been recorded by Bizio: he compared the fat to butter; it is to be regretted, how- ever, that he did not make any microscopic examination of the urine. M. Rayer has stated that in all the cases of fatty urine which have fallen under his notice, albumen has invariably been present. He further remarks, that chylous urine contains globules like those of blood, readily distinguishable from pus granules by microscopic examination. I can view this case in no other light than that of one in which a great tendency to the development of adipose matter existed, and an excess of fat, not capable of being otherwise appropriated, escaped by the kidneys in the form of an emulsion with the spontaneously coagulable albumen of the blood (fibrin). The occasional occurrence of this pathological state of the secretion, 17 194 NON-CRYSTALLINE ORGANIC DEPOSITS. alternating with healthy and even albuminous urine, is at least exceedingly remarkable, and presents anomalies which at present admit of no satisfactory solution. SPERMATOZOA. 208. Spermatic animalcules are by no means very unfrequent in urinary deposits; a few being occasionally found on examining microscopically the inferior portions of the urine of the male adult, after allowing it to repose for some time in a glass vessel. In some cases, however, a sufficient quantity of spermatic fluid is found mixed with the urine to form a visible cloud, and becomes an important guide to the practitioner in the investigation of a case perhaps previously obscure. Diagnosis of spermatic urine. — If a small quantity of spermatic fluid is present in urine, it may easily be passed over and mis- taken for mucus, from which there is no character, independent of microscopic examination, capable of distinguishing it. If, how- ever, we have a specimen of urine passed by a man which is cloudy and opalescent, reddens litmus-paper, and does not become clear on the application of heat or nitric acid, the presence of spermatic fluid may be at least suspected, especially if the cha- racteristic odour of that secretion be perceptible. Should a larger quantity of the secretion be present, it subsides to the bottom of the vessel, and may be recognised by its physical character. If mere traces of spermatic liquor only are mixed with urine, they may easily be detected by violently agitating, and allowing it to repose in a conical glass vessel for a few hours. On carefully decanting all the urine except the last few drops, the spermatozoa may^be detected in the latter by the microscope. The addition of nitric acid will often produce a slight troubling in this urine. M. Lallemand106 describes spermatic urine as opaque and thick, is if mixed with gruel, with a foetid and nauseous odour, cha- racters sufficiently common in ammoniacal mucous urine (145), but certainly by no means necessarily or generally characteristic of urine containing spermatozoa. In fact, an abundance of these little organisms may be present, without modifying materially the physical characters of the urine. SPERMATIC URINE. 195 209. Microscopic characters of spermatic urine. —jNo character can be assumed as distinctly diagnostic of the presence of semen in urine, except the discovery of the spermatozoa. These minute beings never occur living in urine, unless protected by the presence of a deposit of pus, in which they retain their power of moving for a long period after emission. Urine appears to be immediately fatal to their vitality, but exerts no further action upon them, as they may be detected scarcely changed even after it has become ammoniacal. An object-glass, of one-eighth of an inch focus, should be used for the detection of these minute bodies. The drop of urine chosen for examination should be taken from the bottom of the containing vessel, placed on a slip of glass, and covered with a piece of mica or thin glass. The spermatozoa will be observed as minute ovate bodies, provided with a delicate bristle-like tail, which becomes more distinct on allowing the drop of urine to dry on the glass (Fig. 32). Mixed with these are generally found round granular bodies, rather larger than the body of a spermatozoon, and nearly opaque from the numerous asperities on the surface of the investing mem- branes? These appear to be identical with the seminal granules described by Wagner107 and others. 210. Well-defined and often large octohedra of oxalate of lime (115) are of common occurrence in spermatic urine. The con- nexion of this saline body with the presence of spermatozoa was first pointed out to me in a private communication with which I was favoured by Prof. Wolff, of Bonn. Very lately M. Donne has stated, as the result of his observations, that they frequently occur together, and that the presence of oxalate of lime is a con- stant indication of the existence of spermatorrhoea. This state- ment is quite opposed to my own experience, for although in the latter disease oxalate of lime often exists, yet this salt constantly occurs where no suspicion of an escape of semen can be enter- tained (127). 211. Pathological indications.—Whenever spermatozoa, or 196 NON-CRYSTALLINE ORGANIC DEPOSITS. spermatic granules, are detected in the urine, it is quite certain that the seminal secretion must have been mixed with it. The causes of this admixture are numerous, for it must be recollected that if the bladder be emptied even some time after a seminal emission, a sufficient number of spermatozoa will remain in the urethra to be washed away with the urine, and cause it to assume the ordinary microscopic character. A certainly not unfrequent cause of the escape of semen is extreme constipation, for after the passage of hard and scybalous fseces, an oozing of fluid from the urethra, full of spermatozoa, is not uncommon. In some cases of stricture of the urethra, anterior to the orifices of the seminal ducts, an accumulation of semen may, upon sexual excitement, collect, and flowing into the bladder be voided subsequently with the urine. An admixture of semen with the urine may occur occasionally in paraplegia, in persons reduced in health by ex- cessive indulgence in intercourse, or by even less creditable modes of producing excitement of the sexual organs. 212. Therapeutical indications. — The irritable state of the nervous system, the depressed general health, and in some cases the appearance of epilepsy, or of symptoms not unlike mild forms of delirium tremens, and characterised by the most abject melancholy and despondency; are familiar to all, as the effects of the too copious and frequent excretion of seminal fluid, whether excreted or involuntary. To this ailment, spermatorrhoea, as it has been named, great attention has been lately drawn by M. Lallemand, and during the present year by several writers in the English weekly medical journals. That the detection of sperma- tozoa in the urine will often enable the physician to detect a source of exhaustion previously concealed from him, and baffling his treatment, is unquestionable; but that this matter really merits all the verbose attention lately lavished upon it, is not so evident. It certainly is not very consistent with our national character, to dilate so freely upon a subject which, in the great majority of cases, can be treated of only as the effects of a most degrading vice. In the treatment of spermatorrhoea, it appears necessary to ex- amine the therapeutic means to be employed in two points of view; as curative of the involuntary discharge, and of the habits keeping TORULiE IN SACCHARINE URINE. 197 it up. The first indication is best fulfilled by attending to the general health, by cold hip-baths, or by dashing cold water over the genitals; by the use of astringent injections into the urethra, or the application of solid nitrate of silver to that part of the canal where the seminal ducts open, as recommended by Lallemand and Mr. B. Phillips. The use of iron, persisted in for some time, with a little quinine, and a careful use of purgatives, will greatly expedite the recovery of the patient. The second indication is fulfilled by an influence on the moral feelings of the person, and if these have no effect, the application of a blister, or croton oil, to the prepuce, or in some cases circumcision, will be found available in breaking through an iniquitous and injurious habit. TORUL2E. 213. It is well known that in all saccharine fluids undergoing the alcoholic fermentation, minute confervoid, or fungoid vege- tations, or torulse, appear, and pass through certain definite stages of development. There is indeed considerable reason to believe that these vegetations bear to fermentation the relation of cause and effect. The arguments lately advanced by Prof. Liebig, in opposition to this opinion, do not afford a satisfactory answer to the observations previously made on this subject. When urine Contains even very small portions of sugar, too little even to affect its specific gravity materially, or to cause it to assume a diabetic character, certain phenomena are developed connected with the production of the vegetation of the genus torula or saccharomyces, which will at once point out the presence of sugar. These indications are of very great value, as a saccha- rine condition of the urine is not uncommon in dyspepsia and some other affections, and is of course of the highest importance in directing our treatment. 214. When saccharine urine is left in a warm place, a scum soon forms on its surface, as if a little flour had been dusted upon it. This consists of minute oval bodies which soon enlarge from the development of minute granules visible in their interior. These continue expanding, and dilate the oval vesicle containing them into a tubular form; soon afterwards the internal granules become larger and transparent, and project from the exterior of 17* 198 NON-CRYSTALLINE ORGANIC DEPOSITS. the parent vesicle like buds. The whole then resembles a jointed confervoid growth, which ultimately breaks up; and a copious deposit, of oval vesicles or spores, falls to the bottom. All these stages of development (Fig. 33) require but a few hours for their completion. If the deposited spores be placed in weak syrup they rapidly germinate, and exciting fermentation, produce a new crop of torulse. During the growth of the torula, bubbles of carbonic acid gas are evolved, and the urine at length acquires a vinous odour, sometimes accompanied by an odour of butyric acid. There are two kinds of urine which may be mistaken for saccharine, by the occurrence of a kind of fermentation, not unlike that of fluids really containing sugar. I refer to the kind of viscous108 fermentation which occurs in urine and ending in the appearance of much ropy mucus. This has occurred to me repeatedly in specimens of urine containing cystine (105), the odour evolved being, however, disagreeable and sul- phureous, quite distinct from the vinous odour of the alcoholic fermentation. Somewhat similar phenomena are occasionally presented by the urine of persons exhausted in health from scrofu- lous, or syphilitic cachexia. 215. The presence of sugar once suspected, may be easily proved by analysis or the application of tests.109 If a moderate quantity of sugar exists, the urine maybe evaporated to an extract and digested in hot alcohol; when cold, the tincture should be decanted and allowed to evaporate spontaneously in a cylindrical vessel (a cupping-glass answers very well). In this way white granular masses of sugar will crystallise on the sides of the glass, whilst if the evaporation be expedited by heat, crystals are ob- tained with great difficulty, and often not at all, until the urea and other organic ingredients have been got rid of by a tedious process. 216. The most trustworthy tests for the detection of sugar in urine depend for their action upon the reducing action of sugar on salts of copper, or upon the decomposition of the sugar by alkalies. DEVELOPMENT OF VIBRIONES. 199 1. Trommels test.—Add to the suspected urine in a large test-tube just enough of a solution of sulphate of copper, to com- municate a faint blue tint. A slight deposit of phosphate of cop- per generally falls. Liquor potassse must then be added in great excess ; a precipitate of hydrated oxide of copper first falls, which redissolves in the excess of alkali, if sugar be present; forming a blue solution like ammoniuret of copper. On gently heating the mixture to ebullition, a deposit of red suboxide of copper falls if sugar be present. 2. CapezzuoWs test.110 — Add a few grains of blue hydrated oxide of copper to urine contained in a conical glass vessel, and render the whole alkaline by the addition of liquor potassse. If sugar be present, the fluid assumes a reddish colour, and in a few hours the edge of the deposit of oxide assumes a yellow colour which gradually extends through the mass, from the reduction of the oxide to a metallic state (suboxide ?). 3. Moore's test.113 — This very easily applied test was lately proposed by Mr. Moore, of the Queen's Hospital, Birmingham, and depends for its action on the conversion of colourless diabetic (grape) sugar into brown melassic (or perhaps sacchulmic) acid under the influence of a caustic alkali. Place in a test-tube about two drams of the suspected urine, and add nearly half its bulk of liquor potassse. Heat the whole over a spirit-lamp, and allow actual ebullition to continue for a minute or two ; the previously pale urine will become of an orange-brown, or even bistre-tint, according to the proportion of sugar present. This test appears to be remarkably free from sources of fallacy, as boiling with liquor potassse rather tends to bleach non-saccharine urine than to deepen its colour. VIBRIONES. 217. Minute animalcules, belonging to the genus Vibrio (V. Lineola ?ni), are occasionally developed in urine, so soon after passing as to lead to the idea that their germs must have existed in the urine whilst in the bladder. All the urine in which I have found these minute creatures has been pale, neutral, of low specific gravity, and rapidly underwent the putrefactive fermentation. When a drop of such urine is examined under the microscope 200 NON-CRYSTALLINE ORGANIC DEPOSITS. between plates of glass with an object-glass of one-eighth inch focus, it will be found full of minute linear bodies, hardly so long as the diameter of a blood-corpuscle (about ^5) inch moving with great animation. The motion is of an oscillating character, and strong enough to excite tolerably rapid currents in the fluid. Even under a very high magnifying power, no satisfactory evi- dence of organisation can be detected in these minute beings. I have only met with these animalcules in the urine of persons in an excessively low and depressed state. In cases of syphilitic cachexia, where the prostration of the strength is extreme, and in mesenteric diseases, I have repeatedly found them abundantly developed, with remarkable rapidity. THERAPEUTICAL CONSIDERATIONS. 201 CHAPTER XI. REMARKS ON THE THERAPEUTICAL EMPLOYMENT OF REMEDIES IN- FLUENCING THE FUNCTIONS OF THE KIDNEYS. Assumed capricious influence of these remedies, 218—First law regulating them, 219—Second law, 220—Conditions for the entrance of the remedy into the cir- culation, 221—Illustrated in alkaline salts, 222—In mineral waters, 223—Diu- resis opposed by irritable gastro-intestinal mucous membrane, 224—By obstructive diseases of the heart or liver, 225—Dr. Barlow's researches, 226—Applied to the explanation of irregular action of remedies, 227—Practical conclusions, 228. 218. It has been long stated by writers on therapeutics, that few remedies are so capricious in their action as those intended to influence the functions of the kidneys. In some patients, a diuretic effect being obtained by the first remedy prescribed in a most satisfactory manner; whilst in other, apparently parallel cases, all medicines have failed in stimulating the secreting func- tions of the renal capillaries. When we refer to the writings of authors on this subject, we find the remedies which are sup- posed to excite the urinary secretion arranged according to their presumed modes of action ; and although there is always included a class of direct diuretics, or, in other words, of drugs which are supposed really to reach the capillary circulation of the kidneys, and stimulate the vessels by actual contact: yet daily experience proves that even these, too frequently entirely, fail in exciting the medicinal influence which has been accredited to them. As much importance has been attributed in the preceding pages to the impregnation of the urine with solvents for deposits so as to prevent the formation of a concretion, it becomes a matter of especial interest to devote a little space to the consideration of the question, whether by any means we can ensure the exertion of a therapeutical effect upon the secreting functions of the kid- neys, and whether the apparently uncertain results of our diuretic and other analogous remedies are really as capricious as has been supposed. In a word, whether it is not in almost every 202 THERAPEUTICAL CONSIDERATIONS. case possible to predict, with tolerable certainty, from the know- ledge of a few general laws, what will really be the effect of a remedy destined to act upon the kidneys. 219. To save any unnecessary circumlocution, I may be per- mitted to state I take it for granted that, independently of absorp- tion by the lymphatics, fluids can find their way into the various capillaries by direct imbibition ; and further, that living mem- brane is obedient, quoad imbibition and exudation, or endos- mosis and exosmosis to the same physical laws as when removed from the body. A consideration of facts recorded by ob- servers of credit in all modern works on physiology114 will afford ample data for admitting these several assumptions. It will then be necessary to consider, seriatim, the laws wThich appear to be fairly deducible from recorded experience. Law 1st. All therapeutical agents intended to reach the kidneys must either be in solution when administered, or capable of being dissolved in the fluids contained in the stomach or small intestines, after being swallowed. No one in the present state of physiological science can dis- sent from this law ; not the slightest evidence exists of the kid- neys ever allowing a body not in solution to pass their capilla- ries without positive breach of surface. It has, indeed, been stated that metastastatic discharges of pus have occurred from the kidneys; that the purulent effusion of an empyema has been absorbed and finally excreted by those organs. Such statements, however, admit, as we have already seen, of a much more direct explanation. The capillary and lymphatic vessels can be readily submitted to microscopic examination, and no visible pores can be detected in their walls. How then is it possible that organised cells, consisting each of an investing granular membrane with several distinct nuclei (186), can find their way through the walls of a vessel in which no visible pores can be detected, and per- meate without breach of surface, other capillary vessels in the kidney similarly organised ? In the same way, it has been loosely said, that the exudations of blood occur from the renal vessels in some cases of hsematuria. To this statement a similar objection applies. All experience goes to prove that no escape of blood-corpuscles or pus-particles can possibly occur from a capillary without actual solution or continuity. The researches I THERAPEUTICAL CONSIDERATIONS. 203 of Wohler115 have proved to a demonstration that for a body to be excreted by the kidneys it must be actually in solution, and indeed they have shown that the function of these organs is strictly limited to the excretion alone of substances in solution. 220. Law 2d. Bodies intended to reach the kidneys must, to ensure their absorption, have their solutions so diluted as to be of considerably lower density than either the liquor sanguinis, or serum of blood (i. e. below 1.028). Peculiar attention to this important law has been directed by the published remarks of Prof. Liebig already referred to (18). It is founded upon the well-known phenomena described by Dutrochet, under the terms of endosmosis and exosmosis, or imbibition and exudation. They may be thus briefly described. Let a glass tube, open at both extremities, have a piece of ani- mal membrane, as bladder, &c, tied firmly over one end. Partly fill the tube with syrup and immerse it in a glass of distilled water. In a short time the fluid will rise in the tube, the water having permeated the membrane and diluted the syrup ; this is an example of imbibition or endosmosis. Empty the tube, partly fill it with water, and immerse it in syrup ; the fluid will now fall in the tube, exuding through the membrane, and diluting the syrup in the external vessel, by exosmosis. As a general law, it may, as far as living tissue is concerned, be sufficient to state that when two different fluids capable of mixture, be separated by an animal membrane, the fluid lowest in specific gravity will per- meate the membrane to dilute the denser fluid. In dead animal membrane, whilst imbibition goes on, a certain amount of exu- dation occurs, but to a much smaller extent, and vice versa; whether this also occurs in living tissue there are no facts before us, to enable us to decide. 221. WTben, therefore, saline substances, especially, are in- tended to be absorbed and ultimately to reach the kidneys, it is necessary that the density of their solutions should be much be- low 1.028; the proportion of solids dissolved in the aqueous vehicles prescribed being always less than five per cent. Daily experience in the employment of remedies will show the import- ance of this law in a therapeutical sense. Thus a tolerably strong solution of the tartrate, or acetate of potass will altogether escape 204 THERAPEUTICAL CONSIDERATIONS. the absorbents; indeed, so far from being imbibed by the capil- laries, they actually excite an exudation of water from these ves- sels in the stomach and small intestines, thus becoming diluted by exosmosis, and a sensation of thirst is excited, by which the patient is compelled to drink for the purpose of supplying the water removed from the blood by exudation. In strong solu- tions, the salts alluded to, stimulate the bowels and purge. They are, moreover, said to act as hydragogue purgatives, producing watery motions,—a fact also capable of ready explanation on physical laws ; exudation of water from the exhalants (capillaries) occurring, on account of the density of the saline solution tra- versing the intestines, just as exosmosis was produced in the experiment of the tube of water immersed in syrup. We can hence readily perceive why half an ounce of acetate or tartrate of potass will purge, and a scruple of either, excite diuresis. 222. These facts are of the utmost importance to the success of our practice in the treatment of uric acid deposits by saline remedies, especially by phosphate of soda. This salt readily finds its way into the kidneys when administered in a diluted solution ; if prescribed in a strong solution or in large quantities, it, like the tartrate and acetate of potass, excites exosmosis instead of endosmosis, and acts as a mild hydragogue cathartic. A simi- lar remark applies to the majority of salts of alkalies and of mag- nesia. Most neutral salts are therefore diuretic, if properly administered so as to ensure their absorption into the circulation ; once being absorbed, it is the duty of the kidneys to filter them off from the blood, and hence they exert a diuretic influence, merely by giving the kidneys an extra amount of duty to per- form. 223. All the natural waters are diuretic, and if drank in equal quantities are nearly so in the ratio of their levity and consequent purity. Thus the nearly pure water of the Malvern springs, rapidly and readily enters the blood by endosmosis, and escapes by the kidneys, whilst sea-water in equal doses causes the exos- mosis of water from the intestinal capillaries; hence exciting thirst and purging with fluid motions, without inducing any diu- retic action. On the contrary, sea-water, like all moderately strong saline solutions, diminishes the bulk of the urine, and causes it to escape in a more concentrated form, simply from its THERAPEUTICAL CONSIDERATIONS. 205 causing an efflux of water from the blood through the walls of the capillaries of the intestines, which would otherwise have escaped by the capillaries of the kidney. 224. In diseases in which an extremely irritable condition of the gastro-intestinal mucous membrane exists, diuresis is often excited with great difficulty, and it is scarcely possible to cause any remedy to reach the urine by direct absorption. Where purging exists, and copious watery motions are excreted from the bowels, the urine is always scanty and high-coloured, arising from its concentration ; water freely exuding through the intestines from the blood, and hence little is left for the kidneys to execute. An extreme instance of this state of things is found in malignant cholera; here, water is so rapidly pumped off, through the intes- tinal exhalants, that the blood is left absolutely viscid and thick. Hence the nitrogenised elements which it is the duty of the kid- neys to excrete, cannot be removed in consequence of the escape of the water by the intestines which would normally have washed them from the circulation ; and the patient dies from the retention of a poison in his circulation which the kidneys are unable to remove. 1 226. The laws just illustrated must be regarded as obtaining only, when the entrance of water into the capillaries of the intes- tines is unobstructed ; and when no serious obstacle presents itself to the transit of the water with the blood from the intestinal capillaries to the vena-porta, thence through the liver to the ascending cava, through the lungs and heart to the aorta, and finally to the emulgent arteries. When any obstacle materially interferes with the route thus taken by the blood, in any part of its career, a diminished supply of water must reach the kidneys, and the urine will become diminished in bulk and increased in I density. To take a familiar illustration, a patient labours under a contracted condition of either of the auriculo-ventricular open- ings of the heart, and dropsical effusions occur. In consequence of the impediments opposed to the current of blood, the kidneys excrete but a small quantity of urine. The very dropsical effu- sions may be regarded as a sort of vicarious effort to relieve the congested state of the veins, by allowing the watery elements of the blood to filter through the walls of the smaller vessels. Again, if a patient has a scirrhosed or hobnail condition of the liver, 18 206 THERAPEUTICAL CONSIDERATIONS. the portal circulation will be obstructed, and some effects analogous to those produced by a contracted ventricular orifice are the result, viz., dropsical effusions and diminished secretion of urine. In cases of this kind, no good can accrue by goading the kidneys by diuretics, unless the obstruction can possibly be lessened or removed. They may be irritated by stimulants like cantharides, copaiba, or squills, until congestion or something worse occurs, without increasing the secretion of urine, simply because the fluid elements are prevented reaching the kidneys. In cases of this kind, the physician at once sees that all direct diuretics are comparatively useless, and he wisely endeavours to remove the dropsical effusion by remedies which, like elaterium, exert a hydrogogic action on the intestines. 226. The attention of the profession has been especially drawn to these conditions by the recently published researches of my friend and colleague, Dr. Barlow. He has moreover announced the very interesting fact, that whenever a stricture or other ob- struction exists in the course of the small intestines, sufficient to prevent fluids readily passing along them, the urine will be dimi- nished in bulk in the direct ratio of the proximity of the obstruc- tion to the pylorus ; nearly absolute suppression of urine occurring when the stricture is so high up as to allow but a small quantity of the fluid contents of the intestines to be exposed to the absorb- ing influence of the portal capillaries. So absolutely does this obtain, that the observation of the bulk of urine excreted has been proposed by Dr. Barlow as a means of diagnosticating the seat of obstruction in cases of insuperable constipation.* The proposition laid down by the discoverer of these facts, may pro- perly be assumed for a third law governing the influence of re- medies intended to excite the action of the kidneys. I give it in Dr. Barlow's own words. Law 3.—" If a sufficient quantity of water cannot be received into the small intestines, or the circuit through the portal system in the vena-cava ascendens, or thence through the lungs and heart into the systemic circulation, be obstructed, or if there be * For an account of these very important facts, and the arguments deduced from them, I beg to refer the reader to the very philosophical and interesting communi- cations of Dr. Barlow, in the current number of Guy's Hospital Reports (October, 1844, page, 367, et. seq.). THERAPEUTICAL CONSIDERATIONS. 207 extensive disorganisation of the kidneys, the due secretions of urine cannot be effected." 227. I think, then, that the so-called capricious effects of most diuretics, or the entrance of any remedy into the renal circulation, may all be explained by one or other of the foregoing laws, and that the supposed uncertainty attending their action is in most instances to be traced rather to a want of discrimination on the part of the practitioner, than to any fault in the remedy. An example or two of this kind will be sufficient. Bitartrate of potass is regarded as a diuretic; if a dram of it be administered with a little fluid, or in a confection, it irritates the intestines, produces fluid motions, and the kidneys are scarcely affected. Let the same quantity of the drug be dissolved in water and then given: it is imbibed by the capillaries, and causes an increased excretion of water by the kidneys, in accordance with the first law. Suffi- cient examples of the second law have been given already. Of the third we have an excellent illustration in the action of mercury and other cholitic drugs, in " directing," as it has been termed, the action of a diuretic. Thus let us suppose we are called to a patient in whom a sluggish state of the portal circulation exists, the liver being congested or myristicated, and from some drop- sical effusion, or other symptoms, we are anxious to stimulate the action of the kidneys. It is notorious that in these cases the acetate of potass, nitric ether, squill, and other active diuretics, may be prescribed in vain; but as soon as moderately frequently repeated small doses of pil. hydrargyri, or hydrarg. c. creta, or even aloetic remedies have been administered, and the liver dis- gorged of its contents by a free secretion of bile, the kidneys begin to act as the almost necessary result of a readier circulation of portal blood. Perhaps there is no diuretic so valuable in dropsy connected with contracted liver, as a combination of the squill with a little blue-pill. Many remedies regarded as diuretic, probably really act in this manner; thus colchicum appears to influence the secretion of urine by its stimulating the mucous membrane of the duodenum, and thus by irritating the orifice of the common choledic duct, produces an increased secretion of bile and pancreatic juice, and indirectly removing a loaded state of liver. Taraxacum, a deservedly esteemed cholagogue, owes its diuretic action in all probability to a similar cause. Aloes in 208 THERAPEUTICAL CONSIDERATIONS. small doses, and some other remedies, may be referred to this category. Again, in heart-disease, especially when a contracted mitra] orifice, or dilatation of the whole organ exists, and dropsy results, the exhibition of stimulant diuretics is nearly valueless. Here, the guarded employment of the infusion of digitalis, by soothing the irritability of the heart, and calming the irregular circulation, virtually diminishes the congested state of the vascular system, and acts indirectly as an excellent and efficient diuretic. 228. From the above observations, the following practical conclusions may be drawn. 1. Whenever it is desirable to impregnate the urine with a salt, or to excite diuresis by a saline combination, it must be exhibited in solution, so diluted as to contain less than five per cent, of the remedy, or not more than about twenty- five grains in an ordinary draught. The absorption of the drug into the capillaries will be ensured by a copious draught of water, or any diluent, immediately after each dose. 2. When the urine contains purpurine (101), or other evi- dence of portal obstruction exist, the diuretics or other reme- dies employed should be preceded or accompanied by the administration of mild mercurials,—taraxacum, hydrochlorate of ammonia, or other cholitic remedies. By these means, or by local depletion, the portal vessels will be unloaded, and a free passage obtained to the general circulation. 3. In cases of valvular or other obstructions existing in the heart and large vessels, it is next to useless to endea- vour to excite diuretic action, or appeal to the kidneys by remedies intended to be excreted by them. The best diu- retics here will be found in whatever tends to diminish the congested state of the vascular system, and to moderate the action of the heart; as digitalis, colchicum, and other seda- tives, with mild mercurials. APPENDIX. CATALOGUE OF THE URINARY CALCULI CONTAINED IN THE MUSEUM OF GUY'S HOSPITAL. Ix the year 1817, when Dr. Marcet published his Essay, the Museum of Guy's Hospital contained but 228* calculi. During the last twenty-seven years, this number has been augmented to 374; all of which have been divided so as to ex- hibit their internal structure, with the exception of 21. The great majority of the calculi added since Dr. Marcet's publication have been analysed at different periods, as they were placed in the Museum, by Dr. Babington, Dr. Rees, and myself; and in every instance, the examination has not been limited to the composition of the external crust, but has been particularly directed to the chemical constituents of the ingredients composing each layer. Attention has in each specimen been directed to the composition of the nucleus, in contradistinction to that of the body of the con- cretion. This is of very great importance ; for when once a few solid particles of any substance aggregate and form a mass in the bladder, they very readily induce a crystallisation of oxalate of lime, uric acid, or triple phosphate ; or a deposition of urate of ammonia, phosphate of lime, or other amorphous ingredient, according to the lesion of function and state of irritability or innervation present. Hence, if ever, by medical treatment, we shall be enabled to prevent the formation of a calculous concretion, or remove one already formed, it will, in all probability, be by means directed by the character of the matter which there is a tendency to deposit as a nucleus. On this account I have adopted a classification of the calculi in Guy's Hospital Museum, founded not upon the number of alternating layers, but upon the character and composition of the nucleus. In the following Table, it must be borne in mind, that all the distinct constituents present in each concretion have not been mentioned ; those only being inserted which were present in such quantity as to constitute a considerable portion of either body, nucleus, or crust of the concretion. Those ingredients, which existed in mere traces, or in very minute quantities, have been omitted ; as they are rather to be regarded as accidental contaminations, and not as essential elements of the calculus. No urinary concretion, indeed, ever ex- ists perfectly pure and unmixed ; for there are very few in which some traces of uric acid, or phosphates, are not observable: and even if these be absent, the co- louring matter of urine or blood prevents the calculus being regarded as perfectly pure. * Including 142 removed from one patient. 18* 210 APPENDIX. CALCULI IN GUY'S HOSPITAL MUSEUM, OF WHICH SECTIONS HAVE BEEN MADE, ARRANGED ACCORDING TO THE CHEMICAL COMPOSITION OF THE NUCLEI. Genus I.—Nucleus, Uric Acid, 250. Species 1. Calculi nearly entirely composed of Uric Acid or Urates. A. Nearly all uric acid.......32 Uric acid, nearly pure - - - - - 18 Stained with purpurine ----- 2 Contained urate of lime ----- 2 ........and ammonia 3 . . . . urate of soda and lime - - - 1 . . . • oxalate of lime 3 . . . . phosphate of lime 1 . . . . triple phosphate - ... 2 32 - 170 - 142* - 22 - 4 - 2 170 Species 2.—Bodies differing in composition from Nuclei. A. Bodies consisting of oxalate of lime Oxalate of lime and uric acid alternating - - 2 Uric acid in the body, with an outer layer of car- bonate of lime......] Oxalate, chiefly confined to external layers - 1 Oxalate of lime in the bodies nearly pure - - 7 11 B. Bodies consisting chiefly of earthy phosphates Bodies composed of fusible calculus - - - 16 .......phosphate of lime - - 3 ...... . triple phosphate 5 24 C. Body consisting of carbonate of lime 1 B. Body consisting chiefly of urates Contained urate of soda - ........and lime . . . . urate of lime - . ■ . . uric acid in the body 24 From the same patient. APPENDIX. 211 D. Body compound - Body: Urate of ammonia Oxalate of lime 12 Fusible Crust: Fusible - - 1 Uric acid - 3 Fusible - - 3 Triple - - 1 Phosphate of lime 3 Uric acid - 1 12 Genus II.—Nucleus, Urates of Ammonia or Lime, 19. Species I. Calculi nearly all composed of Urate of Ammonia - 8 Urate of ammonia, nearly pure ... 6 Uric acid, in tubercular patches on crust - - 1 Traces of urate of soda and phosphate of lime - 1 Species 2. Bodies differing from Nuclei. - - - - Body: Crust: Uric acid and fusible - As body - - 2 Urate of ammonia - - Uric acid - - 1 .....Oxalate of lime - 1 .....Phosphate of lime 1 and •p Uric acid, with oxalate ~> oxalate of lime 5 and phosphate of lime 5 Urate of ammonia and > . , , , fusible- - - !A9b°dy " " * 10 Urate and phosphate of lime - Oxalate of lime Fusible - }u Ditto Fusible As body 10 Species 3. JVticleus, Urate of Lime. A. Body fusible...... Genus III.—Nucleus, Uric Oxide, 1 Species 1. All Uric Oxide* 1 * A portion of the calculus removed by Langenbeck at Hanover, and analysed by Wohler and Liebig. 212 APPENDIX. Genus IV.—Nucleus, Oxalate of Lime, 47. Species 1. Calculus, nearly all Oxalate - 19 Uric acid in nucleus - - - 1 Crust, covered with opaque octohedral crystals - 1 - transparent ... 3 - not covered with crystals - - - 14 19 Species 2. Bodies differing from Nuclei. A. Bodies consisting of uric acid or urates - - - - Uric acid, nearly pure - - - - - 7 - - - - covered with urate of ammonia - - 1 B. Bodies consisting of phosphates.....14 Phosphate oflime - - - - - - 6 Triple phosphate - - ... - 5 Fusible mixture......3 14 C. Body compound........ Body : Crust: Uric acid .... Fusible 2 - Oxalate of lime J Urate of ammonia - - - Phosphate of lime 1 1. Uric acid - 2. Oxalate of lime \- Oxalate of lime 1 3. Uric acid Cystic oxide } Genus V.—Nucleus, Cystic Oxide. Species 1. All Cystic Oxide......11 Colour, greenish blue.....1 . . . dirty greenish grey .... 9 . . . fawn brown.....1 11 APPENDIX. 213 Genus VI.—Nucleus, Earthy Phosphates, 22. Species 1. All Phosphates of Lime ... - 2 Species 2. All Triple Phosphates 1 Species 3. All Fusible Mixed Phosphates - - - 19 Genus VII.—Ingredients of Calculus mixed, with no evidence of arrangement in con- centric layers ----- A. Uric acid and triple 1 B......phosphate of lime 1 C.....urates of soda and ammonia, with oxalate and phosphate of lime 1 2 1 19 ABSTRACT VIEW OF NUCLEI. Nuclei, consisting of uric acid or urates - - 269 ,.......oxide ... 1 .......cystic oxide - - 11 . . .... . oxalate of lime, - - - 47 , . . . . . . phosphates - * - 22 Mixed calculi 350 Calculi undivided 353 2i 374 I have not included in the ahove Tables the fibrinous calculus of Dr. Marcet, in consequence of its differing so totally from other concretions; as it must be regarded as a portion of dried inspissated albuminous matter exuded from an irritated kidney» rather than as a calculus produced Under circumstances at all analogous to those of other concretions. Several specimens exist in the Museum, of the pelves of kid- neys and ureters being obstructed by clots of fibrin ; but none of them present the hard, concrete condition of the calculus deseribed by Dr. Marcet. I am not aware of this variety having been mentioned by any other author except Brugnatelli, who, in his Litologia Umana, describes some calculi as consisting of crystallised albumen (di materia albuminosa cristallizata di colore d'ambra): they were passed by one individual, and each was about the sifce of a rtut. These pseudo-calculi appeared to consist of dried coagulated albumen, which not unfrequently presents considerable lustre, and a vitreous fracture, although scarcely sufficient to justify its being re- garded as crystallised. 214 APPENDIX. Among the other ingredients existing in calculi, in very minute quantities, and not enumerated in the Table, are, hydrochlorate of ammonia, oxyde of iron, and carbonate of lime. The former has been described by Dr. Yellowly, as a frequent ingredient, generally, however, existing in mere traces in calculi; the second was discovered by Professor Wurtzer, and is often present in uric-acid calculi; and the third is frequently present in phosphatic and oxalic concretions. None of these ingredients are so generally present, as to merit their being regarded as presenting much interest, in a pathlogical sense. Calculi present the greatest possible variety in appearance; generally, however, having more or less of an ovoid figure. Of those in Guy's Museum, the urate of ammonia and uric acid concretions are the most regular, nearly all being ovoid or circular,* a few only reniform ;b this species never presenting any very prominent processes or projections, unless fresh centres of deposition occur on their surfaces, as when crystals of uric acid are deposited on an ovoid urate of ammonia concretion/ The cystic-oxide concretions vary considerably in outline; when large, being gene- rally oval and smooth, as in Fig. 6, Plate II.;> No, 21543, » No 2119. o No. 2158, p No. 2133* APPENDIX. 215 coming dry, the mucus or blood would be diminished to a very thin layer, and the calculus would appear to contain loose matter in it. In a few instances, calculi appear to possess no nucleus, the centre being occupied by a cavity full of stalactitic or mammillated projections, giving the idea of the external layer having been first formed, and the mammillated portions subsequently formed in the interior. This state occurs only, so far as I have seen, in uric-acid calculi.q In one specimen in the collection, the central cavity is lined with fine crystals of triple phosphate, re- sembling the crystals of quartz so often found lining cavities in flints.'' Brugnatelli describes one of a similar kind. Sometimes calculi present very remarkable appearances, as if they had been di- vided into segments: this, in some cases, can be explained by the attrition of calculi' against each other, where several exist at once. In some, they actually appear as if they had been divided by a fine-cutting instrument; and in one, in the Museum, the apparently divided portions seem as if they had again become cemented and framed in by a subsequent deposit.' q No. 2113. * No. 2154. » No. 221888. t No. 213650. ( TABLE OF THE CHEMICAL CONSTITUTION OF ANIMAL AND VEGETABLE PRO- L DUCTS REFERRED TO IN THIS WORK, AND OF SOME OF THEIR MOST IMPORTANT MODIFICATIONS. The letters affixed show the authorities for the respective formulx:—L=Liebig, Wz=.W'6hler, P=P lay fair, B=Bb'kman, S=Schlosser, M=Miihler, E and W=Ettling and Well, D—Demargay, T=Thaulow, K=Dr. Kemp. A. Elements of blood, and tissues formed from it. Ox-blood and muscular flesh - - C48,N6, "39' ^15' P&B ■ C44,N3, H22' °6' Fe M - C48,N6, "36' ^14' L H3> 012, M Albumen of serum=10 Protein-|-S2, P* M -------of eggs =10 Protein+S , P* M Fibrin - =10 Protein+S, P* M Casein - =10 Protein+S M -■ C48,N7$ ' H41' °1S' ' S - C48,N6, "40' ^20' ' S - ^N, H38' °16> " s • C48> N6> "39> "l7» ' K Horny tissue - - " C4S> N7> Hjg, On, - S B. Hepatic elements. Bile of carnivora (leopard) ------omnivora (human) ------graminivora (ox) - Choleic acid ... Taurin - - - - Cholic acid Choloidic acid - Lithofellic acid - Cholesterine - C Renal elements. Urea .... - C2, N2, H4, 02 19 • C48> Nl> H42» °13» ' K " C30' Nl» H45' °10> ' K - C64, N2, H61, O^, - K ^76» ^2' "66» ^22' " ** . C4, N„ H7, O10, - D " C74' H60> °1S» " D * C36» H36' °12' * D - C^, H32, 07, - E & W " C37> H32> 01» ' IS APPENDIX. U»cacid.......CI0,N4, H4, 06 Uric oxide......C5, N2, H2, 02 AHantoin.......C8, N4, H6, 06 Alloxan.......C8, N2, H4, OJ0 cys*™.......C6, Np H6, 04, S2 Murexide.......C]2, N5, H6, Og Hippuric acid......C,8, N,, H8, 05,+HO Benzoic acid......C14 H5, 03 Oxalic acid......C2, 03 Oxaluric acid (2 oxalic acid+1 urea) - - C6, N2, H3, 07+H0 I). Organic acids and neutral bodies. Formic acid......C2, H3, 03, +HO Acetic acid......C4, H3, 03, +HO Lactic acid......C6, H5, 05,+HO Tartaric acid (bibasic) - - - - Cg, H4, O,0,+2 HO Citric acid (tribasic).....C12, H5, Ou,+3 HO Cinnamic acid......C18, H7, 03, +HO Butyric acid......Cg, H6, 03, +HO Stearic acid......C68, H66, Os, +2 HO Margaric acid......C68, H66, 06, +2 HO 01eicacid......C44, H39, 04 Glycerine ......C6, H7, 05,+HO Sugar of canes......c,2, H9, 09,+2 HO ------ SraPes......C12, H12, 012 +2 HO ------milk......C24,H19,019,+5 HO Starch.......C12,H10,O10 Gum.......C12,Hu,Oa LIST OF REFERENCES TO WORKS QUOTED IN THIS VOLUME. N.B. In the first reference to any work its title is given in full. 1. Dr. Prout, Nature and Treatment of Stomach and Urinary Affections, 3d edit. London, 1840, p. xviii. 2. Prof. Liebig, Animal Chemistry, translated by Dr. Gregory, London, 1842, p. 103. 3. Dr. Prout, p. xl. 4. Annalen de Chemie und Pharmacie, B.47, s. 306. 5. Ed. Becquerel, Semeiotique des Urines. Paris, 1841, p. 7. 6. Dr. Kemp's Letter to Prof. Liebig, &c. London, 1844, p. 37. 7. Dr. Golding Bird, Elements of Experimental Philosophy, 2d edit. London, 1844, p. 92—7. 8. Becquerel, p. 13. 9. Dr. Christison, in Library of Medicine. London, 1840, Vol. iv. p. 248. 10. The Lancet. 1844, p. 370. 11. Die Harnsedimente, Nach Dr. Golding Bird, in Hand-bibliothek des Auslandes. Vienna, 1844, B. J, s. 18 (note). 12. The Lancet, June 9, 1844. 13. Becquerel, p. 20. 14. Guy's Hospital Reports. London, Vol. ii. and iii. 15. Comptes rendus de l'Academie des Sciences. Paris, Sept. 7, and Dec. 28, 1840. 16. Repertoire Generales des Sciences Medicales. Paris, T. xviii,, p. 219. 17. Experimental Philosophy, s. c. p. 399. 18. Becquerel, p. 7. 19. Dr. Prout, p. xl. 20. Liebig, p. 137. 22. Simon's Beitrage zur Physiologisch e und Pathologische Chemie und Micro* scopie. Berlin, 1843, B. 1, s. 190. 23. Journal de Pharmacie, T. xxv. p, 261. 24. The London Medical Gazette, Dec. 1843. 25. The Lancet, June 9, 1844. 26. Simon's Handbuch der Medizinschen Chemie. Berlin, 1842. B. 2, s. 355, 27. Dr. Golding Bird, in Medical Gazette, Aug. 24, 1844. 220 APPENDIX. 28. Liebig, p. 55. 29. Quoted in L'Heritier's Traits de Chemie Pathologique, Paris, 1842, p. 439. 30. Die Harnsedimente, p. 56 (note). 31. Simon's Beitrage, p. 190. 32. London Medical Gazette, August, 1844. 33. Simon's Handbuch, B. 1, s. 328. 34. Guy's Hospital Reports, Vol. vii., p. 284. 35. London Medical Gazette, Vol. xiv., p. 600—751. 36.--------------------for Dec. 1843. 37. L'Heritier, p. 446. 38. Memoirs de 1'Academie des Sciences. Paris, 1790. 39. Tiedemann's Zeitschrift, B. 3, s. 321. 40. Berzelius, Traite de Chemie. Paris, 1833, T. vii., p. 327. 41. Dr. Marcet's Essay on the Chemical History and Medical Treatment of Cal- culous Disorders, 2d edit. London, 1819, p. 186. 42. Liebig, p. 137—256. 43. Becquerel, p. 44. 44. Dr. Golding Bird, in Medical Gazette, 1842, p. 397. 45. Guy's Hospital Reports, Vol. vii., p. 175. 46. Dr. Wilson Phillip on Fever, p. 494—583. 47. Medico-Chirurgical Transactions, 1818, Vol. ix., p. 443. 48. Dr. G. Owen Rees, in Guy's Hospital Reports, Vol. i., p. 402. 49. Medico-Chirurgical Transactions, Vol. xxiv. 50. London and Edinburgh Philosophical Magazine, Vol. xx., p. 501. 51. Dr. Marcet, p. 194. 52. Journal de Chemie M£dicale, T. v., p. 513. 53. Annalen der Physik, B. 41, s. 393. 54. Simon's Beitrage, p. 413. 55. Lehrbuch der Chemie, B. 9, s. 491. 56. Journal de Pharmacie, May, 1843. 57. Archiv. des Pharmacie, B. 11, s. 173. 58. Medical Gazette, Vol. xxii., p. 189. 59. Litologia Umana, Ossia Recherche sulle sostance p^trose che si formano in diverso parti del corpo umano. Pavia, 1819, p. 43. 60. Liebig, 321, and Dr. Bence Jones, on Gravel and Gout. London, 1843, p. 116. 61. Dr. Robert Willis, Urinary Diseases and their treatment. London, 1838, p. 109. 62. Dr. Prout, p. 59. 63. Rayer, Traite des Malades des Reins. Paris, 1839, T. i. p. 207. 64. Medical Gazette, Vol. xvii., p. 894. 65.-------------1842, p. 637. 66. Gmelin and Tiedemann, Recherches Experimentales sur la Digestioa. Paris 1827, p. 202. 67. Simon's Handbuch, B. 2, figure 26 of the plate. 68. Dr. Prout, p. 277 ; and Sir E. Brodie's Lectures on Diseases of Urinary Organs, 3d edit. London, 1832, p. 210. APPENDIX. 221 69. Enderlin, in Annalen de Chemie und Pharmacie, 1844, p. 320. 70. Crell's Chemical Journal, 1787, V. ii., p. 103, quoted by Rayer, p. 131. I have not found the paper mentioned by Rayer in this Journal. 71. Medical Gazette, 1834, p. 16 ; and 1836, p. 325. 72. Simon's Handbuch, B. 2, s. 420; and Beitrage, B. 1, s. 107. 73. Becquerel, p. 49. 74. Dublin Journal of Medical Science, Vol. vi., p. 59. 75. Dr. Prout, p. 228. 76. Braithwaite, Retrospect of Practical Medicine, 1843, Vol. vii., p. 47. 77. Dr. Yellowly, on the Calculi in the Norwich Museum, in Philos. Trans., 1830, p. 419. 78. Recueil de Medicine Veterinaire. Paris, p. 445. 79. M. Gurlt's Pathologische Anatomie des Haus—Saugethiere, B. 1, s. 840. 80. Journal de Chemie Medicale, T. i. p. 454. Dr. G. O. Rees, on the Analysis of Blood and Urine. London, p. 81. Journal de Medecine, T. lxxii., p. 174 (Granier's paper). 81. Dr. Prout, p. xcvi. 82. Simon's Beitrage, B. 1, s. 118. 83.-------------------s. 119. 84. Journal de Chemie Medicale, T. i., p. 331. 85.----------------------------p. 454. 86. Medico-Chirurgical Transactions, 1822. 87. Archiv. der Pharmacie, B. 18, s. 159. 88. Guy's Hospital Reports, Vol. vi., p. 121. 89. Dr. Prout, 113—119. 90. Guy's Hospital Reports, Vol. vi., p. 319. 91. Philosophical Transactions, 1822. 92. Guy's Hospital Reports, new series, Vol. ii., p. 514. 93. Inquiry into the Nature and Pathology of Granular Di sease of the Kidney. London, 1842. 94. Medico-Chirurgical Transactions, 1841. 95. Dr. Bright's Reports of Medical Cases, 4to. London, 1827. Dr. Christison on Granular Diseases of the Kidneys; and papers by Drs. Bright, Addison Barlow, &c, scattered through the Guy's Hospital Reports. 96. Guy's Hospital Reports, Vol. iii., p. 51. 97. Sir B. Brodie's Lectures on Diseases of the Urinary Organs, p. 108. 98. Guy's Hospital Reports, Vol. vii., p. 336. 99. Medico-Chirurgical Review, 1839, p. 228, and Journal de Chemie Medicale, 1839. 100. Physiologische Chemie, 1842, B. 1, s. 252. 101. Burdach, Traite de Physiologic Paris, 1839, T. vii. 102. Rayer, T. i., p. 162. 103. Medico-Chirurgical Transactions, Part xviii., p. 80. 104. Dr. Prout, p. 112. 105. Journal de Chemie Mddicale, 1840, p. 68, 106. Lallemand des Pertes Seminales. Paris, 1834. 107. Muller's Elements of Physiology, translated by Dr. Baly, 1842, Vol. ii. p. 1472. 19* 222 APPENDIX. 10S. Elements of Chemistry, by Prof. Graham. London, 1842, p. 808. 109. Dr. Golding Bird, in Medical Gazette, Nov. 24, 1843. 110. Journal de Chemie Medicale, 1844, p. 359. 111. Pritchard's History of Infusoria. London, 1841, p. 134. 112. Paggendorff's Annalen de Physik, V. 1844, and copied into the Chemist for 1844, p. 363. 113. The Lancet for September, 1844, p. 751. 114. Muller's Physiology, by Baly. London, 1840, Vol. i., p. 5. 115. Tiedeman's Zeitschrift. Band 1,—quoted in Mliller's Physiology. 116. Nouvelles Recherches sur l'Endosmose. Paris, 1828. 117. Medical Gazette, March, 1836. 118 Lecon sur la Statique Chemique des etres organise. Paris, 1841, p. 39. ALPHABETICAL INDEX. Abnormal pigments, 160 ----------, tints of urine, 40 Absorption, conditions for, 202 Acids, vegetable, decomposition of, 85 Acid, acetic, test for mucus, 175 ----, Butyric, 57, 184 ----, Hippuric, 50, 88 ----, Lactic, 54 ----, Melanic, 163 ----, Oxalic, 101 ----, Oxaluric, 161 ----, Phosphoric, 59 ----, Sulphuric, 60 ----, Uric, 48, 63 Acute phlegmasia, phosphates in, 139 Albumen, diagnosis of, 166 -------, in pus, 173 -------, in leucorrhoeal discharge, 174 -------, and fibrin, composition of, 60 Alcaline urine, 141 Alcalies, action of, on pus, 41, 173 ——, in uric acid diathesis, 85 Aldridge, Dr., on oxaluria, 126 Assimilation, primary 27 -----------, secondary, 2S Babington, Dr., test for pus, 41,173 Balance of secretion, 32 Barlow, Dr., researches, 206 Becquerel, M., formula for solids in urine, 31 --------------, analysis of urine, 44 ■-------, pathology of uric acid, 79 Berzelius, Prof, on phosphates in feeces, 6 Bile, composition of, 31 ----, Kemp's formula for, 57 ----, tests for, 40, 163 Blot, M., on polarisation, 41 Birds' urine, composition of, 54 Black deposits, 162 Bladder, diseased urine in, 142 Bloody urine, 40, 165 -------------, diagnosis, 165 -------------, microscopic characters of 169 ■------------, pathology of, 170 -------------, treatment of, 170 Blue deposits, 160 Borax, in uric acid diathesis, 86 Braconnot, M., on black deposits, 163 Brett, Dr., on phosphatic deposits, 132 Burdach, Prof, on absorption of milk,185 Butyric acid, 56 Calculi, list of, in Guy's Museum, 209 Capezzuoli, M., test for sugar, 199 Carbonic acid, exhaled from tbe skin, 31 -------------in urine, 89 Carbonate of lime, deposits of, 158 Carnivora, urine of, 51 Casein, in urine, 180 Cases of fatty urine, 189 ------ oxaluria, 116 ------ phosphatic urine, 137, 142,145 ■ pregnancy, 181 ------ uric acid deposits, 83 Chlorine in urine, 59 Chloride of sodium, 98 Christison, Dr., formula for solids, 34 Chylous albumen, 167 ------ urine, 188 Cinnamic acid, 88 Colours of urine, 40 Colouring matters, 57, 160 224 ALPHABETICAL INDEX. Composition of urine, 43 Concretions in glands, 145 Consistence of urine, 40 Curling, Mr., on alcaline urine, 141 Cyanogen in urine, 162 Cyanourine, 160 Cystine, 95 ------, diagnosis, 95 ------, urine containing, 97 ------, microscopic characters, 97 ------, derivation of, 99 Cystitis, phosphatic, 156 Cystorrhoea, 176 Deposits, urinary, 61 ---------------, classification of, 62 ------, cystinic, 95 ------, organic, 165 ------, oxalic, 101 ------, phosphatic, 128 ------, purpuric, 92 ------, siliceous, 158 ------, uric, 63 Density of urine, 33 ---------------, average, 36, 38 -------------—, variations of, 37 Diabetic urine, 41, 76, 197 Diagnosis of albumen, 166 -----------blood, 165 -----------hsematosine, 168 ----------fatty urine, 188 -----------kiestein, 181 -----------mucus, 176 -----------pus, 142 Diuretics, laws of their action, 205 Dropsy, after scarlatina, 172 Dulk, Prof, black deposits, 163 Dumas, Prof, on mucus, 141 Earthy phosphates, 130 Endosmosis, 203 Epithelium, diagnosis of, 179 ----------in oxaluria, 180 Faraday, Dr., on ex ion of nitro- gen, 73 Fat in pus, 173 Fat in urine, 180, 184, 189 -------------, diagnosis, 188 -------------, pathology of, 189 Fermentation of cystinic urine, 97, 198 ---------------saccharine urine, 197 Fever, alcaline urine in, 72 ----, uric deposits in, 72 Fluids, condition of absorption, 202 Food, eflects of different, on urea and uric acid, 47, 78, 83 Formulae for butyric acid, 57 -----------cystine, 99 -----------density, 34 -----------phosphates, 59, 130 -----------oxalic acid, 112, 113, 127, -----------oxaluric acid, 127 -----------urea, 47, 51. 162 -----------uric acid, 51 -----------uric oxide, 91 Gallic acid in hematuria, 171 Gelatinous urine, 40, 184 Gravidine, 185 Gravimeter, 33 Guano, 54 Hssmaphaein in urine, 57 Hsematosine, 168 -----------, diagnosis of, 168 Hssmatoxylum, 168 Henry, Dr., formula for solids, 34 Herbivora, urine of, 158 Hippuric acid, 55, 88 Hydrometer, 33 Indications of the urine, 25 Indigestion, oxalic, 113 ----------, phosphatic, 138, 146 ----------, uric, 82 Indigo in urine, 161 -------------, test for, 162 Jones, Bence, Dr., on urate of ammonia 48 Kemp, Dr., analysis of bile, 31, 57 Kiestein, 181 ALPHABETICAL INDEX. 225 Kiestein, an indication of pregnancy, 188 ■------, absent in urine, 186 ■----<—, absent in fever, 182 ■------, appears on weaning, 187 Lactic acid, 54 ---------, body mistaken for, 55 ---------, relation to food, 55 Law of phosphatic deposits, 144 ------absorption of fluids, 202 Lecanu, M., on urea at different ages, 47 Lehmann, Dr., origin of urea and uric acid, 47, 53 -------------, on butter in kiestein, 184 Liebig, Prof, theory of metamorphosis of tissues, 29 -----------, origin of urea, 46 -----------, action of uric acid on phos- phates, 48 —---------, on a new element in the urine, 55 -----------, hippuric acid, 55 -----------, pathology of uric acid, 74 -----------, tests for cystine, 96 Liquor sanguinis, 165 ------puris, 174 -------muci, 176 Magendie, M., on effects of food on uric acid, 53 Marcet, Dr., on relation of the skin to kidney, 74 ------------, melanic acid, 163 Melanie acid, 163 Melanourine, 162 Metamorphosis of tissue, 28 ---------------muscle, 31 Microscomic salt, 50 Microscopic characters of blood, 169 ----------------------chloride sodi* um, 99 ----------------------cystine, 97 ----------------------carbonate of lime,' 152 ----------------------epithelium, 179 ----------------------fatty urine, 189 193 Microscopic characters of mucus, 176 ————-------------oxalate of lime, 103 --------■—■——-------phosphates, 135 ---------——————- organic glo- bules, 179 --------------■----— pus, 174 .-------------■— uric acid, 66 ------■----i------■----— urate ammonia, 70 .....----------------- urate soda, 71 -----------.----i-----urine of preg- nancy, 183 ----------------—----morbus Brightii, 179 ■' ---u——■ ■ spermatozoa, 195 Milky urine, 180, 186 Moore's, Mr., test for sugar, 199 Morbus Brightii, deposits in, 179 Mucous urine, 175 ---------—, diagnosis, 175 -----------, pathology, 176 ——■-------■, treatment, 177 ------surfaces, secretion of phosphates by, 145 Mulder, Prof, researches on protein, 2 9 Meroxid, 58 Nitric acid, a test for albumen, 166 ------------------bile, 168 Nitrogen excreted in twenty-four hours, 46 Oil in urine, 188 Organic deposits, 165 ----— globules, 178 Oxalic acid, 101, 127 Oxalate of lime, 101 --------------, complications of, 107 147 -, microscopic characters, 102 -, pathology, 109 -, symptoms, 113 -, treatment, 33 -, with spermatozoa, 195 226 ALPHABETICAL INDEX. Oxaluric acid, 127 Pariset,M., test for blood, 168 Pettinkoffer's test for bile, 168 Perspiration, 74 Percyanide of iron, 162 Phosphates, source of, 62 Phosphatic urine, 90 Phosphates, alcaline, in urine, 50 ----------lime, I 35 ---------------secreted by the bladder, 142,145 Phosphate of soda, action of, on uric acid, 49 ---------------in uric diathesis, 88 Phosphates, earthy, basic, 135 ---------------, cases of, 148,152,155 ---------------, concretions of, 145 ---------------, deposited by heat, 107, 132 ---------------, diagnosis of, 127, 130 ---------------, forms of, 133 ---------------, in old age, 138 ---------------, microscopic characters, 135 ---------------, neutral, 133 ---------------, symptoms and treat- ment of, var. 1, 146 ---------------, symptoms and treat- ment of, var. 2, 36 ---------------, symptoms and treat- ment of, var. 3, 154 Physiological origin of urine, 26 Pink deposits, 92 Polarising power of urine, 41 Protein, &c, 29,51 Prout, Dr., on destructive assimilation of tissues, 28 ---------, solubility of uric acid, 48 Purpurine, 57, 92, 167 Purulent urine, 173 Pregnancy, urine, 170, 188 Rees, G. Owen, Dr., on deposition of phosphates by heat, 132 Sailors, rarity of calculus among, 81 Salts in the urine, 45 ----law of absorption of, 202 Schweig's speculations on urine, 38 Seguin, M., on perspiration, 74 Seminal granules, 195 Serpents, urine of, 51 Siliceous deposits, 158 Simon, Franz, Dr., on phosphates in urine, 138 -------------------, urine in fever, 143 Skin, relation of. to the kidneys, 32, 73, 81 Solids in the urine, 34 Sources of the urine, 26 Specific gravity, 33 Spermatic urine, 194 Spine, phosphatic urine in injuries to, 140 Sugar, detection of, 42,198 ----, unconnected with oxaluria, 110 ----, growth of torulse from, 197 Table of analyses of urine, 44, 75 ------ characters of phosphatic urine, 138 ------ colours of urine, 40 ------ composition of organic products, 217 ------ influence of diet in urea, &c, 53 ■ nitrogen excreted in twenty-four hours, 46 ------ oxalate of lime, 105,106, 108 ------ phosphates in food, 59 ------ relation of lactic acid to food, 55 ——— reactions of purpurine, 58 ------ salts in urine, 45 ——— solids in the urine, 36 ------ weights of urine, 36 Therapeutical laws, 1st, 202 -----------------, 3d,206 -----------------, general conclusions from, 208 Torulse in diabetic urine, 197 Trommer's test for sugar, 199 Urate ammonia, diagnosis of, 68 ALPHABETICAL INDEX. 227 Urate ammonia, microscopic characters of, 70 --------------, sources of, 50 Urate of soda, 72 Urea, detection of, 45 ----, physiological sources of, 46 ----, effects of diet and age on, 47, 53 ----, excess of, 137 ----, relation to ammoniacal salts, 47, 144 ---------------- cyanogen, 162 Uric acid, 48 ---------, conditions for its deposition, 47 ---------, diagnosis of, 63 ---------, influence of food on, 53 ---------, microscopic characters of, 66 ---------, pathology of, 71 Uric acid, physiological source of, 51 ---------, state of, in urine, 48 ---------, treatment, 144 Urine, foetid, 139 ----, normal quantity of, 39 ----, ratio to fluids drank, 42 ----, three forms of, 27 Vegetable acids, decomposition of in the stomach, 85 Vibriones in urine, 199 Weight of urine of different densities, 36 Xanthic or uric oxide, 8 Zimmermann, on the urine of birds, 54 THE END. I \ TO THE MEDICAL PROFESSION. The following list of the various professional works published, in press, andpreparingby the subscribers, em* braces numerous TEXT-BOOKS on all the principal departments of Medical Literature, as well as various valu- able specialties. In increasing the number and beauty of the illustrations to these works, anil improving their general appearance and usefulness, it has been the aim of the subscribers to keep ihem at prices within the reach of all, and as low as can be afforded consistent with correct and well executed editions. This, from their extensive engagements in this business, and selling exclusively their own publications, they are enabled lo do with advantage. 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This work is now complete, and forms FOUR LARGE SUPER-ROYAL OCTAVO VOLUMES, CONTAINING THIRTY-TWO HUNDRED AND FIFTY-FOUR UNUSUALLY LARGE PAGES IN DOUBLE COLUMNS, printed on good paper, with a new and clear type. The whole well and strongly bound, WITH RAISED BANDS AND DOUBLE TITLES. Or, to be had, in twenty-four parts, at Fifty cents each. This excellent work has now been before the profession for a short time, and has met with universal approbation as containing a vast body of infopmation on all points connected with Practical Medicine. To physi- cians residing at a distance from Medical libraries, or the means of procu- ring works of reference, it will prove almost invaluable, as a work to be constantly consulted. That the extent of it may be properly understood, the publishers append a list of the contents. It will be seen that one of the peculiar advantages of this work is that every subject has been treated by an author whose attention has been directed peculiarly to that branch, the most eminent physicians of Great Britain having joined in the production of the whole; while the numerous additions of Dr. Dunglison have brought the work up to the very day of publication and with reference particularly to American practice. LEA fy BLANCHARD'S PUBLICATIONS. 5 Cyclopaedia of Practical Medicine, continued. CONTENTS OF VOLUME I. Abdomen, Exploration of the, Dr. Forbes. Abortion, Dr. Lee. Abscess, Internal, Dr, Tweedie. Abstinence, Dr. Marshall Hall. Achor, Dr. Todd. x Acne, Dr. Todd. N Acrodynia, Dr. Dunglison. Acupuncture, Dr. Elliotson. Age, Dr. Roget. Air, Change of. Sir James Clarke. Alopecia, Dr. Todd. Alteratives, Dr. Conolly. Amaurosis, Dr. Jacob. Amenorrhea, Dr. Locock. Anaemia, Dr. Marshall Hall. Anasarca, Dr. Darwall. Angina Pectoris, Dr. Forbes. Anodynes, Dr. Whiting. Anthelmintics, Dr. A. T. Thomson, Anthracion. Dr. Dunglison. Antiphlogistic Regimen, Dr. Barlow. Antispasmodics, Dr. A. T.Thomson. Aorta, Aneurism of, Dr. Hope. Apoplexy, Cerebral, Dr. Clutterbuck. " Pulmonary, Dr. Town- send. Arteritis, Dr. Hope. Ascites, Dr. Darwall. Artisans, Diseases of, Dr. Darwall. Asphyxia, Dr. Roget. " of the New Born, Dr. Dun- glison. Asthma, Dr. Forbes. Astringents, Dr. A. T. Thomson. Atrophy, Dr. Townsend. Auscultation, Dr. Forbes. Barbiers, Dr. Scott. Bathing, Dr. Forbes. Beriberi, Dr. Scott Blood, Determination of. Dr. Bartow. " Morbid Slates of, Dr. Marshall Hall. Blood-letting, Dr. Marshall Hall. Brain, Inflammation of the, Meningitis, Dr. Quain. Ccretoritis, Dr. Adair Craw- ford. Bronchial Glands, Diseases of the, Dr. Dunglison. Bronchitis, Acute and Chronic, Dr. Williams. " Summer, Dr. Dunglison. Bronchocele, Dr. And. Crawford. Bullae, Dr,Todd. Cachexia, Dr. Dunglison. Calculi, Dr. T. Thomson. Calculous Diseases, Dr. Cumin. Catalepsy. Dr. Joy. Catarrh, Dr. Williams. Cathartics, Dr. A. T. Thomson. Chest, Exploration of the, Dr. Forbes. Chicken Pox, Dr. Gregory. Chlorosis, Dr. Marshall Hall. Cholera, Common and Epidemic, Dr. Brown. " Infantum, Dr. Dunglison. Chorea, Dr. And. Crawford. Cirrhosis of the Lung, Dr. Dunglison. Climate, Dr. Clark. Cold, Dr. Whiting. Colic, J3rs. Whiting and Tweedie. Oolica Pictonum, Dr. Whiting. Colon, Torpor of the, Dr. Dunglison Coma, Dr. Adair Crawford. Combustion, Spontaneous, Dr. Ap- john. Congestion of Blood. Dr. Barlow. Constipation, Drs. Hastings and Streeten. Contagion, Dr. Brown. Convalescence, Dr. Tweedie. Convulsions, Dr. Adair, Crawford. " Infantile, Dr. Locock. " x Puerperal, Dr. Locock. Coryr.a, Dr. Williams. Counter Irritation, Dr. Williams. Croup, Dr. Cheyne. Cyanosis, Dr Crampton. Cystitis, Dr. Cumin. .■ . Dead, Persons found, Dr. Beatly. Delirium, Dr. Pritchard. " Tremens, Drs. Carter and Dunglison . Dengue, Dr Dunglison. Dentition, Disorders of, Dr. Joy. Derivation. Dr. Stokes. Diabetes, Dr. Bardsley. Diagnosis, Dr. Marshall Hall. Diaphoretics. Dr. A. T. Thomson. Diarrhoea, Drs. Crampton and Forbes. " Adipous, Dr. Dunglison. Dietetics, Dr. Paris. Disease, Dr. Conolly. Disinfectants. Dr. Dunglison. Disinfection. Dr. Brown. Diuretics. Dr. A. T.Thomson. Dropsy, Dr. Darwall. Dysentery, Dr. Brown. Dysmenorrhea, Dr. Locock. Dysphagia. Dr. Stokes. Dyspnasa, Dr. Williams. Dysuria, Dr. Cumin. Ecthyma, Dr. Todd. Eczema, Dr. Joy. Education, Physical, Dr. Barlow. Electricity, Dr. Apjohn. Elephantiasis, Dr, Joy. Emetics, Dr. A. T. Thomson. Emmenagogues, Dr. A. T. Thomson Emphysema, Dr. R. Townsend. " of the Lungs, Dr. R. Townsend. Empyema, Dr. R. Townsend. Endemic diseases, Dr. Hancock. CONTENTS OF VOLUME II. Fever, Infantile, Dr. Joy. " Hectic, Dr Brown. " Puerperal, Dr. Lee. " Yellow, Dr. Gilkrest. Fungus Haematodes, Dr. Kerr. EnteritiSjDrs. Stokes and Dunglison. Galvanism, Drs. Apjohn and Dungli- Hiccup, Dr. Ash. Haemorrhage, Dr. Watson. Haemorrhoids, Dr. Burne. Hereditary Transmission of Disease, Dr. Brown. Herpes, Dr. A. T. Thomson. Ephelis, Dr. Todd. son. Epidemics, Dr. Hancock. Gastritis, Dr. Stokes. Epilepsy, Dr. Cheyne. Gastrodynia, Dr Barlow, Epistaxis. Dr. Kerr. Gastro-Enteritis, Dr. Stokes Erethismus Mercurialis, Dr. Border. Glanders,_Dr. Dunglison. Erysipelas, Dr. Tweedie. Erythema, Dr. Joy. Eutrophic, Dr. Dunglison. Exanthemata, Dr. Tweedie. Expectorants, Dr. A. T. Thomson. Expectoration, Dr. Williams. Favus, Dr. A. T. Thomson. Feigned diseases, Drs. Scott, Forbes and Marshall. Fever, general doctrine of, Dr. Twee- die. " Continued, and its modifica- tions, Dr. Tweedie. " Typhus, Dr. Tweedie. " Epidemic Gastric,jDr. Cheyne. " Intermittent, Dr. Brown. " Remittent, Dr Brown. " Malignant Remittent, Dr. Dun- glison. Hooping Cough. Dr. Johnson. Hydatids, Dr. Kerr. Hydrocephalus, Dr. Joy. Hydropericardium, Dr. Darwall. Hydrophobia, Dr. Bardsley. Hydrothorax, Dr. Darwall. Hyperesthesia. Dr. Dunglison. Hypertrophy, Dr. Townsend. Hypochondriasis. Dr. Pritchard. Hysteria, Dr. Conolly. Ichthyosis, Dr. Thomson. Identity, Dr. Montgomery. Impetigo, Dr. A. T. Thomson. Impotence, Dr. Beany. Incubus, Dr. Williams. Glossitis, Dr. Kerr. Glottis, Spasm of the, Dr. Joy. Gout, Dr. Barlow. Hasmatemesis, Dr. Goldie. Haemoptysis, Dr. Law. Headache, Dr. Burder. Heart, Diseases of the, Dr. Hope. "' Dilatation of the, Dr. Hope. " Displacement of the, Dr. To v.-n send. " Fatty and greasy degenera- Indigestion, Dr. Todd. tion of the, Dr. Hope. "Induration, Dr. Carswell. " Hypertrophy of the, Dr. Hope. Infanticide, Dr. Arrowsmith. " Malformations of lhe,Dr. Wil- Infection, Dr. Brown. liams. Inflammation, Drs. Adair Crawford " Polypus of the, Dr. Dunglison. and Tweedie. " Rupture of the, Dr. Townsend. " Diseases of the Valves of the, Dr. Hope. CONTENTS OF VOLUME III. Influenza, Dr. Hancock. Insanity, Dr. Pritchard. Intussusception, Dr. Dunglison. Irritation, Dr. Williams. Jaundice, Dr. Burder. '* of the In fant, Dr. Dunglison, Kidneys, diseases o(. Dr. Carter. Lactation, Dr. lx>cock. Laryngitis, Dr. Cheyne. " Chronic, Dr. Dunglison. Latent diseases, Dr. Christison. Lepra, Dr. Houghton. Leucorrhcea, Dr. Locock. Lichen, Dr. Houghton. Liver, Diseases of the, Dr. Stokes. Liver, Diseases of the, Dr. Venables •' Inflammation of the,. Dr. Stokes. Malnria and Miasma, Dr. Brown. Medicine, History of, Dr. Bostock. " American, before the Re' volution, Dr. J. B. Beck. Medicine, Stale of in the 19th Cen- tury, Dr. Alison. " Practical, Principles of, Dr. Conolly. Melnena, Dr. Goldie. Melanosis, Dr. Carswell. Menorrhagia, Dr. Locock. Menstruation, Pathology of, Dr. Lo- cock. Miliaria, Dr. Tweedie. Milk Sickness. Dr. Dunglison. 6 LEA & BLANCHARD'S PUBLICATIOSS. Cyclopaedia of Practical Medicine, continued. CONTENTS OF VOLUME III —Continued. Mind, Soundness and Unsoundness Pancreas, diseases of the, Dr. Carter. Pneumothorax. Dr. Houghton. of, Drs. PritchardtfndDunglison. Paralysis, Dr. Todd. PoTrigo. Dr. A. T, Thomson. Molluscum. Dr. Dunglison. Parotitis, Dr. Kerr. Pregnancy and Delivery, signs of, Mortification, Dr. Carswell, Parturients, Dr. Dunglison, Dr. Montgomery. Narcotics, Dr, A. T. Thomson. Pellagra, Dr. Kerr. Prognosis, Dr. Ash. Nauseants, Dr, Dunglison. Pemphigus, Dr. Corrigan. Prurigo, Dr. A. T. Thomson, Nephralgia and Nephritis. Dr. Carter. Perforation of the Hollow Viscera, Pseudo-Morbid Appearanees, Dr. Neuralgia, Dr. Elliotson.' ' Dr. Carswell. ' Todd. Noli-Me-Tangere or Lupus, Dr. Pericarditis, Dr. Hope. Psoriasis, Dr. Cumin. Houghton. Peritonitis, Drs. Me Adam and Stokes. Ptyalism, Dr. Dunglison. Nyctalopia, Dr Grant. Phlegmasia Dolens, Dr. Lee. Puerperal Diseases, Dr. Marshall Obesity, Dr. Williams, Pityriasis, Dr. Cumin. Hall. CEdema, Dr. Darwall. Plague, Dr. Brown, Pulse, Dr. Bostock. Ophthalmia, Drs. Jacobs and Dungli-Plethora, Dr. Barlow. Purpura, Dr, Goldie. son. Pleurisy, Dr. Law. Pus, Dr. Tweedie. Otalgia and Otitis, Dr. Bnrne. Plica Polonica, Dr. Corrigan. Pyrosis, Dr. Kerr. Ovaria, Diseases of the, Dr. Lee, Pneumonia, Dr, Williams. Rape, Dr, Bealty. Palpitation, Drs. Hope and Dunglison. CONTENTS OF VOLUME IV. Refrigerants, Dr. A. T. Thomson. Statistics, Medical, Dra, Hawkins Toxicology, Drs. Apjohn and Dungli- Rheumatism, Drs. Barlow a"nd Dun- and Dunglison. son. glison.. Stethoscope, Dr. Williams. Transformations, Dr. Duesburv. Rickets. Dr. Cumin. Stimulants, Dr. A. T. Thomson. Transfusion. Dr. Kay. Roseola. Dr. Tweedie. Stomach, Organic Diseases of, Dr.Tnbercle, Dr. Carswell. Rubeola, Dr. Montgomery, Houghton and Dunglison. Tubercular Phthisis, Sir James Clartf, Rupia, Dr. Corrigan. Stomatitis, Dr. Dunglison. Tympanitis. Dr. Kerr. Scabies, Dr. Houghton. Strophulus, Dr. Dunglison, Urine, Incontinence of, Dr. Cumin. Scarlatina, Dr. Tweedie. Succession of Inheritance, Legitima- Urine, Suppression of, Dr. Carter. Scirrhus, Dr. Carswell, cy, Dr. Montgomery, Urine, Morbid States of, Dr. Bostock, Scorbutus, Dr. Kerr. Suppuration, Dr. Todd. Urine, Bloody, Dr. Gwldie. Scrofula, Dr. Cumin. Survivorship, Dr. Beatly. Urticaria, Dr. Houghton. Sedatives, Drs. A. T. Thomson and Sycosis, Dr. Cumin. Uterus, Pathology of, Dr. Lee. Dunglison. Symptomatology, Dr. Marshall Hall. Vaccination, Dr. Gregory, Sex, Doubtful, Dr. Beatty. Syncope, Dr. Ash, Varice la, Dr. Gregory. Small Pox, Dr. Gregory. Tabes Mesenterica. Dr. Joy. Veins, Diseases off Dr. Lee. Softening of Organs, Dr. Carswell. Temperament, Dr. Pritchard, Ventilation, Dr. Brown. Somnambulism and Animai" Magne-Tetanies, Dr. Dunglison. Wakefulness, Df. Cheyne. tism, Dr. Pritchard. Tetanus, Dr. Symonds. Waters Mineral, Dr. T.Thompson. Spermatorrhoea, Dr. Dunglison. Throat, Diseases of the, Dr. Tweedie. Worms, Dr. Joy. Spinal Marrow, Diseases of the, Dr. Tissue Adventitious. Yaws, Dr. Kerr.] Todd. • Tonics, Dr. A.T.Thomson. Index, &c. Spleen, Diseases of the, Drs. Bigsby, Toothache, Dr. Dunglison. .and Dunglison. The Publishers wish it to be particularly understood that this work not only embraces all the subjects properly belonging to PRACTICAL MEDICINE. but includes all the" diseases and treatment of WOMEN AND CHILDREN, as well as all of particular importance on MATERIA MEDICA, THERAPEUTICS, AND MEDICAL JURISPRUDENCE, Thus presenting important claims on the profession from the greater extent of subjects embraced in this than in other works on the mere Practice of Medicine; while, notwithstanding its BEAUTIFUL EXEC UTION, its REMARKABLE CHEAPNESS places it within the reach of all. LEA & BLANCHARD'S PUBLICATIONS. 7 Cyclopaedia of Practical Medicine, continued. The Publishers present a few of the notices which the work has received from the press in this country and in England. " We rejoice that this work is to be placed within great extent and usefulness."—Dr. Barlotc's Address the reach of the profession in this country, it being to the Med. and Sur. Association. unquestionably one of very great value to the practi- " For reference, it is above all price to every practi- tioner. This estimate of it has not been firmed from tioner."— The Western Lancet. a hasty examination, but after an intimate acquaint- "This Cyclopedia is pronounced on all hands to be ance derived from frequent consuhation of it during one of the most valuable medical publications of the the past nine or ten years. Theeditbrs are practiiion- day. It is meant to be a library of Practical Medicine. ers of established reputation, and the list of contribu- As a work of reference it is invaluable. Among the tors embraces many of the most eminent professors contributors to its pages, it numbers many of the most and teachers of London, Edinburgh, Dublin and Glas- experienced and learned physicians of the age, and as gow. It is, indeed, the great merit of this work that a whole it forms a compendium of medical science the principal articles have been furnished by practi- and practice from which practitioners and students Uoners who have not only devoted especial attention may draw the richest instruction.''— Western Journ. to the diseases about which they have written, but of Med. and Surgery. have also enjoyed opportunities for ^n extensive prac- "The contributors are very numerous, including tical acquaintance with them, and whose reputation the most distinguished physicians In the kingdom. carries the assurance of their competency justly to The design of the work embraces practical articles of appreciate the opinions of others, while it stamps their judicious length in Medicine, Therapeutics, Hygiene, own doctrines with high and just authority."—Ameri- &c, so that, within a small compass, and of easy re- can MedicalJournal. ference, the student possesses a complete library, "Do young physicians generally know what a trea- composed of!the highest authorities. To the country sure is offered to them in Dr. Dunglison's revised edi- practitioner, especially, a publication of this kind is tion? Without wishing to be thought importunate, we of inestimable value."— U S. Gazette. cannot very well refrain from urging upon them the " When it is considered that this great work em- claims of this highly meritorious undertaking."—Bos- braces three hundred original essays, from sources of ton Medical and Surgical Journal, the highest authority, we cannot but hope that our " It has been to us, both as learner and teacher, a medical friends will offer all the requisite encourage- work for ready and frequent reference, one In which ment to the publishers."—Boston Medical and Sur- modern English medicine is exhibited in the most gical Journal. advantageous light, and with adaptations to various "In our last number we noticed the publication of tastes and expectations."—Medical Examiner. this splendid work by Lea & Blanchard. We have "Such a work as this has long been wanting in this since received three additional parts, an examination country. British medicine ought to have set itself of which has confirmed us in our first impression, that forth in this way much sooner. We have often won- as a work of reference for the practitioner— as a Cyclo- dered that the medical profession and the enterprising paedia of Practical Medicine—it is admirably adapted publishers of Great Britain did not, long ere this, to the wants of the American profession. In fact, it enter upon such an undertaking as a Cyclopedia of might advantageously find a place'in the library of Practical Medicine."—London Medical Gazette. any gentleman, who has leisure and taste for looking " It is what it claims to be, a Cyclopedia, in which somewhat into the nature, causes, and cure of dis- Practical Medicine is posted up to the present day, eases."— Western Journal of Med. and Surgery. and as such constitutes a storehouse of medical know- "The favourable opinion which we expressed on ledge upon which the student and practitioner may former occasions from the specimens then.before us, draw with equal advantage."—The Western Journal is in no degree lessened by a further acquaintance qf Medicine and Surgery. with its scope and execution."— Medical Examiner, "The Cyclopedia of Practical Medicine, a work "The Cyclopedia must be regarded as the most which does honour to our country, and to which one complete work of Practical Medicine extant; or, at is proud to see the names of so many provincial phy- least in our language. The amount of information on sicians attached."—Dr. Hastings' Address to Pro- every topic which it embraces, is posted up to the vincial Medical and Surgical Association. present time ; and so far as we are able to judge, it is "Of the medical publications of the past year, one generally more free from natural exclusiveness and may be more particularly noticed, as partaking, fr^m prejudices, than is usually the case with British pub- its extent and the number of contributors, somewhat lications. The getting up of the American edition is of the nature of a national undertaking, namely, the very creditableto the Publishers. It will compare very 'Cyclopedia of Practical Medicine.' It accomplishes favourably with the English edition. In some re- what has been noiiced as most desirable, by present- spects, it is much to be preferred. During the original: ing, on several important topics of medical inquiry, publication, many of the articles not being in readi- full, comprehensive, and well digested expositions, ness to be printed in proper alphabetical order, it be- showing the present state of our knowledge on each, came necessary to include them together in a single In this country, a work of this kind was much wanted: volume, as a supplement to the work. This difficuliy and that now supplied cannot but be deemed an im- is obviated in the American edition. On the whole, portanl acquisition. The difficulties of the undertak- we advise those who desire a compendious collection ing were not slight, and it required great energies to of the latest and most important information in the surmount them. These energies, however, were pos- various departments of Practical Medicine, including sessed by the able and distinguished editors, who, Midwifery, Materia Medica, Medical Jurisprudence, with diligence and labour such as few can know or &c, to possess themselves of this work."— The Bvf- appreciate,have succeeded in concentrating in a work falo Medical Journal. of moderate size, a body of practical knowledge of %* In reply to the numerous inquiries made to them respecting Tweedie's Library of Practical Medicine, the Publishers beg leave to state that its place is supplied, in a great measure, by the Cyclopaedia of Practical Medicine, a work much more extended in its plan and execution. The works are entirely distinct and by different authors. The " Library"consists of essays on diseases, systematically arranged. The " Cyclopaedia" embraces these subjects treated in a more extended manner, together with numerous interesting essays on all important points of Medical Jurispru- dence, Materia Medica, Therapeutics, Diseases of Women and Children, History of Medicine, &c, &c, by the first physicians of England, the whole arranged alphabetically for easier reference. 8 LEA & BLANCHARD'S PUBLICATIONS. WATSON'S PRACTICE. NEW AND IMPROVED EDITION. Now Ready, LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. DELIVERED AT KING'S COLLEGE, LONDON. By THOMAS WATSON, M. D., &c. &c. SECOND AMERICAN, FROM THE SECOND LONDON EDITION, REVISED, WITH ADDITIONS, Bv D. FRANCIS CONDIE, M.D., Author of a work wit the " Diseases of Children," &c. In one Octavo Volume. Of nearly eleven hundred large pages, strongly Donnd with raises! hmds* The rapid sale of the first edition of this work is an evidence of its merits, and of its- general favour with the American practitioner. To commend it still more strongly to the profession, the publishers- hare gone to a great expense in preparing this edition with larger type, finer paper, and stronger binding, with raised bands. It is edited with reference par- ticularly to American practice, by Dr. Condie; and with these numerous improvements, the price is still kept so low as to be within the reach of all, and to render it among the cheapest works offered to Ihe profession. It has been received with the utmost favour by the medical press, both of this country and of England, a few of the notices of which, together with a letter from Professor Chapman, are submitted. "We know of no ww4 betfe* calculated for being " We fiftd that, frotw tfte great lengtft we hate gene placed in the hands of the student, and for a text book, is our analysis of this work, we iflust close our notice and as such we are sure it will be very extensively of it here for the present—not, however, without ex-^ _ adopted. On every important point the author seeiws pressing oar unqualified approbatioft of the manner in " io have posted up his knowledge to the day.;'-»-Ameri- whieh the awthor has performed his task. But it is as can Medical Journal. a book of elementary instruetion that we admire Dr. "In the Lectures of tit. Watson, How repabris-bed' WatsonVwork.'— Medico-CkirUrgital Review. here in a large awd elosely-primed volume, we {«ve " One af the most practieally useful books that ever a body of doctrine and practice of medicine well eMl- was presented to1 the student—indeed a more admira- culated, by its intrinsic soundness and correctness of "ble' summary Of gteneral a»d special pathology, and of style, to instruct the student and younger practitioner^ the application-ottrrerapeutiestodiseases, we are free and improve members of the profession of every age." to say has wot appeared1 for very many years. The ^iBvliltin of Medical Seiince. lecturer proceeds through tfte Whole classification of ■'■"We regard these Lecture? as the best exposition human ills, a eapite ad talctm, showing at every step1 of their sobjects of any we remember to have read, an extensive knowledge of his subject, with the ability The author is assuredly master of his art. His has of communicating his precise ideas in a style remark' •been a life of observation and study, and in this Work able for its clearness and simplicity."—-AT. Y. Jottrn*! ' he has given us the matured results of these mental of Medicine and Surgery. *ti&Ut."—New Orleans Medical Journal, LEA & BL\NCHARD'S PUBLICATIONS. WATSON'S PRACTICE—Continued. Philadelphia, September 21th, 1844. Watson's Practice of Physic, in my opinion, is among the most com- prehensive works on the subject extant, replete with curious and important matter, and written with great perspicuity and felicity of manner. As calculated to do much good, I cordially recommend it to that portion of the profession in this country who may be influenced by my judgment. N. CHAPMAN, M.D. Professorofthe Practice and Theory of Medicint in the University of Pennsylvania. "We know not, indeed, of any work of the same "We are free to state that a careful examination of size that contains a greater amount of interesting and this volume has satisfied us that it merits all the, corn- useful matter Tlie iuthor is evidently well acquainted mendation bestowed on it in this country and at with everything appertaining to the principles and home. It is a work adapted to the wants of young practice of medicine, and has incorporated the stores practitioners, combining, as it does, sound principles of his well stocked mind; in the work before us, so and substantial practice. It is not too much to say ably and agreeably, that it is impossible for the inte- that it is a representative of the actual state of medi- rest of the reader to flag for a moment. That they are cine as taught and practised by the most eminent phy- well adapted for such a purpose all must admit; but sicians of the present day, and as such we would their sphere of usefulness may extend much beyond advise every one about embarking in the practice of this. We are satisfied, indeed, that no physician, well physic to provide himself with a copy of it."—Western read and observant as he may be, can rise from their Journal of Medicine and Surgery. perusal without having added largely to his stock of "It is the production of a physician of undoubted valuable information."—Medical Examiner. talent and-great learning, and whose industry in per- "The medical literature of this country has been forming the most laborious duties of this profession enriched by a work of standard excellence, which we has been well known for a long series of years. * * can proudly hold up to our brethren of other countries Let us not forget to add that the style and general as a representative of the natural state of British me- character of the work are peculiarly practical; and dicine, as professed and practised by our most en- the cases which Dr. Watson has from time to time lightened physicians. And, for our own parts, we are introduced to illustrate his views, are highly appro- not only willing that our characters as scientific phy- priate and interesting, and add much to the value of sicians and skilful practitioners may be deduced lrom the work.; and this certainly must be admitted to be the doctrines contained in this book, but we hesitate one of the great advantages of casting this work in not to declare our belief that for sound, trustworthy the shape of lectures, in which these cases assuredly principles, and substantial good practice, it cannot be appear more fitly, and in which they are introduced paralleled by any similar production in any other more easily and naturally than they could have been country. * * * * We would advise no one to set had the form of the work been different. Lastly, we himself down in practice unprovided with a copy."— are well pleased to observe that a strong vein of British and Foreign Medical Review. common sense, as well as good taste, runs through "We cannot refrain from calling the attention of the whole treatise, and sustains both the interest and our younger brethren, as soon as possible, to Dr. Wat- the confidence of the reader throughout"—Edinburgh son's Lectures, if they want a safe and comprehensive Medical and Surgical Journal. guide to the study of practical medicine. " In calling the attention of the profession to the ele- " In fact, to any of our more advanced brethren who gant volume recently published by Lea &. Blanchard wish to possess a commodious book of reference on —the lectures delivered at King's College, London, by any of the topics usually treated of in a course of lee- Dr. Watson—we do not suppose any one at all con- tures on the practice of physic, or who wish to have versant with the medical literature of the day to be a simple enunciation of any facts or doctrines which, unacquainted with its general character. Dr. W. de- from their novelty or their difficulty, the busy practi- livered these now celebrated lectures during the me- tioner may not have made himself master of amidst dical session of 1836-7. They have been revised by the all-absorbing toils of his professional career, we the author, and those who now study these erudite can recommend these lectures most cordially. Here productions will have them divested of any objection- we meet with none of those brilliant theories which able matter that might have formerly crept in through are so leductive to young men, because they are made inadvertence. There are ninety lectures, fully written, to explain every phenomenon, and save all the trouble embracing the whole domain of human maladies, with of observation and reflection; here are no exclusive their treatment, besides an appendix particularly re- doctrines; none of those markable for its richness in important practical infor- mation. We could not give even a tolerable synopsis 'Bubbles that glitter as they rise and break of tne subjects discussed in this great undertaking On vain Philosophy's all babbling spring.' without materially entrenching on ihe limits assigned But we have the sterling production of a liberal, well- to other matter. * * * Open this huge, well-finished stored and truly honest mind, possessed of all that is volume wherever we may, the eye immediately rests currentlyknownandestablishedofprofessionalknow- on something that carries value on its front. We are ledge, and capable of pronouncing a trustworthy and impressed at once with the strength and depth of the impartial judgment on those numerous points in which lecturer's views ; he gains on our admiration in pro- Truth is yet obscured with false facts or false hypo- portion to the extent of our acquaintance with his theses."__Provincial Medical Journal. ' profound researches. Whoever owns this book will "The style is correct and pleasing, and the matter have an acknowledged treasure, if the combined wis- worthy the attention of all practitioners, young and dom of the highest authorities is appreciated."—Boston old."—Western Lancet. » Medical dtnd Surgical Journal. HORNER'S^ANATOMY. SPECIAL ANATOMY AND HISTOLOGY. BY WILLIAM E. HORNER, M.D., Professor of Anatomy in the University of Pennsylvania, Member of the Imperial Medico-Chirurgical Academy of St. Petersburg, of the Am. Philosophical Society, &c, &c. Sixth Edition, in two Volumes, 8vo. " Another edition of this standard work of Professor Horner has made its appearance to which many additions have been made, and upon which much labour has been bestowed by the author.— The additions are chiefly in the department of Histology, or Elementary Anatomy, and so import- ant are they that the Professor has added the term to the title of his work. Every part of this edition seems to have undergone the most careful revision, and its readers may rest assured of hav- ing the science of Anatomy fully brought up to the present day."—Am. Med. Journal. A BXAGITCFXCE1VT AND CHEAP WORK. SMITH & HORNER'S ANATOMICAL ATLAS. Just Published, Price Five Dollars in Parts. AN ANATOMICAL ATLAS ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN BODY. BY HENRY H. SMITH, M. D., Fellow of the College of Physicians, S^c. UNDER THE SUPERVISION OF WILLIAM E. HORNER, M. D., Professor of Anatomy in the University of Pennsylvania. In One large Volume, Imperial Octavo. This work is but just completed, having been delayed over the time intended by the great difficulty in giving to the illustrations the desired finish and perfection. It consists of five parts, whose contents are as follows: Part I. The Bones and Ligaments, with one hundred and thirty engravings. Part II. The Muscular and Dermoid Systems, with ninety-one engravings. Part III. The Organs of Digestion and Generation, with one hundred and ninety-oneengravtngs. Part IV. The Organs of Respiration and Circulation, with ninety-eight engravings. Part V. The Nervous System and the Senses, with one hundred and twenty-six engravings. Forming altogether a complete System of Anatomical Plates, of nearly SIX HUNDRED AND FIFTY FIGURES, executed in the best style of art, and making one large imperial octavo volume. Those who do not want it in parts can have the work bound in extra cloth or sheep at un extra cost. This work possesses novelty both in the design and the execution. It is the first attempt to apply engraving on wood, on a large scale, to the illustration of human unatomy, and the beauty of the parts issued induces the publishers to flatter themselves with the hope of the perfect success of their undertaking. The plan of the work is at once novel and convenient. Each page is perfect in itself, the references being immediately under the figures, so that the eve takes in the whole at a glance, and obviates the necessity of continual reference backwards and forwards. The cuts are selected from the best and most accurate sources; and, where neces- sary, original drawings have been made from the admirable Anatomical Collection of the University of Penn- sylvania. It emljraces all the late beautiful discoveries arising from the use of the microscope in the investi- gation of the minute structure of the tissues. In the getting up of this very complete work, the publishers have spared neither pains nor expense, and they now present it to ihe profession, with the full confidence that it will be deemed all that is wanted in a scientific and artistical point of view, while, at the same time, iis very low price places it within the reach of all. It is particularly adapted to supply the place of skeletons or subjects, as the profession will see by examining the list of plates now annexed. " These figures are well selected, and present a complete and accurate representation of that wonderful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratulate the student upon the completion of this atlas,ns it is the most convenient work of the kind that has yet appeared; and, we must add, the very beautiful manner in which it is ' got up' is so creditable Jo the country us to be flattering to our national pride."—American Medical Journal. "This is an exquisite volume, and a beautiful specimen of art. We have numerous Anatomical Atlases, but wc will venture to say that none equal it in cheapness, and none surpass it in faithfulness and spirit. We strongly recommend lo our friends, both urban and suburban, the purchase of this excellent work< for which both editor and publisher deserve the thanks of the profession."—Medical Examiner. "We would strongly recommend it, not only to the student, but also to the working practitioner, who, although grown rusty in the toils of his harness, still has the desire, and often the necessity, of refreshing his knowledge iu this fundamental part of the science of medicine."—New York Journal of Medicine and Surg. " The plan of this Atlas is admirable, and its execution superior to any thing of the kind before published in this country. It is a real labour-saving affair, and we regard its publication Is the greatest boon that could be conferred on the student of anatomy. It will be equally valuable to the practitioner, by affording him an easy means of recalling the details learned in the dissecting room, and which are soon forgotten."—American Medi- cal Journal. "It is a beautiful as well as particularly useful design, which should be extensively patronized by physicians, surgeons and medical students."—Boston Med. and Surg. Journal. '•It has been the aim of the author of the Atlas to comprise in it the valuable points of all previous works, to embrace the latest microscopical observations on the anatomy of the tissues, und by placing it at a moderate price to enable all to acquire it who may need its assistance in the dissecting or operating room, or other field of practice."—Western Journal of Med. and Surgery. "These numbers complete the series of this beautiful work, which fully merits the praise bestowed upon the earlier numbers. We regard all the engravings g» possessing an accuracy only equalled by their beauty, and cordially recommend the work to all engaged in the study of anatomy."—New York Journal of Medicine and Surgery. " A more ^U-gunt work than the one- before us could not easily be placed by a physician upon the table of Ins student."—Western Journal of Medicine and Surgery. "We were much pleased with Part I, but the Second Part gratifies us still more, both as regards the attract- ive nature of the subject. (The Dermoid and Muscular Systems,) and the beautiful artistical execution of the .llustrations. We have here delineated the most accurate microscopic views of some of the tissues, as, for instance, the cellular and adipose tissues, the epidermis, rete mucosum and cutis vera, the sebaceous and perspiratory organs of the skin, the perspiratory glands and hairs of the skin, and the hair and nails. Then follows the geueral anatomy of the muscles, and, lastly, their separate delineations. We would recommend this Auatomical Atlas to our readers in the very strongest terms.-'—New York Journal of Medicine and Sue gery. LiaT OF THE ILLUSTRATIONS EMBRACING SIX HUNDRED AND THIRTY-SIX FIGURES IN SMITH AND HORNER'S ATLAS. A. Highly-finished View of the Bones of the Head, View of Cuviek's Anatomical Theatre, ..'... facing the title-page . . . . vignette Fig. PART I.—BONES AND LIGAMENTS. Fig. 1 Front view of adult skeleton. 2 Back view of adult skeleton. 3 Fujtal skeleton. 4 Cellular structure of femur. 5 Cellular and compound structure of tibia. 6 Fibres of compact matter of bone. 7 Concentric lamellae of bone. 8 Compact matter under the microscope. 9 Haversian canals and lacuna? of bone. 10 Vessels of compact matter. II Minute structure of bones. 12 Ossification in cartilage. 13 Ossification in the scapula. 14 Puncta ossificationis in femur. 15 Side view of the spinal column. 16 Epiphyses and diaphysis of bone. 17 External periosteum. 18 Punctum ossificationis in the head. 19 A cervical vertebra. 20 The atlas. 21 The dentata. 22 Side view of the cervical vertebras. 23 Sidt- view of the dorsal vertebrae. 24 A dorsal vertebra. 25 Side vie»v of the lumbar vertebrae. 26 Side view of one of the lumbar vertebrae. 27 Perpendicular view of the lumbar vertebrae. 28 Anterior view of sacrum. 29 Posterior view of sacrum. 30 The bones of the coccyx. 31 Outside view of the innominatum. 32 Inside view of the innominatum. 33 Anterior view of the male pelvis. 34 Anterior view of the female pelvis. 35 Front of the thorax. 36 The first rib. 37 General characters of a rib. 38 Front view of the sternum. 39 Head of a Peruvian Indian. 40 Head of a Choctaw Indian. il Front view of the os frontis. 2 Under surface of the os frontis. 43 Internal surface of the os frontis. 44 External surface of the parietal bone.s 45 Internal surface of the parietal hone. 46 External surface of the os occipitis. 47 Internal surface of the os occipitis. 48 External surface of the temporal bone. 49 Internal surface of the temporal bone. 50 Internal surface of the sphenoid boi.e. 51 Anterior surface of the sphenoid bone. 5'i Posterior surface of the ethmoid bone. 53 Front view of the bones of the face. 54 Outside of the upper maxilla. 55 Inside of the upper maxilla. 56 Posterior surface of the palate bone. 57 The nasal bones. 58 The os unguis. 59 Inferior spongy bone. 60 Right malar bone. 61 The vomer. 62 Inferior maxillary bone. 64 Sutures of the posterior of the cranium. 65 Diploe of the cranium. 66 Inside of the base of the cranium. 67 Outside of the base of the cranium. 68 The facial angle. 69 The fontanels. 70 The os hyoides. 71 Posterior of the scapula. 72 Axillary margin of the scapula. 73 The clavicle. 74 The humerus. 75 The ulna. 76 The radius. 77 The bones of the carpus. 78 The bones of the hand. 79 Articulation of the carpal bones. 80 Anterior view of the femur. 81 Posterior view of the femur. 82 The tibia. 83 The fibula. 84 Anterior view of the patella. 85 Posierior view of the patella. 86 The os calcis. 87 The astragalus. 88 The naviculare. 89 The cuboid bone. 90 The three cuneiform'bones. 91 Top of the foot. 92 The sole of the foot. 93 Cells in cartilage. 94 Articular cartilage under the microscope. 95 Costal cartilage under the microscope. 96 Magnified section of cartilage. 97 Magnified view of fibro-cartilage. 98 White fibrous tissue. 99 Yellow fibrous tissue. 100 Ligamentsof the jaw. 101 Internal view of the same. 102 Vertical section of the same. 103 Anterior vertebral ligaments. 104 Posterior vertebral ligaments. 105 Yellow ligaments. 106 Costo-vertebral ligaments. 107 Occipito-altoidien ligaments. 108 Posterior view of the same. 109 Upper part of the same. 110 Moderator ligaments. 111 Anterior pelvic ligaments. 112 Posterior, pelvic ligaments. 113 Sterno-elavicular ligaments. 114 Scapulo-humeral articulation. 115 External view of elbow joint 116 Internal view of elbow joint. 117 Ligamentsof the wrist. 118 Diagram of the carpal synovial membrane 119 Ligaments of the hip joint. 120 Anterior view of the knee joint. 121 Posterior view of the knee joint. 122 Section of the right knee joint. 123 Section of the left knee joint. 124 Internal side of the ankle joint. 125 External side of the ankle joint. 126 Posterior view of the ankle joint 127 Ligaments of the sole of the foot 128 Vertical section of the foot. 63 Sutures of the vault of the cranium. PART II.—DERMOID AND MUSCULAR SYSTEMS. 129 Muscles on the front of the body,/w// length. 133 Blood-vessels of fat. 1 SI Muscles on tlieback of the body,full length. 134 Cell membrane of fat vesicles. ISO The cellular tissue. 132 Fat vesicles. 135 Magnified view of the epidermis. Illustrations to Smith and Horner's JJtlas, continued. Fig. 136 Cellular tissue of the skin. J37 Rete mucosum, &c, of foot. V38 Epidermis and rete mucosum. 139 Cutis vera, magnified. 140 Cutaneous papillae. 141 Internal face of cutis vera. 142 Integuments of foot tinder the microscope. 143 Cutaneous glands. 144 Sudoriferous organs. 145 Sebaceous glands and hairs. 146 Perspiratory gland magnified. 147 A hair under the microscope. 148 A hair from the face under the microscope. 149 Follicle of a hair. 150 Arteries of a hair. 151 Skin of the beard magnified. 152 External surface of the thumb nail. 153 Internal surface of the thumbnail. 154 Section of nail of fore finger. 155 Same highly magnified. 156 Development of muscular fibre. 157 Another view of the same. 158 Arrangement of fibres of muscle. 159 Discs of muscular fibre. J60 Muscular fibre broken transversely. 161 Striped elementary fibres magnified. 162 Stria; of fibres from the heart of an px. 163 Transverse section of biceps muscle. 164 Fibres of the pectoralis major. 165 Attachment of tendon to muscle. 166 Nerve terminating in muscle. 167 Superficial muscles of face and neck. 168 Deep-seated muscles of face and neck. 169 Lateral view of the same. 170 Lateral view of superficial muscles of face. 171 Lateral view of deep-seated muscles of face. 172 Tensor tarsi or muscle of Horner. 173 Pterygoid muscles. 174 Muscles of neck. 175 Muscles of tongue. 176 Fascia profunda colli. 177 Superficial muscles of thorax. 178 Deep-seated muscles of thorax. 179 Front view of abdominal muscles. PART III.—ORGANS OF 220 Digestive organs in their whole length. 221 Cavity of the mouth. 222 Labial and buccal glands. 223 Teeth in the upper and lower jaws. 224 Upper jaw, with sockets for teeth. 225 Lower jaw, with sockets for teeth. 226 Under side of the teeth in the upper jaw. 227 Upper side of the teeth in the lower jaw. 228 to 255. Eight teeth, from the upper jaw. 236 to 243. Eight teeth from the lower jaw. 24 1 to 251. Side view of eight upper jaw teeth. 252 to 259. Side view of eight lower jaw teeth. 260 to 265. Sections of eight teeth, 266 to 267. Enamel and structure of two of the teeth. 268 Bicuspis troth under the microscope. 269 Position oi enamel fibres. 270 Hexagonal enamel fibres. 271 Enamel fibres very highly magnified. 272 A very highly magnified view of fig. 268. 273 Internal portion of the dental tubes. 274 External portion of the dental tubes. 275 Section of the crown of a tooth. '276 Tubes at the root of a bicuspis. 277 Upper surface of the tongue. 278 Under surface of the tongue. 279 Periglottis turned off the tongue. 280 Muscles of the tongue. 2S1 Another view of the same. 282 Section of the tongue. 283 Styloid muscles, &c. 284 Section of a gustatory papilla. 285 View of another papilla. £86 Hoot of the mouth und soft palate. 287 Front view of the pharynx and muscles. 180 Side view of abdominal muscles. 181 External parts concerned in hernia. 182 Internal parts concerned in hernia. 183 Deep-seated muscles of trunk. 184 Inguinal and femoral rings. 185 Deep-seated muscles of neck. 186 Superficial muscles of back. 187 Posterior parietes of chest and abdomen. 188 Under side of diaphragm. 189 Second layer of muscles of back. 190 Muscles of vertebral gutter. 191 Fourth layer of muscles of back. 192 Muscles behind cervical vertebrae. 193 Deltoid muscle. 194 Anterior view of muscles of shoulder. 195 Posterior view of muscles of shoulder. 196 Another view of the same. 197 Fascia brachialis. 198 Fascia of the fore-arm. 199 Muscles on the back of the band. 200 Muscles on the front of the arm. 201 Muscles on the back of the arm. 202 Pronators of the- fore-arm. £03 Flexor muscles of fore-arm. 204 Muscles in palm of hand. 205 Deep flexors of the fingers. 206 Superficial extensors. 207 Deep-seated extensors. 208 Rotator muscles of the thigh. 209 Muscles on the back of the hip. 210 Deep muscles on the front of thigh. 211 Superficial muscles on the front of tbigb. 212 Muscles on the back of the thigh. 213 Muscles on front of leg. 214 Muscles on back of leg. 215 Deep-seated muscles on back of leg. 216 Muscles on the sole of the foot 217 Another view of the same. 218 Deep muscles on front of arm. 219 Deep muscles on back of arm. 288 Back view of the pharynx and muscles. 289 Under side of the soft palate. 290 A lobule of the parotid gland. 291 Salivary glands. 292 Internal surface of the pharynx. 293 External surface of the pharynx. 294 Vertical section of the pharynx. 295 Muscular coat of the oesophagus. 296 Longitudinal section of the esophagus. 297 Parietes of the abdomen. 298 Reflexions of the peritoneum. ' 299 Viscera of the chest and abdomen. 300 Another view of the same. SOI The intestines in situ. 302 Stomach and oesophagus. 303 Front view of the stomach. 304 Interior of the stomach. 305 The stomach and duodenum. 306 Interior of the duodenum. S07 Gastric glands. 308 Mucous coat of the stomach. 309 An intestinal villus. 310 Its vessels. 311 Glands of the stomach magnified. 312 Villus and lacteal. 313 Muscular coat of the ileum. 314 Jejunum distended and dried. 315 Follicles of Lieberkuhn 316 Glands of Brunner. 317 Intestinal glands. 318 Valvulw conniventes. 319 Ileo-colic valve. 320 Villi and intestinal follicles. 321 Veins of the ileum. 322 Villi filled with chyle. 323 Peyer's glands 324 Villi of the jejunum under the microscope. 3'-'5 The caecum. 326 The mesocolon and colon, 327 Muscular coat of the colon. DIGESTION AND GENERATION. Illustrations to Smith and Hornep's Jltlas continued. Fig. 328 Muscular fibres of the rectum. 329 Curvatures of the large intestine. SSO Mucous follicles of the rectum. 331 Rectal pouches. 332 Follicles of the colon, highly magnified. 333 Folds and follicles of the stomach. 334 Follicles, &c. of the jejunum. 335 Villi and follicles of the ileum. 336 Muciparous glands of the stomach. 337 Ileum inverted, &c. 338 Glands of Peyer magnified. 339 Peritoneum of the liver injected. 340 Liver in situ. 341 Under surface of the liver. 342 Hepatic vein. 386 Testis in the foetus Fig. 373 Sphincter apparatus of the bladder. 374 Prostate and vesiculas seminales. 375 Side view of the pelvic viscera. 376 The glans penis injected. 377 The penis distended and dried. 378 Section of the same. 379 Vertical section of the male pelvis, &c. 380 Septum pectiniforme. 381 Arteries of the penis. 382 Vertical section of the urethra. 383 Vesiculas seminales injected. 384 Muscles of the male perineum. S85 Interior of the pelvis, seen from above. 343 Parenchyma of the liver. 344 Hepatic blood-vessels. 345 Biliary ducts. 346 Angular lobules of the liver. 347 Rounded hepatic lobules. 348 Coats of the gall bladder. 349 Gall bladder injected. 350 Vena portarum. 351 External face of the spleen. 352 Internal face of the spleen. S53 Splenic vein. 354 Pancreas &c, injected. 355 Urinary organs. 356 Right kidney and capsule. 357 Left kidney and capsule. 358 Kidney under the microscope. 359 The ureter. 360 Section of right kidney. 361 Section of the left kidney. 362 Pyramids of Malpighi. 363 Lobes of the kidney. 364 Renal arteries, &c, injected. 365 Section of the kidney highly magnified. 366 Copora Malpighiana. 367 Same magnified. 368 Tubuli uriniferi. 369 Corpora Wolfiiana. 370 The bladder and urethra, full length. 371 Muscular coat of the bladder. 387 Diagram of the descent of the testis. 388 Tunica vaginalis testis. S89 Transverse section of the testis. 390 Relative position of the prostate. 391 Vas deferens. 392 Vertical section of the bladder. 393 The testicle injected with mercury. 394 Another view. 395 Minute structure of the testis. 396 Female generative organs. 397 Another view of the same. 398 External organs in the fcetus. 399 Muscles of the female perineum. 400 Side view of the female pelvis, &c. 401 Relative position of the female organs.' 402 Section of the uterus, &c. 403 Fallopian tubes, ovaries, &c. 404 Front view of the mammary gland. 405 The same after removal of the skill. 406 Side view of the breast 407 Origin of lactiferous ducts. 408 Lactiferous tubes during lactation. 409 Minute termination of a tube. 410 Ducts injected; after Sir Astley Cooper. 372 Another view of the same PART IV.—ORGANS OP RESPIRATIQN AND CntCULATION. 411 Front view of the thyroid cartilage. 450 The external carotid artery. 412 Side view of the thyroid cartilage. 451 A front view of arteries ot head and neck. 413 Posterior of the arytenoid cartilage. 452 The internal maxillary artery. 4 4 Anterior of the arytenoid cartilage. 45S Vertebral and carotid arteries with the aorta. 415 Epiglottis cartilage. 416 Cricoid cartilage. 454 Axillary and brachial arteries. 417 Ligaments of the larynx. 418 Side view of the same. 419 The thyroid gland. 420 Internal surface of the larynx. 421 Crico-thyroid muscles. 422 Crico-arytenoid muscles. 423 Articulations of the larynx. 424 Vertical section of the larynx. 425 The vocal ligaments. 426 Thymus gland. 427 Front view of the lungs. 428 Back view of the lungs. 429 The trachea and bronchia. 430 Lungs, heart, &c. 431 First appearance of the blood-vessels. 4S2 Capillary vessels magnified. 433 Another view of the same. 434 Blood globules. 435 Another view of the same. 436 The mediastina. 437 Parenchyma of the lung. 438 The heart and pericardium. 439 Anterior view of the heart. 440 Posterior view of the heart. 441 Anterior view of its muscular structure. 442 Posterior view of the same. ' 443 Interior of the right ventricle. 444 Interior of the left ventricle. 445 Mitral valve, the size of life. 446 The auriculo-ventricular valves. 447 Section of the ventricles. 448 The arteries from the arch of the aorta. 449 The arteries of the neck, the size of life. 455 The brachial artery. 456 Its division at the elbow. 457 One of the anomalies of the brachial artery. 458 Radial and ulnar arteries. 459 Another view of the same. 460 The arcus sublimis and profundus.' 461 The aorta in its entire length. 462 Arteries of the stomach and liver. 463 Superior mesenteric artery. 464 Inferior mesenteric artery. 465 Abdominal aorta. 466 Primitive iliac and femoral arteries. 467 Perineal arteries of the male. 468 Position of the arteries in the inguinal canal. 469 Internal iliac artery. 470 Femoral artery. 471 Gluteal and ischiatic arteries. 472 Branches of the ischiatic artery. 473 Popliteal artery. 474 Anterior tibial artery. 475 Posterior tibial artery. 476 Superficial arteries on the top of the foot 477 Deep-seated arteries on the top of the foot 478 Posterior tibial artery at the ankle. 479 The plantar arteries. 480 Arteries and veins of the face and neck. 481 Great vessels from the heart. 482 External jugular vein. 483 Lateral view of the vertebral sinuses. 484 Posterior view of the vertebral sinuses. 485 Anterior view of the vertebral sinuses. 486 Superficial veins of the arm. 487 The same at the elbow. Illustrations to Smith and Horner's Atlas continued. F'K. 488 I he veins of the hand. 489 The great veins of the trunk. 490 Positions ofthearteriesand veins of the trunk. 491 The venx cavae. 492 The vena portarum. 493 Deep veins of the back of the leg. 494 Positions of the veins to the arteries in the arm. 495 Superficial veins of the thigh. 496 Saphena vein. 497 Superficial veins of the leg. 498 Lymphatics of the upper extremity. Fig. 499 The lymphatics and glands of the ax:lla. 500 The lemoral and aortic lymphatics. 501 The lymphatics of the small intestines. 502 The thoracic duct. 503 The lymphatics of the groin. 504 Superficial lymphatics of the uiigh. 505 Lymphatics of the jejunum. k 506 Deep lymphatics of the thigh. 507 Superficial lymphatics of the leg. 508 Deep lymphatics of the leg. PART V.—THE NERVOUS SYSTEM AND SENSES. 509 Dura mater cerebri and spinalis. 510 Anterior view of brain and spinal marrow. 511 Anterior view of the spinal marrow, Sec. 512 Lateral view of the spinal marrow, &c. | 513 Posterior view of the spinal marrow, etc. 514 Decussation of Mitischelli. 515 Origins of the spinal nerves. 516 Anterior view of spinal marrow and nerves. 517 Posterior view of spinal marrow and nerves. 518 Anterior spinal commissure. 519 Posterior spinal commissure. 520 Transverse section of the spinal marrow. 521 Dura mater and sinuses. 522 Sinuses laid open. 523 Sinuses at the base of the cranium. 524 Pons Varolii, cerebellum, &c. 525 Superior face of the cerebellum. 526 Inferior face of the cerebellum. 527 Another view of the cerebellum. 528 View of the arbor vilae, &c. 529 Posterior view of the medulla oblongata. 530 A vertical section of the cerebellum. 531 Another section of the cerebellum. 532 Convolutions of the cerebrum. 5S3 The cerebrum entire. 534 A section of its base. 535 The corpus callosum entire. 536 Diverging fibres of the cerebrum, &c. 537 Vertical section of the head. 538 Section of the corpus callosum. 539 Longitudinal section of the brain. 540 View of a dissection by Gall. 541 The commissures of the brain. 542 Lateral ventricles. 543 Corpora striata-fornix, &tc. 544 Fifth ventricle and lyra. 545 Anotberjview of the lateral ventricles. 546 Another view of the ventricles. 547 Origins of the 4th and 5th pairs of nerves. 548 The circle of Willis. 549 A side view of the nose. 550 The nasal cartilages. 551 Bones and cartilages of the nose. 552 Oval cartilages, fco. 553 Schneiderian membrane. 554 External parietes of the left nostril. 555 Arteries of the nose. 556 Pituitary membrane injected. 557 Posterior j^rea. 558 Front view of the eye, 559 Side view of the eye. 560 Posterior view of the eyelids, &c. 561 Glandule palpebrarum. 562 Lachrymal canals. 563 Muscles of the eyeball. 564 Side view of the eyeball. 565 Longitudinal section of the eyeball. 566 Horizontal section of the eyeball. 567 Anterior view of a transverse section. 568 Posterior view of a transverse section. 569 Choroid coat injected. 570 Veins of the choroid coat |7l The iris. 572 Tbejrefia and lens, 573 External view of the same. 574 Vessels in the conjunctiva. 575 Retina, injected and magnified. 576 Iris, highly magnified. 577 Vitreous humour and lens. 578 Crystalline adult lens. 579 Lens of the foetus, magnified. 580 Side view of the lens. 581 Membrana pupillaris. 582 Another view of the same. 583 Posterior view of the same. 584 A view of the left ear. 585 Its sebaceous follicles. 586 Cartilages of the ear. 587 The same with its muscles. 588 The cranial side of the ear. 589 Meatus auditorins externus, &c. 590 Labyrinth and bones of the ear. 591 Full view of the malleus. 592 The incut. 593 Another view of the malleus. 594 A front view of the stapes. 595 Magnified view of the stapes. 596 Magnified view of the incus. 597 Cellular structure of the malleus. 598 Magnified view of the labyrinth. 599 Natural size of the labyrinth. 600 Labyrinth laid open and magnified. 601 Labyrinth, natural size. 602 Labyrinth of a foetus. 603 Another view of the same. 604 Nerves of the labyrinth. 605 A view of the vestibule, &c. 606 Its soft parts, &c. 607 An ampulfa and nerve. 608 Plan of the cochlea. 609 Lamina spiralis, &c. 610 The auditory nerve. 611 Nerve on the. lamina spiralis. 612 Arrangement of the cochlea. 613 Veins of the cochlea, highly magnified. 614 Opening of the Eustachian tube in the throat 615 Portio mollis of the seventh pair of nerves. 616 The olfactory nerves. 617 The optic and seven other pairs of nerves. 618 Third, fourth and sixth pairs of nerves, 619 Distribution of the fifth pair. 620 The facial nerve. 621 The hypo-glossal nerves. 622 A plan of the eighth pair of nerves. 623 The distribution of the eighth pair. 624 The great sympathetic nerve. 625 The brachial plexus. 626 Nerves of the front of the arm. 627 Nerves of the back of the arm. 628 Lumbar and ischiatic nerves. 629 Posterior brandies to the hip, &e. 630 Anterior crural nerve. 631. Anterior tibial nerve. 6S2 Branches of the popliteal nerve. 633 Posterior tibial nerve on the leg. 634 Posterior tibial nerve on the foot LEA & BLANCHARD'S PUBLICATIONS. 15 PROFESSOR DUNGUSON'S WORKS. The Works of Professor Dunglison on various departments of Medicine are here presented.— Nearly all of them are extensively used as text books in the branches of science to which they re late, and the profession and students may rely upon the great care and accuracy of the author in having each new edition of his works posted up to the day of publication. A NEW EDITION OF THE STANDARD MEDICAL DICTIONARY. A DICTIONARY OF~MEDICAL SCIENCE: CONTAINING A CONCISE ACCOUNT OF THE VARIOUS SUBJECTS AND TERMS, WITH THE FRENCH AND OTHER SYNONYMES, NOTICES OF CLIMATES AND OF CELE- BRATED MINERAL WATERS, FORMULA FOR VARIOUS OFFICINAL AND EMPIRI- CAL PREPARATIONS, &c. Fifth Edition, Extensively Modified and Improved over former Editions. BY ROBLEY DUNGLISON, M.D. Professor of the Institutes of Medicine, &c, in Jefferson Medical College, Philada.; Secretary to the American Philosophical Society, &c, &c. In one large royal octavo volume of nearly 800 double columned pages, and bound with raised bands. The author's object has not been to make the work a mere Lexicon, or Dictionary of terms, but to afford, under each, a condensed view of its various medical relations, and thus to render the work a complete epitome of the existing condition of medical science. This he has been in a great measure enabled to do, as the work is not stereotyped, by adding in each successive edition all new and interesting matters or whatever of importance had been formerly omitted. To show the advantage of this, it need only be remarked that in the present work will be found at least two thousand subjects and terms not embraced in the third edition. "To execute such a work requires great erudition, unwearied industry, and extensive research; and we know no one who could bring to the task higher qualifications of this description than Pro- fessor Dunglison."—American Medical Journal. DUNGUSON'S PRACTICE, A NEW EDITION, THE PRACTICE! OF MEDICINE, OR A TREATISE ON SPECIAL PATHOLOGY AND THERAPEUTICS. BY ROBLEY DUNGLISON, M.D., Second Edition, carefully Revised and with Additions. In Two Large Octavo Volumes of over thirteen hundred pages. The Publishers annex a condensed statement of the Contents:—Diseases of the Mouth, Tongue, Teeth, Gums, Velum Palati and Uvula, Pharynx and (Esophagus, Stomach, Intestines, Peritoneum, Morbid Productions in the Peritoneum, and Intestines.—Diseases of the Larynx and Trachea, Bron- chia and Lungs, Pleura, Asphyxia.—Morbid conditions of the Blood, Diseases of the Heart and Membranes, Arteries, Veins, Intermediate or Capillary Vessels,—Spleen, Thyroid Gland, Thymus Gland, and Supra Renal Capsules, Mesenteric Glands,—Salivary Glands, Pancreas, Biliary Appara- tus, Kidney, Ureter, Urinary Bladder.—Diseases of the Skin, Exanthematous, Vesicular, Bullar, Pustular, Papular, Squamous, Tuberculous, Maculae, Syphilides.—Organic Diseases of the Nervous Centres, Neuroses, Diseases of the Nerves.—Diseases of the Eye, Ear, Nose.—Diseases of the Male and Female Organs of Reproduction. Fever,—Intermittent, Remittent, Continued, Eruptive, Arthritic.—Cachexies, Scrofulous, Scorbutic, Chlorotic, Rhachitic, Hydropic and Cancerous. This work has been introduced as a text-book in many of the Medical Colleges, and the general favour with which it has been received, is a guarantee of its value to the practitioner and student. " In the volumes before us, Dr. Dunglison has proved that his acquaintance with the present facts and doctrines, wheresoever originating, is most extensive and intimate, and the judgment, skill, and impartiality with which the materials of the work have been collected, weighed, arranged, and «xposed, are strikingly manifested in every chapter. Great care is everywhere taken to indicate the source of information, and under the head of treatment, formulae of the most appropriate reme- dies are everywhere introduced. We congratulate the students and junior practitioners of Ame- rica, on possessing in the present volumes, a work of standard merit, to which they may confidently refer in their doubts and difficulties."—British and Foreign Medical Review, for July, 1842. " Since the foregoing observations were written, we have received a second edition of Dungli- son's work, a sufficient indication of the high character it has already attained in America, and justly attained."—British and Foreign Medical Review, for October, 1844. "We hail the appearance of this work, which has just been issued from the prolific, press of Messrs. Lea & Blanchard of Philadelphia, with no ordinary degree of pleasure. Comprised in two large and closely printed volumes, it exhibits a more full, accurate, and comprehensive digest of the existing state of medicine than any other treatise with which we are acquainted in the English language. It discusses many topics-r-some of them of great practical importance, which are en- tirely omitted in the writings of Eberle, Dewees, Hosack, Graves, Stokes, Mcintosh, and Gregory ; and it cannot fail, therefore, to be of great value, not only to the student, but to the practitioner, as it affords him ready access to information of which he stands in daily need in the exercise of his profession."—Louisville Journal. , 16 LEA & BLANCHARD'S PUBLICATIONS. PROFESSOR DUNGLISON'S WORKS—Continued. GENERAL THERAPEUTICS AND MATERIA MEDICA, ADAPTED FOR A MEDICAL TEXT-BOOK. BY ROBLEY DUNGLISON, M.D., In two Volumes, Svo. v " The subject of Materia Medica has been handled by our author with more than usual judgment. The greater part of treatises on that subject are, in effect expositions of the natural and chemical history of the substances used in medicine, with very brief notices at all of the indications they are capable of fulfilling, and the general principles of Therapeutics. Dr. Dunglison, very wisely, in our opinion, has reversed all this, and given his principal attention to the articles of the Materia Medica as medicines.....In conclusion, we strongly recommend these volumes to our readers.— No medical student on either side of the Atlantic should be without them."—Forbes' British and Foreign Medical Review. " Our junior brethren in America will find in these volumes of Professor Dunglison a e Thesau- rus Medicaminum,' more valuable than a large purse of gold."—Medico-Chirurgical Review, for January, 1845. WITH UPWARDS OF THREE HUNDRED ILLUSTRATIONS, BY ROBLEY DUNGLISON, M.D., Fifth Edition, Greatly Modified and Improved, in 2 Vols, of 1304 Large Octavo Pages. " We have on two former occasions, brought this excellent work under the notice of our readers, and we have now only to say that, instead of falling behind in the rapid march of physiological science, each edition brings it nearer to the van. Without increasing the bulk of the treatise, the author has contrived to introduce a large quantity of new matter into this edition from the works of Valentin, Bischoff, Henle, Wildebrand, Muller, Wagner, Mandl, Gerber, Liebig, Carpenter, Todd and Bowman, as well as from various monographs which have appeared in the Cyclopaedias, Trans- actions of learned societies and journals. The large mass of references which it contains renders it a most valuable bibliographical record, and bears the highest testimony to the zeal and industry of the author."—British and Foreign Medical Review. " Many will be surprised to see a fifth edition of this admirable treatise so rapidly succeeding the fourth. But such has been the rapid progress of physiology within a short period that to make his work a fair reflection of the present state of the science, no less than an account of its extensive popularity, Dr. Dunglison has found it necessary to put forth a new edition with material modifica- tions and additions. To those who may be unacquainted with the work, we may say that, Dr. D. does not belong to the mechanical, chemical, or vital school exclusively ; but that, with a discri- minating hand he culls from each and all, making his treatise a very excellent and complete digest of the vast subject."—Western Journal of Medicine and Surgery. NEW REMEDIES, PHARMACEUTICALLY AND THERAPEUTICALLY CONSIDERED, BY ROBLEY DUNGLISON, M.D., In One Volume, Octavo, over 600 pages, the Fourth Edition. Or, the Influence of Atmosphere and Locality, Change of Air and Climate, Seasons, Food, Clothing, Bathing and Mineral Springs, Exercise, Sleep, Corporeal and Intellectual Pursuits, &c., &c, on Healthy Man: Constituting x ELEMENTSOF HYGIENE. BY ROBLEY DUNGLISON, M.D. A New Edition with many Modifications and Additions. In One Volume, Svo. "We have just received the new edition of this learned work on the « Elements of Hygiene.'__ Dr. Dunglison is one of the most industrious and voluminous authors of the day. How he finds time to amass and arrange the immense amount of matter contained in his various works, is almost above the comprehension of men possessing but ordinary talents and industry. Such labour de- serves immortality."—St. Louis Med. and Surg. Journal. A NEW EDITION OF THE MEDICAL STUDENT, OR AIDS TO THE STUDY OF MEDICINE. A REVISED AND MODIFIED EDITION. BY ROBLEY DUNGLISON, M.D., In One neat I2mo. Volume. LEA & BLANCHARD'S PUBLICATIONS. 17 CHAPMAN'S WORKS ON THE PRACTICE OF MEDICINE. CHAPMAN ON FEVERS, ETC. LECTURES ON THE MORE IMPORTANT ERUPTIVE FEVERS, HEMORRHAGES AND DROPSIES, AND ON GOUT AND RHEUMATISM, DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. By N. CHAPMAN, M.D., Professor of the Theory and Practice of Medicine, &C &c. In one neat Octavo Volume. This volume contains Lectures on the following subjects: EX ANTHEM ATOUS FEVERS. Variola, or Small Pox; Inoculated Small Pox; Varicella, or Chicken Pox; Variolae Vaccinia?, or Vaccinia, or Cow-pock j Varioloid Disease; Rubeola, Morbilli, or Measles; Scarlatina vel Febris Rubra—Scarlet Fever. HEMORRHAGES. Haemoptysis, Spitting of Blood; Hsemorrhagia Nariumjor Haemorrhage from the Nose; Haematemesis, or Vomiting of Blood ; Hematuria, or Voiding of Bloody Urine ; Hsemorrhagia Uterina, or Uterine Haemorrhage; Htemorrhois or Haemorrhoids; Cutaneous Haemorrhage ; Purpura Ha;morrhagica. DROPSIES. Ascites; Encysted Dropsy; Hydrothorax; Hydrops Pericardii; Hydrocephalus Internus, acute, subacute, and chronic : Anasarca; with a Disquisition on the Management of the whole. GOUT, RHEUMATISM, &c. &c. "The name of Chapman stands deservedly high in the annals of American medical science. A teacher and a lecturer for nearly forty years, in the oldest and, we believe, the first medical school on this side of the Atlantic, the intimate friend and companion of Rush, Kuhn, Physick, Wistar, Woodhouse, Dewees, and a host of others scarcely less renowned, Professor Chapman reflects upon the profession of this generation something of the genius and wisdom of that which has passed; he stands out the able and eloquent champion of the doctrines and principles of other times, when Cullen's "first lines" formed the rule of faith for all the Doctors in Medicine throughout Christendom. In him is embodied the experience of three score and ten, strengthened by reading, and enlightened by a familiar intercourse with many of the ablest medical men in the New and Old World. "In conclusion, we must declare our belief that the name of Chapman will survive when that of many of his cotemporaries shall have been forgotten; when other generations shall tread the great theatre of human affairs, and when other discoveries yet undisclosed, shall shed a brighter light upon the path of medical science. The various lectures which he has been publishing, containing, as they do, the doctrines- that he has so long and so eloquently taught to large and admiring classes, we doubt not will be welcomed with delight by his nu- merous pupils throughout the Union."—New Orleans Medical Journal. CHAPMAN ON THORACIC VISCERA, ETC. LECTURES ON THE MORE IMPORTANT DISEASES OF THE THORACIC AND ABDOMINAL VISCERA. DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. By N. CHAPMAN, M.D. Professor of the Theory and Practice of Medicine, &c. In one Volume, Octavo. WILLIAMS AND CLYMER ON THE RESPIRATORY ORGANS, ETC. A TREATISE ON THE DISEASES OF THE RESPIRATORY ORGANS, INCLUDING THE TRACHEA, LARYNX, LUNGS, AND PLEURA. Bv CHARLES J. B. WILLIAMS, M.D., Consulting Physician to the Hospital for Consumption and Diseases of the Chest; Author of " Principles of Medicine," &c. &c. WITH NUMEROUS ADDITIONS AND NOTES. By MEREDITH CLYMER, M.D., Physician to the Philadelphia Hospital. In one neat 8vo. Volume, with Cuts. This work recommends itself to the notice of the profession as containing a more particu- lar and detailed account of the affections of which it treats than perhaps any other volume before the public. " The wood cuts illustrating the physical examination of the chest, are admirably executed, and the whole mechanical execution of the work, does much credit to the publishers. This work is undoubtedly destined to take precedence of all others yet published on the "Respiratory Organs," and as a text book for teachers and students, no better in the present state of the science is to be expected "—New York Journal of Mediein*. 18 LEA & BLANCHARD'S PUBLICATIONS. NOW READY, A NEW AND IMPROVED ESITION OF RAMSBOTHAM'S STANDARD WORK ON PARTURITION. THE PRINCIPLES AND PRACTICE OF Y IN REFERENCE TO THE PROCESS OE PARTURITION. ILLUSTRATED BY One hundred and forty-eight Large Figures on 85 Lithographic Plates. By FRANCIS H. RAMSBOTHAM, M. D., &c. A NEW EDITION, FROM THE ENLARGED AND REVISED LONDON EDITION. In one large imperial octavo volume, well bound. The present edition of this standard work will be found to contain numerous and important improvements over the last. Besides much additional matter, there are several more plates and wood-cuts, and those which were before used have been re-drawn. This book has long been known to the profession, by whom it has been most flatteringly received. The publishers take great pleasure in submitting the followingtestimony to its value from Professor Hodge, of the Pennsylvania University. Philadelphia, August 6th, 1845. Gentlemen:—I have looked over the proofs of Ramsbotham on Human Parturition, with its important improvements, from the new London edition. This Work needs no commendation from me, receiving, as it does, the unanimous recommendation of the British, periodical press, as the standard work on Midwifery; "chaste in language, classical in composition, happy in point of arrangement, and abounding in most interesting illustrations."* To the American public, therefore, it is most valuable—from its intrinsic undoubted excellence, and as being the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive through- out our country. There is, however, a portion of Obstetric Science to which sufficient attention, it appears to me, has not been paid. Through you, I have promised to the public a work on this subject, and although the continued occupation of my time and thoughts in the duties of a teacher and practitioner have as yet prevented the ful- filment of the promise, tlieday, 1 trust, is not distant, when, under the hope of being useful, I shall prepare an account of the Mechanism of Labour, illustrated by suitable engravings, which may be regarded as an addendum to the standard works of Ramsbotham, and our own Dewees. Very respectfully, yours, HUGH L. HODGE, M. D., Professor of Obstetrics^c. #c, in the University of Pennsylvania. Messrs. Lea & Blanchard. ,: This new edition of Dr. Ramsbotham's work forms one of the most complete and thoroughly useful treatises on Midwifery with which we are acquainted. It is not a mere reprint of the first edition; the entire work has undergone a careful revision, with additions. We have already given specimens of the work sufficient to justify our hearty recommendation of it as one of the best guides that the student or young practitioner can follow."—British and Foreign Medical Review, Jan., 1845. # " The work of Dr. Ramsbotham may be described as a complete system of the principles and practice of Midwifery; and the author has been at very great pains, indeed, to present a just and useful view of the pre- sent state of obstetrical knowledge. The illustrations are numerous, well selected, and appropriate, and en- graved with great accuracy and ability. In short, we regard this work, between accurate descriptions and useful illustrations, as by far the most able work on the Principles and Practice of Midwifery that has ap- peared for a long time. Dr. Ramsbotham has contrived to infuse a larger proportion of common sense, and plain unpretending practical knowledge into this work, than is commonly found in works on this subject; * Northern Journal of Medicine for Juty 1845, LEA & BLANCHARD'S PUBLICATIONS. 19 RAMSBOTHAM ON PARTURITION—Continued. v *------ and as rflich we have great pleasure in recommending it to the attention of obstetrical practitioners."— Edin- burgh Medical and Surgical Journal. " This is one of the most beautiful works which have lately issued from the medical press; and is alike creditable to the talents of the author and the enterprise of the publisher. It is a good,and thoroughly prac- tical treatise; the different subjects are laid down in a clear and perspicuous form, and whatever is of import- ance, is illustrated by first rate engravings. A remarkable feature of this work, which ought to be mentioned, is its extraordinary cheapness. As a work conveying good, sound, practical precepts, and clearly demonstra- ting the doctrines of Obstetrical Science, we can confidently recommend it either to the student or practi- tioner."— Edinburgh Journal of Medical Science. " This work forms a very handsome volume. Dr. Ramsbotham has treated the subject in a manner worthy of the reputation he possesses, and has succeeded in forming a book of reference for practitioners, and asolid and easy guide for students. Looking at the contents of the volume, and its remarkably low price, we have no hesitation in saying that it has no parallel in the history of publishing."—Provincial Medical and Surgi- cal Journal. " It is the book of Midwifery for students; clear, but not too minute in its details, and sound in its practi- cal instructions. It is so completely illustrated by plates (admirably chosen and executed,) that the student must be stupid indeed who does not understand the details of this branch of the science, so far at least as description can make them intelligible."—Dublin Journal of Medical Science. "Our chief object now is to state our decided opinion, that this work is by far the best that has appeared in this country for those who seek practical information upon Midwifery, conveyed in a clear and concise style. The value of the work, too, is strongly enhanced by the numerous and beautiful drawings, which are in the first style of excellence."—London Medical Journal. " We most earnestly recommend this work to the student who wishes to acquire knowledge, and to the practitioner who wishes to refresh his memory, as a most faithful picture of practical Midwifery ; and we can with justice say, that altogether it is one of the best books we have read on the subject of Obstetric Medi- cine."—Medico-Chirurgical Review. " All the organs concerned in the process of parturition, and every step of this process, in all its different forms, are illustrated with admirable plates.....When we call to mind the toil we underwent in acquiring a knowledge of this subject, we cannot but envy the student of the present day the aid which this work will afford him.....We recommend the student who desires to master this difficult subject with the least possible trouble, to possess himself at once of a copy of this work."—Americun Journal of the Me- dical Sciences. "It is intended expressly for students and junior practitioners in Midwifery ; it is, therefore, as it ought to be, elementary, and will not consequently, admit of an elaborate and extended review. Our chief object now is to state our decided opinion, that this work is by far the best that has appeared in this country, for those who seek practical information upon Midwifery, conveyed in a clear and concise style. The value off the work, too, is strongly enhanced by the numerous and beautiful drawings by Bagg, which are in the first style of excellence. Every point of practical importance is illustrated, that requires the aid of the engraver to fix it upon the mind, and to render it clear to the comprehension of the student."—London Medical Gazette. " We feel much pleasure in recommending to the notice of the profession one of the cheapest and most ele- gant productions of the medical press of the present day. The text is written in a clear, concise, and simple style. We offer our most sincere wishes that the undertaking may enjoy all the success which it so well merits."—Dublin Medical Press. " We-strongly recommend the work of Dr. Ramsbotham to all our obstetrical readers, especially to those who are entering upon practice. It is not only one of the cheapest, but one of the most beautiful works in Midwifery."— British and Foreign Medical Review. " Among the many literary undertakings with which the Medical press at present teems, there are few that deserve a warmer recommendation at t, , u • l l i • j- admirable exposition of the present^state of chemical less Dr. Fowne6' book seems to be the happiest medium . ; . ... ,. . , ■ ., ... ., -„ j_ , . . ,, science, simply and clearly written, and displaying a I have seen, and admirably euited to fill up the hiatus." , ' . ,, , f „ . ', ., .. thorough practical knowledge of its details, as well as x ----- a profound acquaintance with its principles."—British _ , , - , „ . _. ™- t, . «■. • * and Foreign Medical Review. Extract from a letter from Professor W. E. A. Atkin, of « XT j i. ■ , „ . . ,„. • . ' J "Numerous and useful as are the works extant on the university of Maryland. , „ . . _, . , the Science of Chemistry, we are nevertheless pre- " The first cursory examination left me prepossessed pared to admit that the. author of this publication has in its favour, and a subsequent more careful review made a valuable addition to them by offering the stu- has confirmed these first impressions. I shall certainly dent and those in general who desire to obtain informa- recommend it to my classes, and feel sure that they tioni an accurate compendium of the state of chemical will profit by using it during the session of lectures. science; which is. moreover, well illustrated by ap- "As a judicious compendium, I think Fownes'Che- propriate and neatly executed wood engravings. * * mistry cannot fail to be highly useful to the class of After what we have stated of this work, our readers readers for whom it was designed." will not be surprised that it has our hearty commenda- tion, and that, in our opinion, it is calculated, and at a trifling expense, to spread the doctrines of the intricate "Mr. Fownes'work, although consisting of only a science which it so clearly explains."—Medico-Chi- single thick 12mo. volume, includes a notice of almost rurgical Review. every branch of the subject, nothing of any iraportanca LEA A BLANCHARD'S PUBLICATIONS. SI " This is an unpretending, but decidedly valuable its more abstruse subjects. Such a treatise is the one treatise, on the elements of chemistry, theoretical and which we have now the pleasure of introducing to our practical. Dr. Bridges has a perfect idea of what is readers; no manual of chemistry with which we have needed, and the'preparation of this excellent guide met comes so near meeting the wants of the beginner. should have the countenance of all public instructors, All the prominent truths of the science, up to the pre- and especially those of medical students."—Boston sent time, will be found given in it with the utmost Med. if Surg. Journal. practicable brevity. The style is admirable for its " This is a very excellent manual for the use of stu- conciseness and clearness. Many wood-cuts are dents and junior practitioners, being sufficiently full supplied, by which processes are made intelligible. and complete on the elements of the science, without The author expresses regret, that he could not enter omitting any necessary information, or extending too more largely into organic chemistry, but his details far into detail. It is written in a clear and concise will be found to embrace the most important facts in style, and illustrated }>y a sufficient number of well that interesting branch of the science. We shall re- executed wood-cuts and diagrams. The Editor has commend his manual to our class next winter."— The executed his task in a creditable manner, and we have Western Journal of Medicine-and Surgery. no doubt the work will prove entirely satisfactory, as <• We are presented with a work, not only compre- an introduction to the science of which it treats."—N. hensive as regards general principles, but full of prac- Y. Journal of Med. Sf Surgery. tieal details of the working processes of the scientific " He has succeeded in comprising the matter of his laboratory ; and in addition, it contains numerous work in 4C0 duodecimo pages, which, assuredly, is a wood engravings, showing the most useful forms of recommendation of the volume as a text-book for stu- apparatus, with their adjustments and methods of use. dents. In this respect it has advantages over any "The original work having been full and complete, treatise which has yet been offered to American stu- as far as the limits of such a volume would permit, dents. The difficulty in a text-book of chemistry is to and on every point brought up to the date of its publi- treat the subject with sufficient fullness without going cation (in September last,) the task of the editor has too much into detail. For students comparatively been to add any important matter which appeared ignorant of chemical science, the larger systems are since, and to correct such typographical errors as had unprofitable companions in their attendance upon lee- escaped the author. That this task has been well tures. They need a work of a more elementary cha- and ably performed, the known zeal and competency racter, by which they may be inducted into the first of Dr Bridges afibrd a sufficient guarantee."— The principles of the science, and prepared for mastering j\fe(iiCal Examiner. GRAHAM S CHEMISTRY. THE ELEMENTS ©F GHEMISTRY. INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS. With Numerous Illustrations, BY THOMAS GRAHAM, F. R. S.L. and E. D. Professor of Chemistry in University College, London, &c. &c. WITH NOTES AND ADDITIONS, BY ROBERT BRIDGES, M.D., &c. &c. In One Vol. Octavo. The great advancement recently made in all branches of chemical investigationj'ren- ders necessary an enlarged work which shall clearly elucidate the numerous discoveries, especially in the department connected with organic Chemistry and Physiology, in which such gigantic strides have been made during the last few years. The present treatise is considered by eminent judges to fulfil these indications, and to be pecu- liarly adapted to the necessities of the advanced medical student and practitioner. In adapting it to the wants of the American profession, the editor has endeavoured to render his portion of the work worthy the exalted reputation of the first chemist of England. It is already introduced in many of the Colleges, and has universal approbation. Though so recently published, it has been translated into German, by Dr. F. Julius Otto, the eminent professor at Brunswick, and has already passed to a Second edition. 22 LEA & BLANCHARD'S PUBLICATIONS. A NEW MEDICAL DICTIONARY. In one Volume, large 12moM now ready, at a low price. __^___ A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES; By RICHARD D. HOBLYN, A.M., Ojton. FIRST AMERICAN, FROM THE SECOND LONDON EDITION. REVISED, WITH NUMEROUS ADDITIONS, BY ISAAC HAYS, M.D., EDITOR OF THE AMERICAN JOURNAL OF THE MEDICAT. SCIENCES. Believing that a work of this kind would be useful to the profession in this country, the publishers have issued an edition in a neat form for the office table, at a low price. Its object is to serve as an introduction to the larger and more elaborate Dictionaries, and to assist the student commenc- ing the study of Medicine, by presenting in a concise form an explanation of the terms most used in Medicine and the collateral sciences, by giving the etymology and definition in a manner as simple and clear as possible, without going into details; and bringing up the work to the present time by including the numerous terms lately introduced. This design the author has so ably executed as to elicit the highest encomiums of the medical press, a few of the testimonies of which are subjoined. It has been edited with especial reference to the wants of the Americatl practitioner, the native medicinal plants being introduced, with the for- mulas for the various officinal preparations; and the whole being made to conform to the Pharmacopoeia of the United States. It is now veadyjn one neat royal duodecimo volume of four hundred pages in double co- lumns. ---- Extract from a Letter from Professor Watts of the College of Physicians and Surgeons, N. York. " It is a valuable book for those more advanced in the profession, but especially for students of Medicine, and I shall take pleasure in recommending it to my class during the coming session." OPINIONS OF THE PRESS. " We hardly remember to have seen so much valuable matter condensed into such a small compass as this little volume presents. The first edition was pub- lished in 1835, and the present may be said to be almost re-written, introducing the most recent terms on each subject. The Etymology, Greek, Latin, &c, is carefully attended to, and the explanations are clear and precise. We cannot too strongly recommend this small and cheap volume to the library of every student and every practitioner."—Medico-'Chirurgical Review. •« We gave a very favourable account of this little book on its first appearance, and we have only to repeat the praise with increased emphasis. It is, for its size, decidedly the best book of the kind, and ought to be in the possession of every student. Its plan is sufficiently comprehensive, and it contains an immense mass of necessary information in a very small compass."—British and Foreign Medi- cal Review. " A work much wanted, and very ably executed."—London Medical Journal. " This compendious volume is well adapted for the use of students. It contains a complete glossary of the terms used in medicine—not only those in common use, but also the more recent and less familiar names introduced by modern wri- ters. The introduction of tabular views of different subjects is at once compre- hensive and satisfactory."—Medical Gazette. " Concise and ingenious."—Johnson's Medico-Chirur. Journal. " It is a very learned, pains-taking, complete, and useful work—a Dictionary absolutely necessary in a medical library,"—Spectator, LEA & BLANCHARD'S PUBLICATIONS. 23 SATELTT PUBLISHED. A NEW EDITION OF OARFEOTEIl'S HUMAN PHYSIOLOGY, REVISED AND MDC1I IMPROVED. PRINCIPLES OF HUMAN PHYSIOLOGY. WITH THEIR CHIEF APPLICATIONS TO PATHOLOGY, HYGIENE & FORENSIC MEDICINE. By WILLIAM B. CARPENTER, M.D., F.R.S., &c. SECOND AMERICAN, FROM A NEW AND REVISED LONDON EDITION. WITH NOTES AND ADDITIONS, BY MEREDITH CLYMER, M.D., &c, With Two Hundred and Sixteen Wood-cut and other Illustrations. In one octavo volume, of about 650 closely and beautifully printed pages. The very rapid sale of a large impression of the first edition is an evidence of the merits of this valuable work, and that it has been duly appreciated by the profession of this country. The pub- lishers hope that the present edition will be found still more worthy of approbation, not onlyfro-n» the additions of the author and editor, but also from its superior execution and the abundance of its illustrations. • No less than eighty-five wood-cuts and another lithographic plate will be found to have been added, affording the most material assistance to the student. " We have much satisfaction in declaring our opinion that this work is the best systematic treat- ise on physiology in our own language, and the best adapted for the student existing in any lan- guage."—Medico-Chirurgical Review. NOW READY. A NEW AND IMPROVED EDITION OF PERGTJSSON'S OPERATIVE SURGERY. A SYSTEM OF PRACTICAL SURGERY. By WILLIAM FERGUSSON, F.R.S.E. Second American Edition, Revised and Improved. WITH TWO HUNDRED AND FIFTY-TWO ILLUSTRATIONS FROM DRAWINGS BY BAGG, ENGRAVED BY GILBERT, WITH NOTES AND ADDITIONAL ILLUSTRATIONS, BY GEORGE W. NORRIS, M.D., &c. In one beautiful octavo volume of six hundred and forty large pages. The publishers commend to the attention of the profession this new and improved edition of Fergusson's standard work, as combining cheapness and elegance, with a clear, sound and practical treatment of every subject in surgical science. Neither pains nor expense have been spared to make it worthy ot the reputation which it has already acquired, and of which the rapid exhaustion of the first edition is sufficient evidence. It is extensively used as a text-book in many medical colleges throughout the country. The object and nature of this volume are thus described by the author :—" The present work has not been produced to compete with any already before the Profession; the arrangement, the manner in which the subjects have been treated, and the illustrations, are all different from any of the kind in the English language. It is not intended to be placed in comparison with the elemen- tary systems of Cooper, Burns, Liston, Symes, Lizars, and that excellent epitome of Mr. Druitt.— It may with more propriety be likened to the Operative Surgery of Sir C. Bell, and that of Mr. Averill,both excellent in their day, or the more modern production of Mr. Hargrave, and the Practical Surgery of Mr. Liston. There arc subjects treated of in this volume, however, which none of these gentlemen have noticed ; and the author is sufficiently sanguine to entertain the idea that this work may in some degree assume that relative position in British Surgery, which the classical volumes of Velpeau and Malgaigne occupy on the Continent." "If we were to say that this volume by Mr. Fergusson,is one excellently adapted to the stu- dent, and the yet inexperienced practitioner of surgery, we should restrict unduly its range. It is of the kind which every medical man ought to have by him for ready reference, as a guide to the prompt treatment of many accidents and injuries, which whilst he hesitates, may be followed by incurable defects, and deformities of structure, if not by death itself. In drawing to a close our notice of Mr. Fergusson's Practical Surgery, we cannot refrain from again adverting to the nume- rous and beautiful illustrations by wood-cuts, which contribute so admirably to elucidate the de- scriptions in the text. Dr. Norris has, as usual, acquitted himself judiciously in his office of annotator. His additions are strictly practical and to the point."—Bulletin of Medical Science. 24 LEA & BLANCHARD'S PUBLICATIONS. s EiA.3EX.ir PUBLISHED, A NEW EDITION OF WILSON'S HUMAN ANATOMY, Much Improved. GENERAL AND SPECIAL. BIT E31AS2MIUS WILSON, M.D., Lecturer on Anatgmy, London. SECOND AMERICAN EDITION, EDITED BY PAUL B. GODDARD, A.M., M.D., Lecturer on Anatomy and Demonstrator in the University of Pennsylvania, S[C WITH OVER TWO HUNDRED ILLUSTRATIONS, Beautifully Printed from the Second London Edition. IN ONE VERY NEAT OCTAVO VOLUME. From the Preface to the Second American Edition. " The very rapid sale of the first edition of this work, is evidence of its appreciation by the pro- fession, and is most gratifying to the author and American editor. In preparing the present edition no pains have been spared to render it as complete a manual of Anatomy for the medical student as possible. A chapter on Histology has therefore been prefixed, and a considerable number of new cuts added. Among the latter, are some very fine ones of the nerves which were almost wholly omitted from the original work. Great care has also been taken to have this edition correct, and the cuts carefully and beautifully worked, and it is confidently believed that it will give satisfaction, offering a further inducement to its general use as a Text-book in the various Colleges." " Mr. Wilson, before the publication of this work, was very favourably known to the profession by his treatise on Practical and Surgical Anatomy; and, as this is the Second American Edition, from the second London Edition, since 1840, any special commendation of the high value of the present work, on our part, would be supererogatory. Besides the work has been translated at Ber- lin, and overtures were repeatedly made to the London publisher for its reproduction in France.— The work is, undoubtedly, a complete system of human anatomy, brought up to the present day.-— The illustrations are certainly very beautiful,the originals having been expressly designed and exe- cuted for this work by the celebrated Bagg of London; and, in the American edition they have been copied in a masterly and spirited manner. As a teg-book in the various colleges we would commend it in the highest terms."—Hew York Journal of Medicine. CHURCHILL'S MIDWIFERY. ON THE THEORY AND PRACTICE OF MIDWIFERY, BY FLEETWOOD CHURCHILL, M.D., M.R.I.A., PHYSICIAN TO THE WESTERN LYING-IN-HOSPITAL, ETC., ETC. WITH NOTES AND ADDITIONS , BY ROBERT HUSTON, M.D., Professor in the Jefferson Medical College, &c, &c. And One Hundred and Sixteen Illustrations, Engraved by Gilbert from Drawings by Bagg and others. In one volume, octavo. This work commends itself to the notice of the profession from the high reputation of the author and editor, and the number and beauty of its illustrations. Besides accurate directions for THE PRACTICE OF MIDWIFERY, a portion of the work is also devoted to THE PHYSIOLOGY AND PATHOLOGY connected with that essential branch of medical knowledge. " It is impossible to conceive a more useful or elegant manual: the letter-press contains all that the practical man can desire ; the illustrations are very numerous, well chosen, and of the most ele- gant description, and the work has been brought out at a moderate, price."—Provincial Med. Jour. " We expected a first rate production, and we have not been in the least disappointed. Although we have many, very many valuable works on tokology, were we reduced to the necessity of pos- sessing but one, and permitted to choose, we would unhesitatingly take Churchill."—Western Med. and Surg. Journal. This work is printed, illustrated and bound to match Carpenter's Physiology, Fergusson's Surgery and Wilson's Anatomy, and the whole, with Watson's Prac- tice, Pereira's Materia Medica and Graham's Chemistry, are extensively used in the various colleges. LEA & BLANCHARD'S PUBLICATIONS. 23 PEREIRAS MATERIA MEDICaT WITH NEAR THREE HUNDRED ENGRAVINGS ON WOOD. A NEW EDITION NOW BSADY. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. COMPREHENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPO- SITION, EFFECTS, AND USES OF MEDICINES. BY JONATHAN PEREIRA, M.D., F.R.S. and L, S. Member of the Society of Pharmacy of Paris j Examiner in Materia Medica and Phafmacy of the University of London} Lecturer on Materia Medica at the London Hospital, ttc, &c. Second American, from the last London Edition, enlarged and improved. With Notes and Additions BY JOSEPH CARSON, M.D., In two volumes, octavo. Part I, contains the General Action and Classification of Medicines and the Mineral Materia Me- dica. Part II, the Vegetable and Animal Kingdoms, and including diagrams explanatory of the Processes of the Pharmacopoeias, a tabular view of the History of the Materia Medica, from the earliest times to the present day, and a very copious index. From the last London Edition, which has been thoroughly revised, with the Introduction of the Processes of the New Edinburgh Phar- macopoeia, and containing additional articles on Mental Remedies, Light, Heat, Cold, Electricity, Magnetism, Exercise, Dietetics and Climate, and many additional Wood-cuts, Illustrative of Phar- maceutical Operations, Crystallography, Shape and Organisation of the Feculas of Commerce, and the Natural History of the Materia Medica. The object of the author has been to supply the Medical Student with a Cla3s Book on Materia Medica, containing a faithful outline of this Department of Medicine, which should embrace a con- cise account of the most important discoveries in Natural History, Chemistry, Physiology, and The- rapeutics, in so far as they pertain to Pharmacology, and treat the subjects in the order of theif natural historical relations. The opportunity has been embraced in passing this New Edition through the hands of the Editor, Dr. Carson, to make such additions as were required to the day, and to correct such errors as had passed the inspection of the Author and Editor of the first edition. It may now be considered aa Worthy the entire confidence of the Physician and Pharmaceutist aa a standard work. This great Library or Cyclopadid of Materia Medica has been fully revised, the errors corrected, and numerous additions made by DR. JOSEPH CARSON, Professor of Materia Medica and Phar- macy in the "College of Pharmacy," and forms Two Volumes, octavo, of near 1600 large and closely printed pages. It may be fully relied upon as a permanent and standard work for the coun- try—embodying, as it does, full references to the U. S. Pharmacopoeia and an account of the Medi- cal Plants indigenous to the United States. " An Encyclopoedia of knowledge in that department of medica] science—by the common con| sent of the profession the most elaborate and scientific Treatise on Materia Medica in our lan- guage."—'Western journal of Medicine dnd Surgery. " Upon looking over the American edition of the Materia Medica of Dr. Pereira, we have seen no- reason to alter the very favourable opinion expressed in former numbers of this Journal. (See Am. Med. Journal, XXIV, 413, and N. S., I. 192.) We are glad to perceive that it has been repub- lished here without curtailment. Independently of the injustice done to an author by putting forth an abbreviated edition of his works, without his superintendence or consent, such a course woHld in the present instance have been unjust also to the public, as one of the chief recommendations of Dr. Pereira'st treatise is its almost encyclopedic copiousness. We -turn to its pages with the expectation of finding infofmation upon all points of Materia Medica, and would have good reason to complain were this expectation disappointed by the scissors of an American Editor, Indeed, the main defect of the work, in relation to American practitioners, was the want of sufficient notices of the medicines and preparations peculiar to this country. In the edition before us this defect has been supplied by the Editor, Dr. Joseph Carson, who was, in a high degree qualified for the task, and, so far as we are able to judge from a very partial perusal, has executed it with judgment and fidelity. The nomenclature and preparations of our national standard have been introduced when wanting in the English edition, and many of our medical plants, either briefly noticed or altogether omitted by Dr. Pereira, because unknown in Europe, have been sufficiently described. We must repeat the expression of our opinion that the work will be found an invaluable storehouse of information for the physician and medical teacher, and con- gratulate the profession of this country that it is now placed within their reach,"—Am. Med.Journ. <* To say that these volumes on Materia Medica and Therapeutics, by Dr. Pereira,are comprehen- sive, learned and practical, and adapted to the requirements of the practitioner, the advanced stu- dent, as well as the apothecary, expresses the opinion, we will venture to assert, of nearly every judge of the Subject, but fails to convey to those who are not acquainted with the work, a definite idea of its really distinctive traits, according to our general usage, we shall, therefore, proceed to place these before our readers, so that they may know what it is, and why we praise. Valuable and various as are the contents of the volumes of Dr. Pereira, we have no hesitation in assert- ing, despite the adverse cant in some quarters on the subject of the American additions to English works, that the value of the present edition is enhanced by the appropriate contributions of Dr. Carson, who has introduced succinct histories of the most important indigenous medicines of the United States Pharmacopoeia."—Selett Med. Library. S5 LEA & BLANCHARD'S PUBLICATIONS. THE SURGICAL WORKS OF SIR ASTLEY COOPER. LEA & BLANCHARD have now completed the last volume of the illustrated works of Sir Astley Cooper. They form an elesant series; the works on Hernia, the Testis, the Thymus Gland and the Breast, beine print- ed, illustrated and bound to match, in imperial octavo with numerous LITHOGRAPHIC PLATES, while the Treatise on Dislotations is in a neat medium octavo form, with NUMEROUS WOOD-CUTS similar to the last London Edition. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST. &o,. JUST PUBLISHED. This large and beautiful volume contains THE ANATOMY OF THE BREAST; THE COMPARATIVE ANATOMY OF THE MAMMARY GLANDS; ILLUSTRATIONS OF THE DISEASES OF THE BREAST," And Twenty-five Miscellaneous Surgical Papers, now first published in a collected form. By SIR ASTLEY COOPER, Bart., F.R.S.,&c. The whole in one large imperial octavo volume, illustrated with two hundred and fifty-two figures on thirty six Lithographic Plates ; well and strongly bound. SIR ASTLEY COOPER ON HERNIA, With One Hundred and Thirty Figures in Lithography, THE ANATOMY AND SURGICAL TREATMENT OF ABBOMEMAL HERNIA, By Sir ASTLEY COOPER, Bart. ' Edited by C. Aston Key, Surgeon to Guy's Hospital, &c. This important work of Sir Astley is primed from the authorized second edition, published in London, in large super-royal folio, and edited by his nephew, Professor Key. It contains all the Plates and all the Let- terpress—there are no omissions, interpolations, or modifications—it is the complete work in One Large Imperial Octavo Volume. WITH OVER ISO FIGURES ON 26 PLATES, AND OVER 400 LARGE PAGES OF LETTERPRESS. The correctness of the Plates is guaranteed by a revision and close examination under the eye of a distin- guished Surgeon of this city. ANOTHER VOLUME OF THE SERIES CONTAINS HIS TREATISE ON THE STRUCTURE AND DISEASES OF THE TESTIS, Illustrated by 120 Figures. From the Second London Edition. By BRANSBY B. COOPER, Esq. AND ALSO ON THE ANATOMY OF THE THYMUS GLAND, Illustrated by 57 Figures. The two works together in one beautiful imperial octavo volume, illustrated with twenty-nine plates In the best style of lithography, and primed and bound to match. GODFER ON FRACTURES AND DISLOCATIONS, WITH NUMEROUS WOOD-CUTS. A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS. By SIR ASTLEY COOPER, Bart., F. R. S., Sergeant Surgeon to the King, &c. A. new edition much enlarged ; edited by BRANSBY COOPER, F.R.S, Surgeon to Guy's Hospital, with ad- ditional Observations from Professor John C. Warren, of Boston. \V ith numerous engravings on wood, after designs by Bagg, a memoir and a splendid portrait of Sir Astley. In one oclavo_Volume. The peculiar value of this, as of all Sir Astley Cooper's works, consists in its eminently practical character. His nephew, Bransby B. Cooper, from his own experience, has added a number of cases. Besides this, Sir Astley left behind hiin very considerable additions in MS. for the express purpose of being introduced into this edition. The volume is embellished with ONE HUNDRED AND THIRTY-THREE WOOD-CUTS, and contains the history of no less than three hundred and sixty-one cases, thus embodying the records of a life of practiceof the Author and his various editors. There are also additional Observations from notes furnished by John C. Warren, M.D., the Professor of Anatomy and Surgery in Harvard University. '' After the fiat of the profession, it would be absurd in us to eulogize Sir Astley Cooper's work on Fractures and Dislocations. It is a national one, and will probably subsist as long as English surgery."—Medico-Chirur- gical Rev ieio. LEA & BLANCHARD'S PUBLICATIONS. 27 LATELY PUBLISHED. MEIGS' TRANSLATION % OF COLOMBAT DEL'iSERE (N THE DISEASES CF FEMALES. A TREATISE ON THE DISEASES OF FEMALES, AND ON THE SPECIAL HYGIENE OF THEIR SEX. WITH NUMEROUS WOOD-CUTS. BY COLOMBAT DE L'ISfiRE, M.D., Chevalier of the Legion of Honor; late Surgeon to the Hospital of the Rue de Valois, devoted to tlie Diseases of Females, Sec. Sec. TRANSLATED, WITH MANY NOTES AND ADDITIONS, By C. D. MEIGS, M.D., Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, Sec, Sec. In One Large Volume, 8vo. " We are satisfied it is' destined to take the front rank in this department of medical science; it i» beyond all comparison, the most learned Treatise on the Diseases of Females that has ever been Written, there being more than one thousand distinct authorities quoted and collected by the inde- fatigable author. It is in fact a complete exposition of the opinions and practical methods of all the celebrated practitioners of ancient and modern times. The Editor and Translator has per- formed his part in a manner hardly to be surpassed. The translation is faithful to the original, and yet elegant. More than one hundred pages of original matter have been incorporated in tho text, constituting a seventh part of the whole volume."—New York Journal of Medicine. ASHWELL ON THE DISEASES OF FEMALES. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN, ILLUSTRATED BY CASES DERIVED FROM HOSPITAL AND PRIVATE PRACTICE. Br SAMUEL ASHWELL, M.D., Member of the Royal College of Physicians; Obstetric Physician and Lecturer to Guy's Hospital, &c. WITH ADDITIONS, By PAUL BECK GODDARD, M.D. The whole complete in one Large Octavo Volume. " The most able, and certainly the most standard and practical work on female disease that we have yet seen."—Medico-Chirurgical Review. A NEW EDITION OF CHURCHILL ON FEMALES, THE DISEASES OF FEMALES. INCLUDING THOSE OF ' By FLEETWOOD CHURCHILL, M.D., Author of "Theory and Practice of Midwifery," &c, &c. THIRD AMERICAN, FROM THE SECOND LONDON EDITION. With Illustrations. Edited with Notes, By ROBERT M. HUSTON, M.D., &c, &o. In One Volume, Svo. " In complying with the demand of the profession in this country for a third edition, the Editor has much pleasure in the opportunity thus afforded of presenting the work in its more perfect form. All the additional referenees and illustrations contained in the English copy, are retained in this," TAITLOR'S JURISPRUDENCE. MEDICAL JURISPRUDENCE, BY ALFRED S. TAYLOR. Lecturer on Medical Jurisprudence and Chemistry at Guy's Hospital, With numerous Notes and Additions, and References to American Law. BY R. E. GRIFFITH, M. D. In one volume, octavo, sheep. Also, done up in neat law sheep, ft 28 LEA & BLANCHARD'S PUBLICATIONS. CONDID ON CHILDREN. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN, BY D. FRANCIS CONDIE, M. D. Fellow of the College of Physicians; Member of the American Philosophical Society^ &c. ice. In one volume, octavo. frCT The Publishers would particularly call the attention ofuhe Profession to an examination ■ of this work. " Dr. Condie, from the very great labour which he has evidently bestowed upon this book, is entitled to our respect as an indefatigable and conscientious student; but if we consider the results of his labour, we cannot but admit his claim to a place in the very first rank of eminent writers on the practice of medicine. Regarding his treatise as a whole, it is more complete and accurate in its descriptions, while it is more copious and more judicious in its therapeutical precepts than any of its predecessors, and we feel persuaded that the American medical profession will very soon regard it, not only as a very good, but as the vety best ' Practical Treatise on the Diseases of Children.' " —Am. Med. Journal. THOMSON ON THE SICK ROOM. THE DOMESTIC MANAGEMENT OF THE SICK ROOM, NECESSARY, IN AID OF MEDICAL TREATMENT, FOR THE CURE OF DISEASES. BY A. T. THOMSON, M. D., &c. &c. First American, from the Second London Edition. Edited by R. E. GRIFFITH, M.D. In one royal 12mo. volume, extra cloth, with cuts. " There is no interference with the duties of the medical attendant, but sound, sensible, and clear advice what to do, and how to act, so as to meet unforeseen emergencies, and co-operate with professional skill."—Literary Gazette. MILLER'S PRINCIPLES OF SURGERY. 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