In corpulent persons I have often noticed a tendency to great congestion of the blood-vessels of the kidneys, indicated either by hæmaturia or by a suppression of the urine: the disease is sometimes owing to the cessation of a hæmorrhoidal discharge." M. Salesse, himself a native of the Isle of France, and now a resident practitioner there, gave the following account of this endemic hæmaturia in 1834: "Three-fourths of the children in this island are affected with it. Masturbation, the use of spiced meats, &c. are its exciting causes; the bad quality of the water also has been blamed... .... When the blood comes from the kidneys, the patient is usually subject to attacks of nephritic colic: this in some cases is owing to the presence of renal calculi. The urine is mixed with blood; its colour is the same from the first jet to the last drops; and in some cases coagula come away with it. The only pain which is experienced is felt at the extremity of the glans. After any excess, whether in the pleasures of venery or of the table, the colour of the urine is usually more deep; the same effect is often induced by fatigue from long walking, dancing, and so forth. . . . . . When the blood comes from the bladder, the patient experiences pain in this region and about the anus; the perineum is the seat of an uneasy tension and sense of weight: and any excess will sometimes have the effect of rendering the urine less sanguinolent. The calls to pass urine are frequent; and coagula are not unfrequently mixed with it: the semen also is sometimes sanguinolent. Persons affected with this hæmaturia are in general of a pale complexion and feeble constitution." Dr. Salesse quotes some very curious cases, most of which are reproduced in M. Rayer's work. The first is that of a gentleman, who had been subject to continual hæmaturia since he was seven years of age. In his 21st year, he made a voyage to France, in the hope that he might get rid of this complaint, although he did not experience any distress from it, except occasionally a sense of weight and tension in the perineum. While in Paris, the hæmaturia increased, and he consulted M. Andral, who recommended him to take a decoction of rhatany root. He had several attacks of ague, during which the urine was usually much freer from blood than it was at other times: the sulphate of quinine was freely administered. He always observed that the sanguineous admixture was less after the use of the cold bath. He never suffered from any pain or uneasiness in the renal region. In another case, the patient, who had been affected with hematuria from his infancy, made a voyage from the Isle of France to France, to prosecute his studies. Soon after his arrival in Paris, his complaint disappeared, and did not recur during the whole time-a period of from six to seven years-that he resided there. He then went to the Mauritius; and a few months afterwards the hæmaturia returned, and still continues. In some cases of this endemic hæmaturia, the urine is found to contain uric sand or gravel at the same time. M. Rayer observes that the reports of the preceding cases are not sufficiently minute, as to the nature of the urinary sediment, to enable us to determine whether there was not an admixture of the urates in them also. He very properly suggests that a chemical and microscopic examination of the urine should never be neglected. A curious circumstance connected with this endemic disease is that the sanguineous state of the urine is occasionally followed by a milky, or as it has been called a chylous, state of the secretion.* Several illustrative cases are given at considerable length by M. Rayer from the works of M. Chapotin and others; but we cannot do more than refer to them. at present. This peculiar anomaly of the urinary secretion is not unfrequently met with in the Brazils, as well as in the Isles of France and Bourbon. A very interesting case, which occurred in a gentleman, a native of the former country, is related at greath length in the Journal La Presse by M. Caffe.* Some years ago an elaborate discussion on the nature of this disease, which is known under the name of milky diabetes, took place in the Medical Society of Rio Janeiro. A committee was appointed for the purpose of investigating it with attention. It appears from their report that it is often met with in that eity, more especially in hospital practice. It is more common in women than in men. Its duration is very variable; lasting sometimes for months and years, and then ceasing without appreciable cause. From the irregularity of its character, and the inconstancy of the morbid appearances found on dissection, Dr. Simoni (one of the physicians of the Misericorde Hospital) regards it as a nervous affection of the kidneys. He recommends the use of steel, valerian, &e. in the treatment of this disorder; but acknowledges that in some cases no remedy seems to be of any avail, and that the secretion will often assume a healthy appearance when nothing is done. The health of the patients is often surprisingly little affected during its continuance. The term diabetes is, Dr. Simoni remarks, improperly applied to this disease; as, in the majority of cases, there is no decided increase in the quantity of the urinary secretion. It seems to be generally admitted that a strengthening diet, tonic remedies, and the use of the cold bath, are the most useful means that can be employed. M. Rayer remarks, that he has several times bad occasion to observe that hæmaturia, occuring in persons born and residing in Europe, has been followed by an albuminous state of the urine; but that he has never met with an instance of the chylous or albumino-fatty transformation except in persons born in tropical countries. The medical man must be on his guard not to mistake the whitish urine produced by the admixture of purulent matter with it, for this condition of the secrtion. Purulent urine, if examined with the microscope, will be found to exhibit globules of pus diffused through it; and, when allowed to rest, a puriform sediment will be observed, while the urine above becomes less opaque and troubled. Chylous urine, on the other hand, is observed to contain either globules like those of the blood, or no globules ate all (the albumino-fatty urine); and, after some hours' repose, the opaque matter rises to the surface and the urine below becomes somewhat less opaque. Before quitting this subject, we may mention that hæmaturia seems to be of frequent occurrence in some other tropical countries, besides the Isle of France and the Brazils. We read that many of the soldiers of the French army in Egypt suffered from it. M. Renoult says that is was more common in the cavalry than in the infantry soldiers, and that even the horses were not exempted from it. He attributes it to the great diminution of the renal secretion, induced by the excessive perspirations, and to the irritation caused by the scanty acrid urine on the inner surface of the bladder. Severe exercise on horseback is occasionally apt to produce hæmaturia in some persons, even in temperate climates: M. Aran published a memoir on this subject in 1811. We must here draw our remarks to a close. The deservedly great attention that has of late years been paid to the diseases of the urinary organs has rendered it quite necessary that every well-informed medical man should be acquainted with the recent standard publications on the subject. This has been our motive for giving a second review of M. Rayer's large and elaborate work-a work which reflects the highest credit on the author, and impresses on the reader a most favourable opinion of the present state of French medical literature. The report is inserted in the Number of the Medico-Chirurgical Review for April, 1839, and will repay the trouble of a re-perusal. DERANGEMENTS, PRIMARY AND REFLEX, OF THE ORGANS OF DIGESTION. By Robert Dick, M. D. 8vo. Edinb. 1840. We have perused this work with pleasure and instruction. It is decidedly the best compilation in the English language on the extensive class of disorders and diseases comprehended under the term dyspepsia, united. with a very large proportion of original matter, both in the form of able comments on other writers, and practical information derived from the author's own experience. But the mass of compiled and original matters is so well mixed and amalgamated as to defy the powers of the most. laborious German analyst to separate the one from the other. The former we cannot introduce without the latter, and both we are unable to review.. The work itself, indeed, is very comprehensive review, critical, analytical, synthetical, and auto-graphical. We shall introduce two or three cases, or passages, from the author's, own note-book, that may not be without interest. CASE 1. Nitrate of Silver.-A young gentleman, who had stomach ailments almost from infancy. The most distressing symptom,, however, was eructation of an acid and burning fluid and gas from the stomach, which often commenced even during meals, and continued for hours afterwards. Yet his bowels were regular, urine natural, and the functions of the skin normal, with sound sleep-and no apparent disorder or disease: of any other organ in the body. The "The case of this young gentleman appearing to me to betray an union of morbid secretions and morbid sensibility, I commenced the treatment with small doses of blue pill and ipecacuanha, from which no immediate benefit appeared to result. I then put him upon a month's course of nitrate of silver, with a view to allay the morbid sensibility of the mucous membrane.* effect in this, as in almost every other case in which I have tried it, was surprizing and gratifying in the extreme. This patient, in common with many others who had taken this medicine, warmly expressed the great relief from irritation, flatulence, cutaneous chillness, discomfort, which it promptly procured them. This gentleman assured me that he had not felt himself so much in possession of the sensation of health, so far back as his memory could carry him, as he did since he began the use of the medicine in question. I have once or twice laid it aside from fears of its discolorizing property; but, after a while, returned to it, and always with augmented benefit. And this young man who, when he came to me, did not dare to go into company, partly from the depression of his spirits, partly from his well-founded terror of being led into dietetic excess, partly from the disastrous effects which the moral excitement of society ever had on his enfeebled and irritable nervous system; who, when I first saw him, was plunged into the deepest despondency and despair, is now cheerful and confident,-mingless freely in society, and looks and feels like one in excellent health." 202. This is a very striking case, and we think we may pretty confidently say that the oxyde of silver will be found equally beneficial in gastric derangements, with little or no risk of discoloration of the skin. * See Dr. J. Johnson's work on Morbid Sensibility, pages 43, 84, 85.. 2. The Dyspeptic's Melancholy Tale." There is a class of patients who enter the apartments of physicians, with a mixed air of timorousness, reserve, peevishness and impatience. Their emaciation, if they are emaciated, is not of a ghastly character; something in their gait or countenance announces in general to the eye of the physician, that the malady of his visitor is not of an exceedingly urgent or of a violent nature. The fretfulness and restlessness engendered by the disease, hinders the patient from devoting much time to the civil ceremonial of introduction or explanation; but almost without a question on the physician's part, hurries him abruptly in medias res. It is easy to perceive, from the fluency and fullness with which the invalid pursues the history of his feelings and symptoms, that that history is rehearsed neither for the first nor fiftieth time. Sufferings usually stated as unprecedented; plans of diet suggested to him, and followed with various success; changes made from time to time in medicines and physicians; benefit derived from this doctor but not from that, from this watering place, but not from the other; total inability to enjoy society or life; gradual departure of the powers of intellectual application; growing hebetude of thought; a resolution of embarking in a totally new mode of life; of exchanging town for country, active and civic, for rural life; misery, and, by no means infrequently, a propensity to suicide,—these, or some of these, are the staple heads of a dyspeptic's inaugural discourse to any physician whom he may visit for the first time. The whole is delivered in a tone slightly querulous, the consequence of a physical and mental irritation of a sort entirely peculiar." 43. A large class of these dyspeptics seem to experience as much pleasure in rehearsing their catalogue of miseries, as an infant does in sucking its thumb! 3. Dyspeptic Phthisis.-Our author appears to go far beyond Dr. Philip in respect to the influence of disorders of the stomach in inducing diseases of the lungs. We shall introduce one of the proofs adduced in support of the doctrine. 66 22 years of age, and born of healthy parents; had suffered for several years from unpleasant sensations in the stomach; heat, pain, heaviness after meals. His tongue was clean; his bowels variable; easily deranged; his belly tense; his urine natural; his pulse 80; small; he was irritable; nervous, easily exhausted; easily chilled. His chest was perfectly normal. fact I repeatedly ascertained, and that within ten days of his death. He had horrid dreams. This By treating him with sedatives and antispasmodics, and the mildest laxatives the dyspeptic symptoms were greatly relieved; but he did not gather flesh, although his strength improved, and any departure from a very strict regimen immediately re-produced great gastric irritability and suffering. He constantly complained of chillness. On this account, I cautioned him against exposure to cold; aware of the truth of Andral's remark, that when the system has been long kept in a state of debility and febrility by a gastric irritation, any pulmonary affection is apt to be rapid and destructive. In May, was seized with influenza. A cavernous rhonchus was heard on the fourth day, and the fifth terminated his life. Inspection. The stomach, which had tortured -'s existence for many years, was perfectly sound!! so was the liver, so were the intestines. The left lung was entirely disorganized; almost one purulent sac. The right lung was greatly diseased. And all this in the course of five days, not from a regular pneumonia, or ungovernable pleurisy, but from ordinary influenza. It was clear that, in this case, the long constitutional irritation produced by the merely functional gastric affection, had by the maintenance of a constant febrility, annihilated the conservative vigour of the system. No doubt, had the brain been the organ of attack, structural change would have taken place in it as rapidly as it did in the lungs." 276. We confess that this line of argument savours a good deal of the post hoc ergo propter hoc. Much confidence as we have in auscultation, we should be very sorry to pronounce lungs to be positively sound because we could detect no disease there. Have not lungs often broken down rapidly under inflammation, without any previous dyspepsia? Dr. D. says the right lung was "greatly diseased." If he had stated the nature of the diseased condition, we should have been better able to form an opinion as to that lung being perfectly sound five days before the death of the patient. Be this as it may, we quite approve the following direction. "Our rule in all doubtful cases is, to use carefully the stethoscope; to consider carefully the history of the origin of the disease; to determine the absence or presence of pain or tumefaction in the abdomen; to watch if attention to the digestive organs, and the subjugation of irritation there, dissipate the pulmonary phenomena. We idle our time, if we treat a cough, sympathetic of gastric irritation, by measures directed exclusively to the chest. But, on the other hand, we may err fatally in mistaking for a merely secondary affection, an incipient and true phthisis, which sometimes signalises its commencement, by simultaneous gastric symptoms, whose more marked, but comparatively unimportant presence, may mask the graver malady." 281. If Dr. Dick saw a tithe of those who, in the second or even third stage of phthisis, present themselves to us, labouring as they say, and as they have been told under "STOMACH-COUGH," but no affection of the lungs," he would be a little more guarded in his doctrines on this point. We will not say (though we might do so with a clear conscience) that this doctrine is the annual destruction of thousands in this country; but we may aver that it ruins the reputation of many young medical practitioners every year. Patients come to them with cough. Among the first questions is this. "Have you had any indigestion, or affection of your stomach, before the cough began?" "Oh, yes, Sir, I have indigestion for years before." With the " stomach cough" doctrine in his mind, the inexperienced practitioner naturally says to himself, here is a clear case. The indigestion was the cause,-the pulmonary disease is the effect. "Sublata causa, tollitur effectus, is philosophical, and that rule I will pursue. Meanwhile the patient dies of unequivocal phthisis, and as other medical men will probably have been consulted, the philosophical doctor -the doctrinaire-will be severely commented on, for telling the patient and friends, that it was merely a "stomach cough." Now all we recommend is this :-If you find gastric and pulmonary disorder co-existent, do not be led away by the affirmations of the patient, that the former preceded the latter, and prescribe mutton chops thrice a day with sherry and the shower-bath-not forgetting sulphate of iron and Epsom salts-but treat both complaints. The practitioner may depend upon it that the pulmonary affection is the main one, whether original or secondary, and that, whether he consults his patient's health or his own reputation, he will do well to direct his principal attention to the |