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by the researches of Dr. William Jenner, who has demonstrated the separate identity of at least three species-namely, typhus fever, typhoid fever, and relapsing fever (vol. ii. p. 800). We are glad to observe, that in a note to the previous Lecture (p. 795), Dr. Watson bears a willing testimony to the fact of Dr. Alexander P. Stewart, of the Middlesex Hospital, having, so early as the spring of 1840, in a paper read to the Parisian Medical Society, * clearly set forth the main distinctions between typhus and the enteric fever.
Dr. Barclay, like not a few distinguished physicians, is evidently not prepared to yo the same length as Dr. Watson. We cannot, however, doubt that his description of fevers would have been more intelligible to the student if he had furnished an account of those symptoms which are considered to be characteristic of enteric fever on the one hand, and of typhus on the other; instead of pleading in an apologetic manner, that “in a treatise on diagnosis it is obviously impossible to discuss disputed points in semeiology, and all that can be done in this place is to point out the different characters the spots are liable to present.” (p. 55.) We further think that a résumé-it need not bave been otherwise than brief-of Dr. Jenner's observations would have been more valuaable--followed by a caution from Dr. Barclay regarding a too exclusive acceptance of them, if he deemed such required-than the following sentence, where again referring to spots, he observes, “ But the student must work out for himself the question whether there be any specific virus that produces one appearance or the other; as, in fact, their cause is yet quite undetermined.” (p. 56.)
We have thus very briefly alluded to the subject of fever, in connexion more especially with that particular point which has of late years peculiarly occupied the attention of physicians. Nothing could be clearer, and according to our own view nothing more satisfactory, than the statements of Dr. Watson upon this topic; but as in the pages of this Review the matter has very recently been frequently discussed, we need not now enlarge upon it. In noticing, even in a manner the most cursory, some of the recent advances in practical medicine, it were unpardonable not to allude, even were an entire adberence to their correctness kept back, to the patient and sagacious labours of Dr. William Jenner.t
Fevers form the subject of Dr. Barclay's fourth chapter; the fifth is devoted to Rheumatism and Gout. The particular symptoms of the former disease, and the means of forining a correct diagnosis, are, with one exception, sufficiently clearly stated; there is no reference to the characters usually presented, nor to the changes undergone by the urinary secretion. Yet the careful examination of the urine is most important, and at all times required. Dr. Aitken in his brief definition of rheumatism very properly alludes to the condition of this secretion; and Dr. Watson, in his usual perspicuous and comprehensive manner, when detailing the chief symptoms of acute rheumatism (vol. ii. p. 739), refers to the “ turbid and acid urine.” Dr. Barclay notices the acid odour of the perspiration; the acidity of the urine surely deserves as much attention. Notwithstanding the remarkable ability with which of late years the disease now under consideration bas been studied, we are still forced to acknowledge that our notions in regard to it are vague and unsatisfactory. We have, it is true, by clinical observation and chemical research, arrived at the knowledge of many most important and valuable truths, but we are still ignorant of the real essence of rheumatism." Before we shall succeed in obtaining correct views upon this all-important point, it appears necessary that a more precise acquaintance should be formed with the different varieties of rheumatism as varieties; there must be a juster discrimination of these. When this shall have been effected, we may then perhaps be able—and all must assent to the extreme importance of such advance in our knowledge—to determine the cases of rheumatism in which the cardiac affections for example, are most apt to supervene, and those in which the arthritic changes will most probably prove serious. As yet any opinion formed on these points is merely conjectural. It really appears as if, under the title rheumatism, there were included several diseases, resembling one another in some particulars, but widely
Afterwards published in the Edinburgh Medical and Surgical Journal for 1840. 1 Care must be taken that, in the present discussion of this subject the important observations of Dr. Peacock, as well as of other physicians, are not lost sight of.
different in others. The physician who shall succeed in unravelling this complex subject will deserve well of his profession. The variable degrees of success which attend the different modes of treatment of the so-called acute rheumatism, appear to attest the truth of our former observation. This is especially the case in regard to colchicum, still a favourite remedy with many ; its preparations have sometimes, to use Dr. Watson's words, "an almost magical effect in subduing the disease;" while at others, without the occurrence of any of those specific effects of this drug, and which indicate the propriety of its being discontinued, no good results, the course of the disease is unaltered—the secret essence of it is evidently unreached. Dr. Watson very probably has assigned the correct reason—practically it does appear to be so—when he observes :“ I believe that, in proportion as the synovial symptoms predominate or mix themselves distinctly with the fibrous--in proportion as the disease approaches in its character to gout-you may expect to be successful with colchicum.” (vol. ii. p. 746.)
We are glad to find that Dr. Watson has assigned a prominent position to the remarks of the late lamented Dr. Golding Bird on the treatment of acute rheumatism by the salts of potash, and more especially by the acetate—his " favourite drug." Dr. Bird's views on blood depuration, and on the existence of a peculiar class of remedies, the renal depurants, are, in our opinion, eminently sound, and in the highest degree worthy the attention of all physicians. We can confirm, after an extensive trial of the acetate of potash in cases of acute rheumatism, Dr. Bird's observation as to the pain becoming remarkably and suddenly less as soon as the urine becomes alkaline and rises in specific gravity. We regard Dr. Bird's observations as among not the least import
. ant of the recent advances of practical medicine; and we must express our regret that Dr. Aitken, while referring to the interesting experiments with liqucr potassæ made by Dr. Parkes, and to Dr. Fuller's important experience of alkaline remedies in the treatment of rheumatism (p. 395), has not had his attention directed to the still more valuable results of Dr. Bird's inquiry.
Gout receives from Dr. Barclay not more than a definition; the pathology of the disease is not touched upon, further than to state that "the researches of recent times have gradually led to the discovery of an important element in gout—the presence of an excess of uric acid in the blood.” Dr. Aitken might, with advantage to his readers, have quoted more fully the opinions and observations of Dr. William Budd and Dr. Garrod, and less those of certain authors, who, however respectable, cannot be regarded in the same light as the physicians now mentioned. As the most recent champion of those views in regard to the pathology of gout which are opposed to the theory of the presence of a morbific matter (materies morbi) in the blood, and as the author of an excellent practical treatise on gout, we should have been glad to have found reference to the opinions and experiments of Dr. Gairdner. *
In Dr. Watson's account of gout, the views of Dr. Budd and Dr. Garrod receive that prominence to which they are justly entitled. No recent observations have had a more important influence, as well from the careful nature of the experiments upon which those of the latter were founded, as from the ingenuity of the former's speculations, in upholding the humoral pathology of gout. Dr. 'Watson is satisfied that this, the ancient doctrine of the origin of gout, is the true one. Gout is very properly described by Dr. Aitken under the head of Constitutional Diseases, and under the first order of that class-namely, Diathetic Diseases-Diathetici. Our only regret is, that Dr. Aitken has rested satisfied with the account of this disease viewed per se, and has not offered illustrations of the manner in which many affections-inflammatory and otherwise-are modified by the gouty diathesis. That the treatment of pneumonia and bronchitis, for example, occurring in a gouty subject, require the employment of such remedial means as tend to eliminate the blood poison, as well as of such as are efficaciously used in the more ordinary cases of the inflammatory affections just named, is undoubted. This indeed is borne testimony to by the recent observations of many practical physicians; and it is probably not going too far to say, that were an increased attention bestowed upon such modifying circumstances in particular cases of various diseases
* On Gout; its History, its Causes, and its Cure. By William Gairdner, M.D. London. Third edition. 1854.
, a corresponding improvement in their treatment would be the gratifying result.
Dr. Aitken passes from gout to the consideration of anæmia, of which condition both he and Dr. Barclay offer brief but comprehensive accounts. Neither author notices, however, that peculiar association of phenomena in connexion with anæmia, which, first alluded to by Dr. Parry, was afterwards described by Dr. Graves and Sir Henry Marsh, and more recently by Drs. Macdonnell, Begbie, Stokes, Banks, Bellingham, and Messrs. White Cooper and Taylor, in this country ; by Romberg and Henoch in Germany; and Hervieux in France. Dr. Watson thus refers to the affection in question:
"Among anæmic young women, more or less fulness of the fore part of the neck, from slight enlargement of the thyroid gland, is of very frequent occurrence. Sometimes the eyeballs are at the same time unduly prominent."
That this particular disorder, represented specially by enlarged thyroid gland, often greatly enlarged and prominent eyeballs, has its dependence on some specific change in the blood, at least analogous to anæmia, was first pointed out by Dr. Begbie, and seems now to be the generally received opinion. The morbid condition just described is almost invariably preceded by such circumstances as are met with in the cases of most marked anæmia, while the sufferers from it, as a general rule, present unmistakable evidences of blood impoverishment, and except in very rare cases, are benefited by such treatment as is likely to overcome the general disorder. We regret that Dr. Watson has not more fully alluded to the subject; he has only done so, incidentally almost, when treating in Lecture forty-third (vol. i. p. 810), of bronchocele; cases of the disease are by no means uncommon, while the prevalence of correct views in respect to its nature is still to be desired. Though most frequent among women, just as anæmia itself is, the affection has been observed in men. Perhaps the most correct and complete account of the subject is contained in the twenty-first chapter of the lamented Dr. Bellingham's treatise On Diseases of the Heart.'
There is another peculiar condition depending on alteration of the blood, which, as possessing “more of physiological than of practical interest," Dr. Watson merely treats with a passing notice-namely, leukæmia or leucocythemia. Dr. Aitken's account of this constitutional disease is extended and complete. He has very judiciously ascribed the exact amount of credit due to the erudite and distinguished German pathologist, Virchow, and to the able professor at Edinburgh, Dr. Hughes Bennett, in connexion with this subject. The essential and prominent character of this affection, that from which its name is derived, is the increase of the colourless or white cells of the blood. In close connexion with this, however, there are certain other morbid conditions, and two of these of very great importance-namely, enlargement of the spleen, and affection of the lymphatic glands. Dr. Spiess's observations on this disease, under the head of morbid changes in the blood and lymph (page 321), are very instructive. He remarks :
" According to recent researches, especially by Virchow, it appears that the morbid increase of the colourless blood corpuscles apon which the condition of leukæmia or leucocythæmia chiefly depends, is an immediate consequence of the enlargement of the spleen and lymphatic glands, with which the former is so intimately connected. The morbid increase of the colourless corpuscles may attain so great a degree as to constitute a fourth part or even a half of the whole blood globules.”
The various important questions, both of physiological and pathological interest, which suggest themselves in connexion with this remarkable condition of the system, are also alluded to by Dr. Spiess. Among others, whether, in relation to the origin and purpose of the white cells, these represent an earlier development of the normal blood globules. Whether, also, the spleen and lymphatic glands are the organs in which these embryo blood globules—if they be such-are formed. Then, in more direct relation to leucocythæmia, Dr. Spiess inquires whether the morbid enlargements of the spleen and the lymphatic glands are to be regarded as the consequences of an increased formation of the colourless blood globules, or as—and this is the more probable
view—due in some way or other to the diseased condition of the newly-formed blood globules. It will be evident that these are inquiries of very great importance as well as interest, and while for the present no very satisfactory conclusions can be drawn, still, from the amount of knowledge that has recently been accumulated, it is reasonable to suppose that this is one of the directions in which the science of medicine is likely to make further and early advances. It is not likely that the removal of the spleen, which has been proposed and practised in Germany as a means of treatment in this and allied splenic affections, will ever be generally adopted. From the consideration of the affection with which the names of Virchow and Dr. Bennett are intimately connected, Dr. Aitken passes by an easy transition to that of “ bronzed skin,” in connexion with disease of the supra-renal capsules, associated as closely with the name of another highly distinguished physician, Dr. Addison. Of this most interesting condition in its various relations, Dr. Aitken has afforded a remarkably interesting and instructive summary. Dr. Watson's remarks upon this affection are well entitled to attention, and as they appear for the first time in the present edition of his Lectures, we shall transfer some of them to our pages :
“In former courses of these lectures, I have said nothing, for I knew nothing, of the morbid conditions of the supra-renal capsules. I was ignorant alike of their physiology and of their pathology, of their uses and of their diseases. A pathology, however, they have, which vindicates the importance of these little organs in the bodily economy, although it does not disclose their parpose. The suspension of their function (the necessary result of the destruction or the extensive impairment of their structure) is fatal to life.* And this mortal inward change is revealed before death by one very conspicuous signal--unregarded, indeed, till our own day, and reserved for the sagacity of our distinguished countryman, Dr. Addison, to discern and to interpret. It is very remarkable that two physicians living at the same time, in the same town, and attached to the same hospital, should have brought to light two such serious forms of disease, utterly unknown before, in parts of the body so contiguous, and have thereby won for themselves an enduring place in the records of medical science. Henceforward the names of Bright and of Addison must be held in honourable remembrance whenever mention is made of renal and of supra-renal pathology.”
The reader previously familiar with Dr. Watson's elegant and graphic style will recognize it in the sentences quoted. What is new in the volumes now for the fourth time issued, is in this respect as remarkable as are the most admired of the well-known passages in the former editions. No medical author of our day approaches Dr. Watson's felicitous manner in rendering honour to whom honour is due.
“It is not uncommon,” he continues, “ to meet with a sick person whose history is of this kind. He knows not how, nor precisely when, his illness commenced, but he has gradually fallen from his usual state of health; has become weak, pale, thinner, but generally not emaciated, languid, spiritless, unequal to bodily or to mental exertion, with flabby muscles, and a soft pulse, which commonly is very feeble also. For this deteriorated and anæmio condition you can trace no intelligible cause. There has been no exhausting profluvium, no loss of blood, morbid or artificial; no diarrhea, diuresis, or other drain upon the strength; no wasting excess or indulgence; no mental shock or anxiety. No fault is discoverable in the lungs, in the heart, in the kidneys, in the digestive organs; no direct evidence of malignant disease in any part. Yet the diminution of strength is progressive—faintness and vomiting sometimes supervene--the mind becomes confused, the pulse grows weaker and weaker, until at length the flickering flame of life goes out, or is extinguished in a sudden convulsion. This unexplained train of symptoms should suggest the suspicion of disease in the supra-renal capsules. And the suspicion will be turned into something like certainty if, during the progress of the case, a change of colour begins to be perceptible in the patient's skin, first and chiefly in parts that are uncovered by the dress, as the face and hands, but elsewhere also. The colour which thus takes the place of the natural hue is a brownish yellow. . . The hue is often partial, and occupies principally the front of the body and of the limbs, especially of the thighs. When it is spread over the whole surface, it varies in intensity, being darkest in the flexures of the body, in the armpits and groins, round the navel, and upon the scrotum. Sometimes it is deeper here and there, and gives a mottled appearance to the surface; and sometimes it
* The experiments of M. Philipeaux and Dr. Harley on animals (rats) show that the supra-renal capsules are not absolutely essential to life.
is diversified with white patches, in which the skin is blanched, is more white and colourless tban healthy skin, like the nails and conjunctivæ ; and the hair on the head and on the pabes corresponding to these spots becomes perfectly white." (vol. ii. p. 729-30.)
Such is Dr. Watson's description of a class of phenomena which, first noticed and described by Dr. Addison, has since been found, in numerous instances, by other observers, both in this country and abroad, to be in a remarkable manner related to disease of the supra-renal capsules. The condition of disease in which these bodies have been found has differed considerably; sometimes they have been the seat of cancerous, sometimes of tubercular deposit ; in some cases atrophied, in others hypertrophied. "Most frequently of all they have undergone a calcareous degeneration, or have been converted into a softer putty-like substance.” The “extent and completeness," rather than the “character," of the change, seems to be the important fact. The careful reader of Dr. Addison's observations will remember that it is to the peculiar constitutional cachexia now described that he especially directed attention. In connexion with it the clinical fact was announced, of the frequent occurrence as a symptom of bronzed skin. Now, and as Dr. Aitken very properly observes, there can be little doubt that, since Dr. Addison's observations appeared, too much attention has been given to this peculiar symptom—at least in the sense of too little attention having been directed to the investigation of the constitutional state. It is plain, however, that the latter is the direction in which labours must be prosecuted before we shall arrive at a satisfactory knowledge of this peculiar condition. We have not the opportunity at present for entering upon an examination or discussion of the recent observations on this subject which have been made. There are, however, many discrepancies which require reconcilement. Disease of the supra-renal capsules does occur without a trace of the characteristic bronzing. Still more frequently it will, we believe, be found that bronzing occurs without disease of the capsules. Dr. Watson says once only, so far as known to him, has this occurred. The most marked instance of bronzed skin we have seen, in which the trunk of the body anteriorly and posteriorly, the limbs upper and lower, hands and feet, with the neck and face, were variously but symmetrically marked; there existed cancerous disease of the stomach, but the supra-renal bodies were perfectly healthy. As far as our own experience goes, we feel inclined to agree with those who associate the bronzing of the skin with the constitutional malady, and not with the affection of any particular organ.
The following remark of Dr. Aitken is of great significance :
* One very important point is remarkably deficient of illustration-namely, the early symptoms of this cachexia, independent of bronzing of the skin. From what has been shown relative to the disease, it would appear that when bronzing of the skin has been established, & sign of disease has been discovered when it is too late to be of any service, for all the cases appear to terminate fatally in which this state has been unequivocally established.” (p. 421.)
Previous to the valuable observations of Dr. Addison, the connexion of a peculiar darkening of the skin with a very marked constitutional affection, had been noticed in the disease, not known in this country, but endemic in certain parts of Italy, “Pellagra." The pathology of this remarkable disease remains most obscure. Certain it is, that in many fatal cases of pellagra, no lesion is found capable of satisfactorily accounting for death. Again, recent observers are unanimous in considering the characteristic dark appearance of the skin, which first appears on the hands and face and then extends over the body, to be nothing more than one of the manifestations of a peculiar constitutional condition under which the victims of pellagra labour. We are not aware of any observations which have been made in regard to the state of the supra-renal capsules in pellagra, but the inquiry will, we trust, be instituted. We ought not to omit mentioning that, by a recent Italian author, Dr. Labus, of Milan,* it has been attempted to prove that there does exist a distinguishing pathological condition in this disease-namely, an atrophy, or extreme attenuation of the ileum (assottigliamento dell ileo), specially
* La Pellagra investigata sopra quasi ducсento Cadaveri di Pellagrost. Milano, 1847.