THE

EDINBURGH

MEDICAL AND SURGICAL JOURNAL.

1. APRIL 1811.

PART I.

ORIGINAL COMMUNICATIONS:

I.

Medical Report for Nottingham. By JAMES CLARKE, M. D. Physician to the General Hospital, and to the Vaccine Institution.

"Il suffit de tenir un compte exact, mois par mois, des maladies, d'examiner celles qui sont à peu près egalement frequentes dans tous les temps de l'année, de noter ensuite celles qui varient, soit pour le nombre, soit pour les caracteres specifiques, et de comparer seulement ces derniers avec l'état de l'atmosphere. PINEL, Medecine Clinique, p. 371.

OU UR attention, since the time of Hippocrates, has been repeatedly called to an examination of the great influence the seasons evidently have, directly or indirectly, in modifying, and even inducing disease; but although this agency has ever been admitted, the science of medicine has not received that assistance which might have been expected with the source of information so clearly exposed. The difficulty and trouble of keeping meteorogical registers on a plan sufficiently accurate and compre hensive to form a satisfactory history of the atmosphere, and the deficiency of attentive observation, highly necessary to the improvement of medicine, are the causes to which we must in a great measure attribute our present deficiency in the application of this essential auxiliary to medical science. In keeping a VOL. VII. NO. 26.

I

register of the atmosphere, it is necessary to be well assured of the correctness of the barometer, thermometer, and other instruments employed for the purpose, carefully examining them from time to time, that we may not be deceived in our observations. Of the want of this attention the reporter has seen many instances. It must always tend to the elucidation of subjects of this nature, if a regular form be generally adopted; the comparison of two or more registers may then be made with greater ease, and the conclusion drawn with more satisfaction. The meteorological table inserted in these reports is thus formed. The highest and the lowest state of the thermometer is noted every twenty-four hours; the state of the barometer at two P. M.; the points of the wind during the day, and the nature of the weather, remarking any atmospheric phenomena. The greatest variation of the barometer and thermometer during the month, with the quantity of rain, completes the journal.

The object of this meteorological register, is not only to foretel the probable changes of weather, but also to enable the attentive practitioner to explain the cause of symptoms which may arise in the course of disease. To elucidate this observation, we may call to our minds what often occurs in typhus fever, when a frost suddenly sets in: The patient complains of pain in the sides or chest, increased on deep inspiration; the pulse is sharp, yet feeble, the debility and other previous symptoms of the fever remaining equally distressing. The medical practitioner is now called upon to afford the patient immediate relief; he knows well that the pain may be moderated, if not removed, by general bleeding; but he is also aware of the consequences likely to arise from the abstraction of blood in the advanced stage of this disease; he therefore more prudently reasons upon the cause of this sudden alteration in the state of his patient; and instead of treating this accession of symptoms as pure pneumonia, he pursues a practice to moderate their urgency, and still follows up the plan he had laid down for the treatment of the disease. This, it must be allowed, is but a slight illustration of the advantage to be derived from extending our researches to the alternations of the atmosphere, and thus enlisting into our service a branch of science which has been neglected, only because its application has not been understood.

The case of diabetes related in the Sixth Volume of this Jour nal, page 264, has excited the attention of the Reviewer in the Medical and Physical Journal, * who, after quoting the theory

* See Medical and Physical Journal, Vol. xxiv. p. 157,

says,

which follows the case, makes the following objections to it. He "If the increased flow of urine in the first instance is merely a vicarious discharge, if nothing but the sweating fluid is sent to the kidneys to be thrown off by them, in combination with the urine, we see no possible source of mischief, nor can we allow that any unnatural irritation is thereby produced, the two fluids being so exactly similar, we may almost say identically the same. In answer to these objections, it may be stated, that the profuse sweating cannot be a natural, but must be a morbid discharge, diverted from the skin by sudden exposure to cold, by eating acid fruits, drinking cold liquids, &c. Gaubius says, "Great profusion of sweat, which neither a more intense exercitation of the body, or emotion of mind, nor external heat, or what things are ingested, or applied externally, create, acknowledges for its causes laxity of the cutaneous pores, an accelerated circulation of the blood, an increased impetus towards the surface, or redundance of aqueous matter in the humours, or its too easy separation from the crassamentum.

This discharge, besides being morbidly profuse, is, like other secretions; susceptible of a change, and may become stimulating even to the skin itself, and consequently much more so to the kidney, where it then must certainly act as a foreign body, exciting that organ to extraordinary action. But even supposing it to arise from a profuse natural discharge (the sweat) diverted to the kidney, we know from the experiments of Rye, that the average quantity of insensible perspiration in a day, in the healthy state, is estimated at 56 oz. and of urine at 39 oz. Although Fourcroy in his system considers the sweat as the product of the accumulation of the molecules of perspiration which the air cannot carry off; ; yet we think this opinion is not sufficient to explain this profuse discharge on the cuticular surface, which may be moderately calculated at three times the amount of the perspiration in a given time. It may also be conjectured, and with much probability, that the watery parts which are secreted in the kidney, are not absorbed, but pass forward into the bladder. "In the mean time, the patulent veins, extended into the cavity of the follicle, absorb the more aqueous parts from the thin mucus, so that it becomes thicker as it is retained longer; but if, by the force of some stimulus, it be directly discharged after it is secreted, it comes out thin and watery. "+ From such sources, the urinary organs must give out a considerable quantity of fluid; and if we still keep in mind that the body is in a state of

• Erskine's Translation, p. 312.

f Haller, Translation, p. 102.

diseased activity, we shall find sufficient source for the quantity of urinous fluid discharged by a diabetic patient. If these two fluids, sweat and urine, be identical, which certainly remains to be proved, (for nothing but bare assertion is advanced by the Re-. viewer in support of that opinion); and although Fourcroy in his system treats copiously on this subject, yet he advances nothing which can be considered as proving their identity; it still remains to be considered, how far the kiduey may be influenced by the unusual quantity of fluid thrown into its capsule: For in examining the bodies of persons dead of diabetes, the vessels of the kidneys have always been found morbidly enlarged, and the secretion appeared to have been conducted on a large scale. This ought to have reminded us of the absolute necessity of accommodating our physiological reasoning to diseased structure, and of the advantages to be derived from morbid anatomy, in explana tion of deranged action.

The Reviewer continues, "If also we suppose urine to be secreted in greater quantity, we should not expect the constant irritation of the urinary passages, and phymosis, to be referable to this circumstance, since we should apprehend these symptoms: would rather take place from a greater concentration of that fluid, than from its increased quantity, and greater dilution." That there is a constant irritation of the urinary passages, and phymosis, in this disease, is thus tacitly admitted; but the great difficulty. is to explain the cause of this symptom. It is not difficult to conceive, that irritation must exist, or why the constant desire to evacuate the bladder, which cannot be occasioned by the irritation of distention? but as it must have a cause, we naturally conjecture that it arises from the stimulus of the morbid urine on the urethra. Phymosis is not admitted in the general definition of ischuria, in which disease, the urine obtains the greatest concentration; we may therefore conclude, that this symptom is not the consequence of irritation of the bladder,-but it enters into the definition of what is called the ischuria urethralis, which plainly indicates, that it arises from an irritation of the urethra alone, and not of the urinary organs generally; but as the urine cannot be concentrated in this disease, it is vain to argue upon it as a cause of this symptom. There is one symptom in diabetes which affords some explanation of this affection; it is the great irritability of the body, as well as of the mind, and the proneness to inflam mation. This was marked in Omrad to a great degree, and is admitted, by Dr Watt and others, as a general symptom of the disease. The extreme sensibility of the urethra subjects it to the ticular influence of this general irritation, and thus may render it

par

so sensible to the stimulus of the urinous fluid, as to produce phymosis.

Admitting," the Reviewer says, "the increased action of the kidneys to take place, we do not see why a greater supply of blood will be required for the system, so that the stomach must be called into inordinate action, and the desire for food proportionably increased, without time being allowed for its complete formation into blood." It appears almost self-evident, that if a greater quantity of urine be secreted, a proportionable supply of blood must be sent to the kidney,-as from this source only can this fluid be separated; but in the enlarged and excited state of the vessels, time is not allowed for this secretion to be perfect, and chyle may pass off with the secreted urine, or it may be called the urine of digestion or of the chyle, which, in the healthy state, is passed two or three hours after a meal, and cannot be considered as perfect urine. * The same arguments cannot justly, however, be applied by the Reviewer "to hæmorrhage, or extensive local inflammations." In hæmorrhage, nature effects a relief, and often a cure, by inducing syncope. If the bleeding returns, the fainting follows, and the system thus obtains relief; but the effect of syncope is to allay all irritation, or rather to impede for a time the circulation of the blood, and to induce atony; in consequence, the digestion receives a long interrupIn extensive local inflammation, "the stomach nauseates food, and ill digests that which is taken." The reverse of this occurs in diabetes; bulimia is admitted a prominent symptom of the disease; digestion is particularly active; the body nevertheless emaciates; the quantity of feces is not increased; yet the extraordinary quantity of solid and fluid aliment must be passed off,-and what objection can there be to admit that it passes by the kidney? Dr Bostock says, "except the kidney, there is indeed no obvious exit by which the contents of the stomach can be evacuated; the perspiration is checked; the alvine discharge is, in general, not increased; and the weight of the body is daily diminishing."†

tion.

The Reviewer then proceeds to remark, that "the stomach being irritated by the gastric juice, which the constant sense of hunger calls into the stomach, is certainly a novel idea, but perhaps not a very just one. Wherein resides this sense of hunger? and how is it produced? The converse of this proposition may be true, and the constant sense of hunger be produced by the presence of the gastric juice, perhaps in a vitiated state, from some

* See Fourcroy's System.

Memoirs of the Medical Society, London, Vol. VI. p. 256,