VII. ACCOUNT OF OBSERVATIONS MADE UNDER THE SUPERINTENDENCE OF DR. BRIGHT, ON PATIENTS WHOSE URINE WAS ALBUMINOUS: By GEORGE HILARO BARLOW, M.A. and M.D. WITH A CHEMICAL ExAMINATION OF THE BLOOD AND SECRETIONS. By G. O. REES, M.D.

Dr. Bright observes :

"The few following pages will be found to contain the record of the first experiment which, as far as I know, has yet been made in this country to turn the ample resources of an hospital to the investigation of a particular disease, by bringing the patients labouring under it into one ward, properly arranged for observation. I fear that the attempt has been less effective than it might have been, and than, I trust, others will hereafter prove; but if this is the case, the imperfection must fairly be ascribed to my want, not so much of zeal as of time, for carrying out, in its fullest extent, a most interesting experiment.

"The Clinical Wards of Guy's Hospital seemed to afford a most appropriate opportunity for the object in view; and I applied to the Treasurer of Guy's for permission to occupy them after the Clinical Session had concluded, in May. Mr. Harrison entered heartily into the plan, and offered every facility. Accordingly, it was determined, that from May to October I should be allowed the full use of the Male and Female Clinical Wards; and all my colleagues readily granted permission to select any cases from the other wards which I might consider likely to promote the object.

"Dr. Barlow, with the greatest readiness, undertook to make up for my neg. lects; whilst Dr. Rees took charge of the chemical part of the inquiries: and it is entirely to these two that our Reports are indebted for the connected account of proceedings which the present communication contains.

"Our establishment then consisted of a female ward with eighteen beds; a male ward with twenty-four beds; a room between the two wards for the meeting of the physicians and pupils, and for the registry of the cases; and a small laboratory communicating with the middle room, fitted up and decorated entirely to our purpose.

"Dr. Barlow and myself were in charge of the medical treatment of the cases, with the assistance of Dr. J. T. Francis, Mr. J. H. Browne, and Mr. Allen Williams, as Clinical Clerks, whose duty it was to take daily reports.

"Dr. Rees had charge of the laboratory, in which he was assisted by Mr. Pearce; and, thus prepared, we began our operations, and proceeded pretty steadily with them.

"The objects which we proposed to ourselves were, to examine as far as it was possible, the changes which accompanied the secretion of albuminous urine in the various functions and secretions of the body; whilst at the same time we registered the various circumstances connected with the origin, progress, and treatment of the disease;-a disease than which there is certainly none which offers a more extended field for careful and well-directed observation."

The Paper contains the particulars of 34 cases, an elaborate table, and several plates. It would be quite inconsistent with our limits or plan to go into such details on a complaint on which so much is daily said. The utmost we can do is to notice some facts or inferences that appear of interest.

After relating seven cases, Dr. Bright makes some remarks. He first touches on the cerebral complication of this disease.

"The two cases, in which the complication consisted of affections of the encephalon, illustrate forcibly the danger of the sudden invasion of cerebral symptoms; which always exist where albumen is present in the urine, in any quantity, however small, accompanied with a diminution in the specific gravity of that secretion; a danger which is not diminished by the absence or the subsidence of any dropsical swelling: for, in the former case, it is worthy of notice, that the quantity of albumen

in the urine was but small throughout, and that the dropsical effusion had nearly subsided before the more alarming symptoms manifested themselves; and in the second case (that of Henry Stanley), the anasarca was much diminished, and the urine improved in every respect, except its specific gravity, just at the time that the fatal attack occurred. Indeed, I think that, from a careful observation of no very limited number of cases of this disease, I may pretty confidently affirm that in those cases of albuminous urine, in which there is little or no dropsical swelling, with but a moderate or even scanty deposit of albumen, the skin being at the same time moist and perspirable, but the urine defective in its solid contents as evinced by its light specific gravity, and the absence of urinous odour upon the application of heat or nitric acid-there is more especial danger of the sudden invasion of disease in the brain or its membranes. In one or two very well-marked cases of this kind, almost the only dropsical effusion has been a sort of watery chemosis, produced, as I believe, by anasarca of the cellular membrane under the conjunctiva.”

He then adverts to another and an interesting question-the relation of cardiac hypertrophy and renal disease to one another.

The origin, however, of this hypertrophy is a matter of some difficulty, as well as of some importance, as the question has been raised and it is certainly one deserving of grave consideration.-Whether, in cases of this kind, where disease of the heart co-exists with disease of the kidney (a coincidence which is observed so often as to render it in the highest degree probable that the two lesions bear some necessary connexion with each other) the former or the latter is to be regarded as the primary affection-whether, in fact, the renal disease is any thing more than the result of congestion produced by mechanical obstruction or whether the disease of the heart can be in any way shewn to be the result of that of the kidney? Upon this question, Cases 3, 4, 5, 6, and 7, tend to throw considerable light.

"To begin, then, with Case 3;--and let us, first of all, endeavour to reconcile it with the former hypothesis. The hypertrophy of the left ventricle, then, was notable, and its injecting force must have been excessive: there is, however, much difficulty in accounting for this hypertrophy, as there was no valvular disease; unless we refer it to the morbid changes which had taken place in the arteries, and which may certainly be regarded as a real and a sufficient cause for the phænomenon: for it must be obvious that the disease of the arteries was not produced by the violence which might have been done to their lining membranes by the too-powerful ventricles; since, in the arch of the aorta, where such violence would have been the greatest, the injury was less than in the descending portion, where the force of the heart's action must have been far less.

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According to this hypothesis, then, the arterial derangement must have been the primary lesion; which, by the impediment it offered to the free passage of the blood, gave rise to hypertrophy of the left ventricle, which, in its turn, by its too-powerful injecting force, caused a congestion of the kidneys, which led to their ultimate disorganization. It need hardly be remarked, that there is a contradiction involved in the very terms of the explanation: but further than this there is the difficulty of explaining why the kidneys should have suffered so much, whilst the liver, which is generally the first organ to be affected by disease of the heart, should have escaped; and, also, of accounting for disease of the arteries, which there is every reason to believe is a rare affection, when occurring idiopathically.

"Let us now assume, that the disease of the kidney was the primary affection: and in so doing, we may observe that we are not met in limine by the same difficulty which we had to encounter on the former hypothesis; for although to assume that the kidneys are often primarily affected with this disease would be, in some measure, begging the question, yet numberless analogies may be drawn from other secreting organs, to shew that over-stimulation may give rise to

kyperæmia and subsequent disorganization: and that the kidneys were so stimumulated in this case, is rendered highly probable, from the history of the invasion of the disease, as well as the previous habits of the patient. It is also ascertained that changes were produced in the condition both of the secretion of the kidneys and of the blood; the former being deficient in some of its natural solid contents, which were found to exist in excess in the blood; whilst the latter fluid was deficient in an important solid ingredient, which was being continually abstracted by the kidneys; so that there was a two-fold change produced in the latter fluid; namely, the presence of an irritating substance, which it is the office of the kidneys in health to remove; and also the absence of a substance, which, independently of other important purposes in the animal economy, gives to the blood a viscidity which (according to the observations of Magendie) renders it more easy of transmission through the capillary vessels. We have, then, a cause sufficient to account for the disease in the arterial tunics, whereby the circulation in the larger vessels must be impeded; as well as a further obstacle to the transmission of the blood, resulting from the change in the blood itself: both of which circumstances must have co-operated in producing the hypertrophy of the left ventricle. It cannot then, I think, be doubted, that the latter hypothesis accounts for the phenomena in this instance more readily than the former.

"The same line of reasoning, with very little alteration, applies to Cases 4 and 5 though perhaps, in the latter, there might be some suspicion of disease in the chest giving rise to venous congestion in some of the abdominal viscera, and, amongst others, in the kidneys, although not to a sufficient extent to account for the change which those organs had undergone.

"In Case 4, indeed, there had been cough and dyspnoea for some time, before any dropsical swelling manifested itself: but although it is by no means improbable, from the history of the case, that bronchitis existed, yet it is now so well ascertained that renal disease may exist without any dropsical swelling, and also that, when it does exist, it is so uncertain in its situation, that we are not justified by its absence in assuming that the kidneys were sound, or even that disease in those organs might not have existed to an extent capable of producing œdema of the lungs whereas the copious diuresis which existed for some time previously would be sufficient to lead us to believe that the kidneys had been for a long time in a state of over-activity-a belief which is most fully confirmed by the advanced state of disorganization in which these organs were found after death. "In Case 5, again, we have evidence of a still greater amount of obstructive disease in the lungs and heart, though the left side of the latter organ was principally affected; so that, although there existed a cause for venous congestion in the abdominal viscera, and, amongst the rest, in the kidneys, it was not sufficient to account for the extent of degeneration which these organs had undergone.

"In Case 6, again, we have a still greater amount of obstruction to the return of the venous blood: and, with it, considerable disease of the kidney, which, however, was principally of a congestive character. But it is in Case 7 that we find the causes of venous obstruction in their fullest extent; there being great dilatation and hypertrophy of the right ventricle, owing to the impediment to the pulmonary circulation, caused by the narrowing of the left auriculo-ventricular opening on the right side of the heart: yet here the disease in the kidney was less advanced than in any of the preceding cases, but that disease was of a congestive character, and during life the urine contained a scarcely appreciable quantity of albumen.

"The five last cases, in fact, present a series in which the renal disease becomes less and less, whilst the thoracic disease becomes greater and greater: the former affection, however, assuming more of the congestive character, as we approach the close of the series.

No. LXXVII.

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"We are then, I think, justified in concluding, that although disease in the heart or lungs may, by the impediment which it causes to the return of blood through the veins, give rise to congestion in the kidneys, in common with other organs in the abdomen, and thereby derange their functions, and in some cases lead to their ultimate disorganization, yet, as such disease was the least in those cases where the renal disease was the most advanced, and the converse, we are not to conclude that such disease in the chest is the universal or even frequent cause of the true Renal Disease; and that we must look elsewhere for the seat of the primary lesion in this formidable malady."

This reasoning is ingenious, if not conclusive, and the subject is one that merits close attention. The remaining Cases in the Report will repay a careful perusal. We see little more to notice.

ST. GEORGE'S HOSPITAL.

REPORT OF SOME CASES OCCURRING UNDER THE CARE OF MR. HENRY JAMES JOHNSON, ASSISTANT-SURGEON TO THE HOSPITAL.

Perhaps some apology is due for obtruding on the notice of the reader cases of so desultory, if not trivial a character as the succeeding. But as life is made up of small incidents, and the most happy and successful man is he who contrives to extract pleasure and profit from them, so professional existence is mainly composed of little matters, which, managed well or ill, constitute the difference between satisfaction and discomfort, perhaps between fortune and failure.

Even in a great Metropolitan Hospital, with all its appliances for attracting to itself what is rare and severe in the mass of human maladies, the bulk of the cases are of common occurrence, and of a mild description. They therefore present those opportunities for observation, practice, and experience, best calculated to qualify the physician or the surgeon for the duties of every day. To neglect them is to neglect the very business of life; to study them, goes far towards making him master of it. It is a trite observation, that the student too frequently does neglect them, and the practitioner too late regrets it.

I have always been of opinion, that it is the duty of those who have the charge of Hospitals, to render the facts that they contain as available as possible for the whole profession. These appointments are necessarily few, and their fortunate possessors should look on them not as prizes in a lottery, given for the exclusive advantage of the drawers, but as public trusts for the public benefit. Actuated, then, by this conviction, I have felt that even ordinary cases might convey some information to those whose means of obtaining it are straightened, and tend to bring the isolated country surgeon to the level of the knowledge of the capital. For, in hospitals, new medicines can be given, new methods can be tried, to an extent not permitted by the narrow limits, and strict responsibilities of private practice.

Whatever may be thought of the performance of the task, I trust that no exception will be taken to the spirit of it. I am sensible that, at present, the execution lags sadly behind the promise, but venture to indulge the hope that something more worthy may be effected bye-and-bye.

The first subject to which I shall allude is the

I. MANAGEMENT OF ULCERS OF THE LEGS.

Those who have been much about Dispensaries or Hospitals are aware both of the frequency and the obstinacy of ulcers of the lower limbs in the out-door

patients. They often tire out surgeon, dresser, and all, and week after week, and month after month, there is the same sore with the surface just as foul, or the edges just as hard as ever, to the shame and confusion of ointments of all colours and bandaging of the first order. Any treatment which has some success to boast of, and curtails the duration of these opprobia chirurgorum, is “a consummation devoutly to be wished for."

On first assuming the office, I was naturally inclined, " stare super antiquas vias," and to appeal to poultices, unguents, or strapping as the fit and proper things for ulcerated legs. But in spite of them, the dresser, and myself, too many of those legs grew little better, and some got even worse. It was obvious that either a happier method must be found, or else that sore legs were a nuisance not likely to be materially abated. A plan was tried by the Assistant House-Surgeon, and myself, which, on the whole, has not disappointed our anticipations, and has really effected so much benefit, as to render an ulcer of the lower limbs a hopeful sort of case. Whatever claims others may possess to the integral parts of the plan in question, I beg to make freely over to them.

I may be permitted to state that these observations are neither calculated nor intended for a copious account of the varieties or treatment of ulcers. They are hints for their management, and nothing more. But to the point.

As a general rule, subject unquestionably to many exceptions, moist applications seem to suit ulcers best-a piece of lint dipped in the liquid, whatever it may be, larger than the sore on which it is laid, and covered with a piece of fine oiled silk, larger still, is the sort of dressing employed. The lint should be changed sufficiently often, or, at all events, dipped frequently enough in the liquid, to ensure its permanent moisture. Three or four such applications in the twentyfour hours are, in most instances, sufficient. When the discharge is copious, attention to this is particularly necessary. A girl with an ulcer on the arm, of large dimensions, the consequence of a burn, allowed the lint to remain in contact with it for more than forty-eight hours. The matter had collected and became offensive, and the granulations were absorbed, and the sore much deepened.

In most cases, it is well to employ a bandage. If the patient maintains the horizontal posture, this is not so requisite. The bandage should, in general, be applied lightly, and may, in some instances, be advantageously kept wet.

It is foreign to my purpose to inquire into the manner in which these liquid dressings act. It is probable, however, that the sustained temperature of the sore and its vicinity occasioned by the prevention of evaporation, operates as a stimulus, while the moistened lint forms a sort of nidus for the granulations. That the temperature of the part is kept up is certain.

I have, hitherto, said nothing of the nature of the liquid selected as an application. My impression is, that in the bulk of cases some gentle stimulus is best. I have tried plain water, the solution of the nitrate of silver, of the sulphate of zinc, of the soda chlorinata, of opium, and the black wash. Amongst all these, the solution of the sulphate of zinc, in the proportion of two grains to the ounce of water, has appeared to suit most generally. When the sore has been more than usually painful, the solution of opium, of a similar strength, has agreed better. And foul, dirty, cachectic looking ulcers have seemed most benefited by the solution of the soda chlorinata, one part of which is dissolved in sixteen of water. These, however, are merely hints thrown out, as approximations to the truth. It remains for other surgeons, and for further experiments, to determine. what may be their value.

I have observed that a light bandage is usually adviscable. In some cases, more decided support is needed. Where the ulcer depends on a varicose state of the veins of the limb, without that inflamed, and eczematous or psoriasitic state of skin to which varices of the veins often lead, soap-strapping may be usefully employed. Perhaps the best method of applying this consists in setting on the