accomplish them. As the production of a physician, our Royal College, we think, should testify its approbation, of such a work, even although emanating from an unfortunate Licentiate! It certainly would seem better in the eyes of foreigners to expend a few pounds annually in such a way, than in litigations with the graduates of Scotch universities. We fear, however, that Dr. Bright has little to hope from any other patronage than that of the PUBLIC-a patronage not yet totally swallowed up by the insatiable stomachs of medical monopolists !*

Our author modestly states it as his wish to render, through this publication, the labours of an hospital more permanently useful, by bringing together such facts as seem to throw light upon each other-and, also to preserve and explain, by faithful engravings, the recent appearances of those morbid changes of structure which have been connected with the symptoms, or have influenced the treatment of the disease.† He considers it unnecessary, in the present day, to expatiate on the utility of hospital reports, or "the importance of that information which our profession derives from the study of morbid anatomy." Dr. Bright must know, however, that it is not many months since discredit was attempted to be thrown on pathology from "high authority," as it has been called-probably, in reference to the geographical position or altitude of the theatre where the sublime dogmas were delivered. But we must proceed to the work.

This first volume is divided into several sections, the chief of these exhibiting a collection of cases, with appropriate drawings, of the appearances observable in diseases terminating in dropsical effusion--first, of the appearance in the kidneysecondly, of those in the liver-and, thirdly, of those in the thoracic viscera. There are some other sections on the effects

* We think that every opulent individual, and every medical society, should make a point of subscribing to Dr. Bright's book, as the proper way to lend their separate and collective aid in rewarding merit, and promoting the publication of valuable works. There will still be a large class who must take the matter at second hand.

+ In passing a high encomium on Dr. Bright's plates, we do not mean to say that they are faultless, or that they are equally meritorious. Those representing diseases of the kidney we consider as the best-and those of the lungs the worst. We thing it quite impossible that any portion of lung in phthisis pulmonalis could faithfully present all the most brilliant colours of the rainbow, as seen in Plates IX and X. The same observation would pos sibly apply to some plates of morbid conditions of the intestines. The second figure in Plate XII. we cannot but think is meretriciously set forth, and as "flaunting in rags, or fluttering in brocade." The principal, perhaps the whole failing in these beautiful plates, is their excess of beauty.

of inflammation in different textures of the lungs--on phthisis pulmonalis--on jaundice--on dysentery-on fever. All these sections we shall notice seriatim, in this and succeeding numbers of our Journal.

1. ON THE APPEARANCES OBSERVABLE IN DISEASES
TERMINATING IN DROPSICAL EFFUSION.

These are exceedingly numerous as well as various--and it is often difficult to say how far these changes of structure are the causes, the auxiliaries, or merely the consequences, of the effusion. One great cause is, unquestionably, obstructed circulation, especially in the venous system. Thus, whatever either generally or locally checks the return of blood through that system, as diseases of the heart, the liver, or the lungs, has a strong tendency to produce serous effusion, either in the cavities or in the cellular tissues. But there are many other diseases besides these more obvious ones of the three great organs alluded to, which give rise to dropsy. Certain affections of the peritoneum, as tuberculation, false membranes, &c. give the tendency to effusion, and leave open a considerable field for the investigation of the pathologist.

In

Dr. Bright, however, has particularly directed his attention to a class of organic changes which have hitherto attracted too little attention-namely, morbid changes in the kidney, which, "whether they are to be considered as the cause of the dropsical effusion, or as the consequence of some other disease, cannot be unimportant." In these conditions of the kidney, Dr. B. has often found the dropsy connected with the secretion of albuminous urine, more or less coagulable by heat. such cases, the liver did not betray any considerable marks of disease, either in its function during life, or structure after death. On the other hand, where the dropsy has clearly depended on organic disease of the liver, there was generally no morbid alteration in the kidney-no coagulable urine. Dr. B. avers that he has never found the kidneys free from disease in the bodies of those who have died of dropsy, attended with coagulable urine. Whether this morbid structure in its incipient state, may be considered as giving rise to the altered secretion -or whether it be owing to the long-continued disorder of the renal function, may admit of some doubt. Dr. B. is of the opinion that the altered action of the kidney is the result of various hurtful causes operating through the medium of the stomach and skin, thus deranging the healthy balance of the

circulation, or inducing an inflammatory state of the kidney itself and that a long continuance of this disturbed function leads to permanent change of structure. This, we think, is the more probable solution; and it is, in fact, in accordance with what we see in other organs of the body, as well as in the kidney. Dr. Bright's observations on the condition of the urine in dropsy coincide, in a great degree, with those of Dr. Blackall. We must observe, however, that Dr. Blackall's conclusions have not been borne out by the experiments of others-and especially by those of Dr. Crampton of Dublin, as seen in the Dublin Hospital Reports.

"Where anasarca has come on from exposure to cold, or from some accidental excess, I have in general found the urine to be coagulable by heat. The coagulation is in different degrees; it likewise differs somewhat in its character: most commonly when the urine has been exposed to the heat of a candle in a spoon, before it rises quite to the boiling point it becomes clouded, sometimes simply opalescent, at other times almost milky, beginning at the edges of the spoon and quickly meeting in the middle. In a short time the coagulating particles break up into a flocculent or a curdled form, and the quantity of this flocculent matter varies from a quantity scarcely perceptible floating in the fluid, to so much as converts the whole into the appearance of curdled milk. Sometimes it rises to the surface in the form of a fine scum, which still

remains after the boiled fluid has completely cooled. There is another form of coagulable urine, which in my experience has been much more rare; when the urine being exposed to heat assumes a gelatinous appearance, as if a certain quantity of isinglass had been dissolved in water. I have indeed met with this in one or two cases only." 3.

gen

In the progress of these anasarcous cases, Dr. B. has erally found a strong tendency to throw off the red particles of the blood by the kidneys, in the form of hæmaturia, varying from the simple dingy colour of the urine, with slight brown deposit, to complete bloody urine, with, occasionally, a thick ropy deposition at the bottom of the pot.

Besides these cases of sudden anasarcous swelling being generally accompanied by coagulable urine, I have found another and apparently a very opposite state of the system prone to a secretion of the same character; namely, in persons who have been long the subjects of anasarca recurring again and again, worn out and cachectic in their whole frame and appearance, and usually persons addicted to an irregular life and to the use of spirituous liquors. In these cases the albuminous matter has coagulated, in the more ordinary way, in flakes and little curdled clots; but instead of rendering the whole milky, the flocculi often incline to a brown colour,

looking like the finest particles of bran more or less thickly disseminated throughout the heated urine. Occasionally in these cases the urine has been much loaded with saline ingredients becoming turbid by standing, but rendered quite clear by the application of a much lower degree of heat, than is necessary to coagulate the albumen.

In all the cases in which I have observed the albuminous urine, it has appeared to me that the kidney has itself acted a more important part, and has been more deranged, both functionally and organically, than has generally been imagined. In the latter class of cases I have always found the kidney decidedly disorganized. In the former, when very recent, I have found the kidney gorged with blood. And in mixed cases, where the attack was recent, although apparently the foundation has been laid for it in a course of intemperance, I have found the kidney likewise disorganized." 4.

Dr. Bright now proceeds to the detail of cases, some of which we shall introduce under a very abridged form.

Case 1. A sailor, aged 34, who like most sailors, had made free with the grog-bottle, entered Guy's Hospital on the 12th Oct. 1825. He stated that, for the four last years, he had left the sea, and with it the habit of ingurgitation. He was of a pale, unhealthy aspect. Three weeks before admission, he was seized with pains in his loins, knees, and ankles--his legs swelled, and his hands and face were occasionally oedematous. His abdomen, on admission, was painful on pressure-pulse 78-tongue pale -fæces light coloured-urine scanty, a pint in the 24 hoursappetite good. A pill, containing mercury, squill, and opium, was administered every night, and, during the next five days, he improved, in respect to the urinary secretion; but the œdema was little reduced, and he could not lie easy in bed without being highly propped up. On the 20th of the same month, he was attacked with general inflammatory symptoms in the thorax and abdomen, for which he was bled-had fomentations applied-and took effervescing draughts, with ipecacuan wine. The blood was inflamed. The symptoms returned the next evening, with herpes labialis on the face--and some blood had passed in his motions. The urine however was more in quantity, and less sedimentous. On the 25th, the urine was much more free, and it had assumed the dingy brown colour, marking an admixture of red particles of blood. He continued to improve, but complained of pain and weakness in his loins. He lies down easily, but his legs continue to swell-tenderness of abdomen gone--urine in good quantity, and clear, but coagulates by heat. 27th. Gums sore from mercury. By the 2d Nov. he was so much improved as to be able to walk about the ward, and was only taking a grain of ipecacuan thrice a day for his bowels. On the evening of

the 10th November, Mr. Stocker was suddenly called to him for an attack of dyspnoea, with symptoms of thoracic inflammation. Venesect. ad 3x.-blister. He was somewhat relieved-the blood was inflamed--but he was quite unable to lie down. The urine again became scanty-and the dyspnoea was increasing. Squill pill and mercury-venesectio-another blister. We deem it unnecessary to pursue the diurnal details. The symptoms of thoracic and anasarcous effusion increased, together with the dyspnoea, emaciation, and general prostration. He died on the 29th November.*

Dissection. The pericardium contained about four ounces of clear water, which soon became gelatinous. Both portions of pericardium showed strong marks of inflammation, in the shape of fibrinous deposits, some of recent formation, others of longer standing. The heart was large and firm. The semilunar valves of the aorta showed ossification. The left lung was every where adherent, and every where converted into " grey hepatization," very few portions admitting air. "The right lung was soft, and in structure not unnatural, but oedematous; filled by the effusion of serum, so that the fluid ran out, mixed with innumerable fine bubbles of air, immediately it was cut into. The whole cavity of the chest, on this side, was filled with serum, but the lung not compressed by it." There was some serous effusion in the abdomen. The peritoneal coat of the liver was coated with a fibrinous deposit, not very recent. No obvious disease in the size or structure of this organ, except that it was"rather pale-coloured, of a purplish drab throughout, and not of firm consistence." The kidneys were completely granulated throughout, as seen in plate I. with rough external surface, while all traces of natural organization were gone from within, except in the tubular parts, which were of a lighter and more pinky colour than natural.

Remarks. Dr. B. thinks that, if we can form any judgment as to the comparative priority of diseased structure in this patient, we should be inclined to give that priority to the disease in the kidney, which "had probably laid the foundation for that effusion into the cellular membrane, which had taken place pre

* We see no mention made of auscultation or percussion till the day of this man's death, when the right side of the chest was found to be more sonorous than the left; and, by the assistance of the stethoscope, Dr. B. thought he could hear the heart beat through a fluid. In all cases where the thoracic affections are present, the stethoscope should be employed, for we can assure those who cultivate that instrument, that it will require years of study and practice, to make themselves even imperfectly acquainted with the indications which it points out. The dissection of the above case will show that auscultation, properly employed, would have detected irremediable organie disease in the chest for months before the man died.