of the first urinary strainer, the kidneys, descending progressively
through the conduits and reservoir, the ureters, bladder, and urethra.
During the last 30 years of the preceding century, those marked in the
mortal catalogue of London as cut of the stone, gravel, and strangury,
are only 1796; and at present the mortality is more inconsiderable; and
perhaps, in some degree, maybe accounted for by modern improvements in
the cure of the venereal disease, and in the operation of lithotomy;
for as to lithontripticks, we are as yet as ignorant as of the
philosopher’s stone. From Dr. Dobson’s Treatise it appears, that out
of 192,394 sick of various diseases, medical and surgical, in different
county hospitals, throughout England, 430 of these underwent the
operation of lithotomy. Some countries more than others, are obnoxious
to calculous concretions; which have been variously imputed to air,
food, drink, and water. Gravel and sand in the urinary organs is a
frequent complaint, to which infancy and childhood are by no means such
martyrs as adults, those especially in the decline of life: but from
the shortness and width of the female urethra, they are preserved freer
from calculi in the bladder than the male sex. Diseases of the urinary
organs have been often described by authors under three general heads;
Ischury, Dysury, and Strangury. Ischuria means a total suppression of
urine; and from the seat of the disease is called renalis, uretoria,
vesicalis: Dysury is only a slighter degree of the former: Strangury,
a constant irritation to urine, in small quantity, and often with
tenesmus.
_Inflammation and Calculi of the Kidneys_, nephritis, nephralgia: and
generally confined to one kidney. The symptoms, shivering, fever,
acute pains and heat in the lumbar region, following the tract of the
ureters, and various in severity, from calculi excruciating; frequent
efforts to micturition; the urine in small quantity, red, bloody,
hot, often intermixed with sand, sometimes totally suppressed; with
colick, flatulence, bilious vomiting, costiveness. When the disease
is severe, and from calculi, there is stupor of the leg of the same
side, and pains in the groin and male testicle, and often retraction
of the latter. There is also difficulty and pain in walking or
erecting the body; but the rheumatick lumbago, with which it may be
confounded, has no concomitant fever, nor disorder of the stomach; and
has more intense pain on bending or erecting the body. It is always
dangerous and precipitate, especially when the urine is suppressed,
terminating within seven, or, the utmost, fourteen days, by discussion,
suppuration, gangrene, scirrhus: discussion indicated by a copious flow
of urine and sweats.
But the most frequent malady about the fountain of the urinary
secretion, is from calculi in the ureters. The kidneys have few
nerves, and therefore not very acute sensation. Calculi or gravel in
the strainers of the kidneys, seldom excite much uneasiness until they
are forced into the ureters by the current of urine, by exercise,
exertions of the body, agitations of a coach, passions of mind,
stimulating diet and drink: then they excite atrocious pain, like a
stake driven into the back, which is exasperated by certain postures,
by every motion of the body, and by a full stomach; together with
all the other symptoms common to inflammation, except the fever; to
which, however, and to inflammation calculi, often give birth. At
the beginning the urine is limpid; afterwards it becomes turbid and
fabulous. This is a chronic periodical disease, with intermissions and
nephritic exacerbations at uncertain intervals. It is distinguishable
from intestinal colick by the pain fixed in the loins, the urinary
obstruction, stupor of the leg, and retraction of the testicle.
_Inflammation and also Calculus of the Bladder._ Of cystitis, the
symptoms are acute burning pain in the region of the bladder and
perineum, and extending to the loins; tumour, tension, and hardness
of the abdomen from the distended bladder, which may be felt between
the pubis and navel; and sometimes is turgid to an enormous magnitude;
perpetual painful efforts to urine and stool, and the urine either
suppressed, or in small quantity; a finger introduced into the anus,
or into the female vagina, feels the vesical tumour; or if the
inflammation particularly fixes upon the neck of the bladder, the
surgical catheter cannot, without immense difficulty, be introduced;
and with all these symptoms, symptomatick fever, quick, hard,
phlogistic pulse. It is very rapid and dangerous: total suppression
within a very few days excites burning fever, lethargy, delirium,
convulsions, gangrene: or even after recovery from a violent disease,
incontinence of urine may remain for a considerable time.
Of calculus, or stone in the bladder, the symptoms are all dubious,
without sounding the bladder with the surgical instrument. It is a
chronic disease, slow in accumulation; and is frequently endured many
years, without having recourse to lithotomy. The symptoms vary in
severity, and recur in exacerbations at uncertain intervals; such
are frequent irritation to urine, and difficulty in the evacuation;
strangury, tenesmus, pain, and titillation of the glans of the penis,
and the urethra, especially after making water; itching of the
genitals; sometimes bloody urine after riding, or exercise. If the
stone is large, there is a sensation of weight in the region of the
pubis and perineum; sudden stoppage of the urine during micturition;
sometimes necessity of kneeling, and of a prone posture in endeavouring
to evacuate the bladder. A finger introduced into the anus, will
sometimes feel the stone; but the sound is the only certain criterion.
The size, shape, and number of stones are various: often only one, but
sometimes several are extracted by lithotomy. Internal incrustations,
and also scirrhus of the bladder, or even internal hemorrhoides, have
imposed on medical judgment as cystic calculi.
Inflammation and obstruction of the urethra cannot be thoroughly
investigated, without a description of the venereal disease, to which
we have not yet arrived; but which there could be no impropriety to
introduce amongst this group.
The predisposing and occasional _causes_ of urinary suppression,
obstruction, and strangury, whether originating in the kidneys,
ureters, bladder, or urethra, are inflammation of the kidney or ureter,
calculi or sand in the kidneys or ureters; acrid diureticks; spirituous
liquors; plethora, spasm, poisons, severe riding, violent heat and
muscular exercise; strains of the lumbar and dorsal muscles; long
continued posture in a bent position or supine on the back; inactive
sedentary life; wounds, contusions, abscess; defecation and crisis
of other diseases by the kidneys; scirrhous, incysted, dropsical,
paralytick kidney; gout; inflammation of the bladder or its sphincter,
stone in the bladder; the urine too long retained in the bladder, by
which it becomes violently stretched, and paralytic; hernia of the
bladder; obstructions in the neck of the bladder, or in the urethra;
varicous blood vessels; the prostrate glands or seminal vesicles
scirrhous, or enlarged; inflammation, caruncles, and stricture in the
urethra; the corpus cavernosum thickened; contiguous diseases of
the anus, vagina, and womb; hardened feces, hemorrhoides, wounds of
the rectum, fistula; ulcers of the womb, obstructed menses, or their
retention in the vagina; pregnancy; ulcers and worms in the kidneys,
bladder, or urethra, and excretion of acrid pus or membranes, by urine;
grumous, extravasated blood in the bladder and urethra; inspissated
semen after coition; excess of venery; too acute sensibility of the
urethra, defect of mucus; acrid urine; tartarous and astringent wine
or drink, food, or medicines; stimulating food and drink; frequent
ebriety; terrestrious water; sudden refrigeration of the body;
contusion; old age; plethora; lunar, venereal, rheumatick, arthritick,
hysterick, scorbutick, dropsy, violent colick, retraction and shrinking
of the penis.
_Incontinence of Urine, and also Diabetes._ Of incontinence, or
eneuresis, authors make three species; one involuntary, without
sense or effort; the second involuntary, but with a knowledge of its
excretion; the third involuntary, during sleep. The Diabetes was
unnoticed in the London bills until the present century; and perhaps
its trifling depredations were thrown amongst consumptions. It denotes
a chronic discharge of urine beyond the natural quantity, and sometimes
exceeding in weight all the fluids and solids taken by aliment: it
is generally clear and colourless, but sometimes white and chylous,
or unctuous, or, like honey dissolved in water, a yellowish green,
and tastes sweet like honey: there is unquenchable thirst, intense
heat, flow hectic and emaciation, pain in the loins; increased flow of
saliva, voraciousness, or inappetency. It often invades by slow and
imperceptible steps, and without any other disorder, until, by long
continuance, emaciation is visible, with debility and obscure fever. It
is sometimes periodical, and in hystericks symptomatic.
The predisposing and occasional _causes_ of incontinence of urine are,
palsy of the sphincter of the bladder, from either too great dilatation
and accumulation of urine, or from violent efforts in parturition;
debility, old age, excess of venery; fistula, abscess, ulcers,
lithotomy, stone, spasm, gout, apoplexy, palsy, external injuries.
Also, copious, watery, acrid urine: the bladder irritable from
inflammation, ulcers, excoriation, defect of mucus; spasm, relaxation
of the sphincter; weakness of the sphincter ani, and accelerator
muscles; pregnancy, laborious parturition; compression and irritation
of the bladder; habit.—Of diabetes, aqueous tenuity, and also acrimony
of the blood; weakness, laxity of the kidneys and renal vessels; the
crassamentum of the blood not cohering with the serum; faults in the
assimilation of the nutriment, and sanguification; excess of watery
drink and ebriety; diureticks; sudden refrigeration of the body, and
suppression of perspiration; unusual determination of blood and serum
to the kidneys; excess of venery; increase of cutaneous absorption;
obstructions of the abdominal viscera; spasm; nervous; habit: often
unknown.
_Ulcers in the Kidneys and Bladder, and Bloody Urine._ Of ulcers in
the kidneys, thick fetid urine, sometimes with mouldered fragments of
the kidneys; heat and weight in the loins; hectic emaciation, stupor
of the leg, and some other symptoms of nephritis. It is tedious and
dangerous. Of ulcer in the bladder, pain in the pelvis and perineum,
exasperated at intervals; heat, strangury, dysury; the urine fetid
with intermixtures of pus, mucus, and blood; sometimes the rectum also
is eroded. Of bloody urine, or hematuria from the kidneys, ureters,
bladder, seminal vesicles, or urethra. From the kidneys the hemorrhage
is sometimes profuse, and the blood of various colours, according to
its solution and stagnation in the bladder; and sometimes coagulated,
takes the mould of the urethra: the urine tinges linen dipped into
it of a red colour, and the blood is coagulable by heat. There are
instances of its periodical flow, like the menses. The predisposing
and occasional causes of urinary hemorrhage are the general causes
of hemorrhages; calculi in the kidneys or bladder; falls, blows on
the loins; violent exertion of the lumbar muscles, riding, exercise;
venery; plethora; obstructed evacuations, hemorrhoids, menses;
hemorrhoids of the bladder and varicous veins; acrid diureticks;
ulcers, symptomatick in scurvy; putrid small pox, and malignant fever.
* * * * *
_Dropsy._ During the last thirty years of the preceding century, Dropsy
and Tympany amount to 23,366. In the present century, dropsy makes
about one twentieth share in the London funerals. It has been alledged,
that more women die of this internal deluge than men; and, according
to Sydenham, more of the former at the final menstrual ebb, than at
any other period. But, so far as my reading extends, neither the age,
sex, mortality absolute or comparative, have to this day been decided
from facts or numbers; but rather principally in the mode of tradition,
and aphorisms of individual oracles. I therefore, through my learned
friend, Dr. Sims, procured the registers of diseases in the Aldersgate
Dispensary of London, which is accessible to all ages and diseases,
and to both sexes: the result of this scrutiny is as follows:—Out
of 70,000, during seventeen years, from 1770 to 1788, the dropsical
amounted to rather more than one twentieth part of the whole maladies;
that is, to 1,188: of which number, I find there were of males, 439;
females, 749; cured, 674; relieved, 56; discharged or not accounted
for, 275; dead, 186. Of these their sundry ages were, from birth to the
10th year, 106; from 10 to 20, 53; from 20 to 30, 112; from 30 to 40,
249; from 40 to 50, 321; from 50 to 60, 209; from 60 to 70, 110; from
70 to 80, 23; from 80 to 90, 9. Total, 1,188. These include every genus
and species of dropsy, the hydrocephalus and hydrocele; neither of
which were numerous: and the former principally fatal to children under
ten years of age. Anasarca was the most frequent genus; and next to
that, Ascites. Besides, all cases of anasarca and œdematous legs were
ranged in this dropsical group; nor was it possible to form an estimate
of the genera separately, as the word Hydrops was often indefinitely
used.
From these data we may draw the following conclusions: That dropsy is
more inimical to the female than to the male sex: but at the same time
it must be recollected, that in London, and other cities, the women
are considerably more numerous; which somewhat detracts from the
comparative excess in them of dropsical mortality. For reasons, which
medical men of experience will anticipate, we may add to the dropsical
dead list some of the relieved, discharged, and not accounted for. It
appears, therefore, that, under skilful medical treatment, rather more
than one half of dropsies, promiscuously, were cured; that about one
third or fourth died; that dropsical ravages are principally amongst
adults; for notwithstanding that one half of the community are under
twenty years of age, yet but a small portion of these are dropsical.
It is chiefly against adults, and those in the decline of life, that
dropsy prowls with slow and sullen destruction; and is, as 8 to 1, more
fatal after twenty, than before that period. We may here also observe,
that, by retrospection to a former proposition, a sort of medical
geometry and trigonometry, a gross estimate may be formed from the
deaths, of the number of dropsical in a community.
_Dropsy in the Brain_ and Spine, hydrocephalus, and spina bifida, is
most frequent in infancy and childhood; but is often very difficult
to detect, and the symptoms at the beginning are dubious. The most
usual symptoms are loss of appetite, strength, spirits, flesh; fixed
pain in the head and eye-brows, drowsiness or restlessness, heaviness,
stupidity; pale countenance and tongue; obscure or double vision,
dilated pupil, insensibility of the retina, even when exposed to
the darting rays of the sun, or of a candle; the hand often applied
to the head; irregular pulse; vomiting. It is commonly slow in
increase; from months to a year, or more. It is seldom cured; and
the fatal termination frequently palsy and convulsions. The external
hydrocephalus, or local anasarca, is soft and elastic to the touch, and
the enlargement visible. The spinal dropsy is sometimes complicated
with hydrocephalus; in it a tumour turgid with fluid, the size of
a chesnut, or larger, is protruded from the opening in the lumbar
vertebræ of infants.
_Dropsy of the Thorax_, hydrops pectoris, and pericardii: in one or
both sacs of the pleura, or in the pericardium; or in the pulmonic
cellular texture. This is much less frequent than the abdominal; and
is often very difficult in the early stages to be detected, as the
same, or nearly similar symptoms, occur in some other diseases of
the breast: such are difficult and laborious respiration, especially
on any exercise or motion, or in a horizontal posture, and gradually
increasing; frequent cough, at first dry, but after some time, with
mucous expectoration; weight and oppression in the breast; disturbed
sleep, and sudden startings, with anxiety and dyspnœa; necessity of an
erect posture; palpitation of the heart, and irregular pulse: there is
also commonly scantiness of urine, œdematous tumour of the feet and
ancles; a pasty paleness of the face; and sometimes a fluctuation of
water in the thorax is perceptible to the patient.
Sometimes it is circumscribed and local; at other times, it begins
by anasarca, and is complicated with universal dropsy of the other
cavities, or with asthma; sometimes it consists of hydatides. It is
distinguishable from the empyema, and from the polypus and aneurism of
the large vessels, by the symptoms peculiar to each. After some fevers,
thoracic dropsy has formed with surprizing rapidity in one or two
days. The fatal event is often preceded by spitting of blood, anxiety,
and accelerated respiration. In the dropsy of the capsula of the heart,
the pericardium, there is difficulty of respiration, and of laying on
the left side; quick, weak, intermittent pulse, palpitation of the
heart, syncope, dry cough; anasarcous ancles, scantiness of urine: and
sometimes a sensation of fluctuation during the motion of the heart. In
dropsy of the mediastinum, the symptoms are conjectural.
_Abdominal Dropsy_, including the ascites, the dropsy of the ovaria,
fallopian tubes, and womb. The ascites, or exudation between the
peritoneum, intestines, and viscera, is much more frequent than the
hydrothorax. The symptoms are enlargement and prominence of the belly;
sense of fluctuation to the fingers and ears on striking it with one
hand, and applying the other to the opposite side; the urine scanty,
turbid, and high-coloured; costiveness; the thirst at the beginning
is inconsiderable, but generally becomes irksome and insatiable; the
skin dry; the body sluggish, and increased in weight: the countenance
becomes squalid, sallow, and unwholesome; the upper part of the body
and arms emaciated, and, sooner or later, the ancles œdematous. Where
there is a large accumulation of water the diaphragm is impeded, with
difficulty of respiration and dry cough, particularly in a horizontal
posture. The serous transudation is the general form of ascites; but
sometimes it is of a gelatinous consistence, and more of coagulable
lymph from the blood, and the fluctuation not perceptible: in other
cases it is inclosed in numerous morbid cysts, called hydatides; which
cannot be known to a certainty until after the experiment of tapping.
It may, however, be suspected, where there is no general cachexy,
dropsy, thirst, or scantiness of urine; where the appetite and sleep
are natural, and the tumour has begun in one part of the abdomen.
Some survive many years under ascites, and after reiterated evacuations
by tapping; on the whole, often amounting to several hogsheads of
water. In others, there are instances of accumulation so extraordinary,
sudden, and profuse, as to render it necessary to be drawn off
repeatedly in the short interval of a few weeks. It occurs either
singly, or as a part of universal dropsy. Ascites encysted; from
broken constitutions; unsound viscera; the consequence of other
diseases; chronic; with decay of appetite; with urine considerably
disproportioned to the drink, are all species unfavourable, some
desperate. But in the most deplorable stages, patients entertain some
hopes of recovery.
Dropsy of the Ovaria, fallopian tubes, and womb, are female, and not
unfrequent maladies. It is rarely that both ovaria are affected. The
disease begins with a soft tumour at one side of the abdomen, generally
increasing by slow gradations, and at length sometimes to an enormous
size and weight, so as to distend the whole abdomen: it is accompanied
with several ascitic symptoms, and with pain about the pubis and loins;
but the fluctuation is imperceptible, or obscure; and the extravasation
is often encysted and gelatinous. That in the fallopian tubes requires
no particular description after the preceding, which it so nearly
resembles. Both are often incurable. Dropsy of the womb is a very rare
disease: it has been described as occurring either in the pregnant or
unimpregnated state; and in the latter case, as contained within the
cavity of the womb, or between the fetal membranes and the womb; or
within the layers of the membranes. I cannot find an author to satisfy
my doubts respecting the accurate diagnostick of this disease; and
therefore shall not copy what I distrust.
_Dropsy of the Cellular Membrane_, externally, in the cellular texture
under the skin; the species anasarca, leucophlegmatia, œdema. It
generally appears first in the lower extremities, and there too only
in the evening, disappearing by a horizontal posture in the night:
at length, it reaches up, progressively, to the legs, thighs, trunk,
and scrotum; and in some instances, to the face, particularly in the
mornings. The intumescence of the skin is pale and soft, and, on
pressure of the finger, indents; but is soon again filled up with
water. As it increases to a universal anasarca, there is difficulty of
breathing, particularly after exercise, scanty urine, thirst, decay of
strength, slow hectic diminution of the natural heat, and more or less
insensibility of the skin, which is dry. Sometimes the legs and thighs
only are enlarged and distended to a monstrous magnitude; their skin
bursts, ulcerates, or is irritated to erysipelatous inflammation. It is
either complicated with ascites or hydrothorax, or beginning as œdema,
and increasing to anasarca, it oozes through all the external cellular
texture; and having inundated all the out-works, proceeds in drowning
the vital organs.
_Dropsy of the Scrotum_, hydrocele. This is a local disease, confined
to the male sex; and to which all ages are subject. There are two
principal species; that between the vaginal coat and testicle, and that
in the spermatic chord; and either collected in cysts, or dispersed
through all the cellular membranes inclosing the spermatick vessels.
In general, hydrocele is confined to one testicle, at the beginning
is not painful, and neither diminishes nor disappears: it has usually
a conical pyriform appearance, the large end downwards: sometimes
it is very hard and incompressible; and when the membranes are much
thickened, it is not transparent: there is slow gradual accumulation
of the fluid from below: it is incapable of reduction, or return
into the abdomen through the rings: it is not affected by posture,
cough, or sneezing of the patient: there is neither nausea, vomiting,
quick pulse, nor is the fecal discharge interrupted. If the quantity
of water is considerable, the testicle cannot be felt, at least not
distinguished. In most cases the spermatick vessels may be felt at
their exit, through the abdominal rings; but sometimes the hydrocele
tumour reaches up to the rings, and renders such cases puzzling to
discriminate, as the spermatick chord is then concealed. Again,
hydrocele of the spermatick chord has been mistaken for rupture, from
its ascension to the rings: this species feels like a distended bladder.