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the same pace up from Charing-cross station here." I have not seen him since.

Case 4.-Wm. P., aged 38, has been asthmatic seventeen years. His attacks come on every morning on rising from bed, but often trouble him throughout the day as well. There is defective respiration at the right base, violent paroxysmal cough, and a good deal of expectoration. This patient came to me on Oct. 13th. A week after I made the following note:"Since coming to me this patient has taken the belladonna every nighttwenty, twenty-five, and then thirty drops, to which last dose he has stuck. The result is that he is quite a different man. He has slept all through the night, dressed himself without any trouble or difficulty, and has walked half over London as quickly and well as ever he did in his life. When he arrived in town his breath was so bad that he had the greatest difficulty in getting from Vauxhall station to the church near the bridge. He spits hardly anything. There is now a complete absence of all musical wheezing, and of any adventitious sound whatever: respiratory murmur quite re-established at right base, and indeed perfectly natural everywhere. And this change has taken place in one week."

I believe one reason why belladonna has not had a greater reputation as a remedy for asthma is that it has not been given in large enough doses. I think that, like lobelia, it must be given in doses sufficiently large to produce its physiological effects, otherwise we have no right to say that it has been fairly tried, or to conclude that it has been a failure if it has not achieved a cure. I think to give ten minims three times a day in some mixture is simply worthless. I have seen now numberless cases in which belladonna and lobelia have been consigned to the limbo of failures, when a fresh trial of them, on the plan of gradually increasing the doses till an ultimatum has been reached, has proved them to be perfectly successful remedies. Sometimes, but very rarely, belladonna will relieve asthma when given short of a physiological dose; sometimes, but still rarely, it fails to give any relief even when pushed to its full physiological effects; the common thing is for it to fail till so pushed, and then to succeed. When I find belladonna has only been taken in the ordinary small doses, without any increment, I always regard it as not having been tried at all.

The advantages of administering it in the way I have described are:

1. That, giving it at night, you bring the full force of the drug to bear upon the disease at the time at which it is most liable to come on, and thus, if you are successful, tide your patient over the critical time.

2. By gradually feeling your way up to the required dose, you are able ultimately to reach without fear a dose which you would be unwilling to prescribe without such a tentative approach.

3. In those cases in which the therapeutical dose is reached before the physiological—that is, in which the asthma yields before the sight or head is appreciably affected, it enables you to stop short as soon as relief is obtained, and thus spare your patient any of the disagreeable effects of the drug.

4. By giving it only once in the twenty-four hours, you are able to give a larger dose than you would be able to do if oftener repeated.

5. By confining the dose to bedtime, the patient's days are, in spite of a large dose, passed in comfort; for, as the morning advances, the dulness of head, confusion of sight, and drought of mouth pass away.

6. You are thus enabled to find out what is the dose for the individual-a very important point. People differ very much in their tolerance of belladonna. Some of my patients have been unable to take more than twenty minims once in the twenty-four hours without very unpleasant symptoms; while I have known others able to take a drachm three times in the same interval without any inconvenience. And as they differ in their tolerance of the drug, so do they differ in the dose at which their asthma will yield. The only way to ascertain what that dose is, is to make each case a separate experiment, and this can only be done in the way I describe.

7. By giving the remedy three or four hours before the attack is likely to come on, the treatment becomes prophylactic. If by taking a dose every

night for thirty nights the attacks have been for that time prevented, the patient has ceased to be an asthmatic for a month. This is a very different thing from having had thirty attacks in the same time which have been cut short by the remedy. In all "habitual" diseases, in which the recurrence keeps up the tendency, prophylactic treatment has, in relation to final cure, a pre-eminence it does not possess in diseases in which habit has no place. For such diseases it is the treatment. It does more than spare your patient an attack of his malady; it breaks, pro tanto, that chain of sequences which is the very life of the morbid tendency.-Lancet, Jan. 30, 1869, p. 152.

35.-BROMIDE OF POTASSIUM IN SPASMODIC ASTHMA OF CHILDREN.

HERR SONDAHL reports a very interesting case in which he tried this remedy, on account of the recommendation of it by Dr. Warburton Begbie (Edinburgh Medical Journal, 1866). The patient was a child of fourteen months, of very fatty development. He was first attacked with spasms of dyspnoea early in 1866. By dieting (modified Bantingism) and the use of emeties, expectorants, and Carlsbad water, he improved for a time, but towards the end of September he relapsed. The distress became extreme; hardly any sleep was obtained; the urine was nearly suppressed; general œdema at last set in and all the symptoms were excessively bad. All manner of narcotics, expectorants, and anti-spasmodics having been vainly tried, Sondahl resorted to the bromide. It was given in six-grain doses, in syrup, every two hours. A most remarkable improvement was rapidly produced; the dyspnoea subsided, the lividity of the face and œdema disappeared, the secretion of urine returned, and sleep was obtained without difficulty. In seven days from the commencement of the bromide treatment, the little patient was substantially convalescent. Sondahl has also obtained excellent results with the bromide in a case of asthma in a boy of fourteen. In two old asthmatic patients, on the contrary, no good effects were obtained; neither the spasmodic symptoms nor the cough were relieved.-Practitioner, Feb., 1869, p. 121.

DISEASES OF THE URINARY ORGANS.

36.-ON EXCESS OF UREA IN THE URINE IN CERTAIN FORMS OF DYSPEPSIA AND NERVOUSNESS.

By Dr. HENRY WILLIAM FULLER, Physician to St. George's Hospital.

In the year 1846 I had occasion to examine the urine of a patient who was suffering from symptoms of a nervous and dyspeptic character. The urine was frothy, somewhat pale, and clear, sp. gr. 1025; it had an acid reaction and a strong urinous smell; it contained neither sugar nor albumen, and only a few small crystals of oxalate of lime were visible under the microscope, but the addition of nitric acid caused intense effervescence, and about twenty minutes after this had subsided crystals of nitrate of urea began to form and ultimately filled the interior of the test-tube. During a period of rather more than three weeks I examined this patient's urine every second day, and invariably found it to contain urea in quantity sufficient to crystallize readily on the addition of nitric acid, without any previous evaporation or concentration of the urine. The degree of crystallization varied at each examination, in consequence, doubtless, of a variation in the amount of the urea contained in a given bulk of the urine; but inasmuch as I could not persuade the patient to save and measure the quantity of urine voided in twenty-four hours, I am unable to state whether less urea was secreted when the crystallization was at its minimum, or whether the variation arose from an increase in the quantity of water and a consequent dilution of the

urea.

The patient, however, declared, as the result of his observations, that he was passing about two pints of urine, and that the quantity scarcely varied from day to day.

The patient was thirty-seven years of age, of spare habit, in good condition, and apparently healthy; he was not a large eater, but he relished his food, and ate meat three times a day. His principal complaint was of nervousness and depression of spirits, indisposition for exertion, whether mental or bodily, and dyspepsia, with irregularity of the bowels, acidity of stomach, and excessive flatus.

The case made a strong impression on me at the time, for the reason that I was not prepared for the discovery of so much urea, and had never heard such cases spoken of by my professional friends or seen any notice of them by authors. I have therefore kept the matter steadily in view, and within the last two years have examined the urine of every patient in whom, judging from the character of the symptoms, I have thought it likely that urea might exist in excess. The result has been that I have detected urea in excess in twenty-seven cases, and so well marked and peculiar are the symptoms by which that condition of the urine is accompanied, that now, if the features of the patient's malady induce me to suspect its existence and to examine the urine with a view to its discovery, I am seldom disappointed in obtaining the characteristic crystals of nitrate of urea.

The cases under discussion resemble each other so closely in many of their more prominent symptoms, that it will suffice to give the details of one or two which may be fairly taken as samples of the whole.

A. T., aged 43, a spare but healthy looking man, 5 feet 8 inches in height, 10 stone 9 lbs. in weight, and florid complexion, but somewhat bilious temperament, reported that he had been nervous throughout his life, and since the age of thirty had not felt well for any lengthened period. If he had unusual worry in his profession or any anxiety in his family, or even if he was unable to obtain his ordinary amount of outdoor exercise, he was apt to become irritable, low, and depressed, indisposed for exertion, and easily fatigued, unable to fix his mind on any subject requiring continuous application, and afraid to encounter the rubs and vexations incident to his daily life. His present illness he attributed to anxiety arising from the illness of one of his children, together with the want of his usual exercise. He had been remarkably well for some time previously, and became conscious of some change or disturbance in his system within a week after the commencement of his trouble. At first he became restless at night; then drowsy after meals, especially after dinner, and began to suffer from flatulence and acidity; shortly he found himself nervous and dejected without obvious cause, especially in the morning, unable to apply himself to his professional duties, and unwilling, if not unequal, to take his wonted exercise. Nervous fancies and wretched feelings, occasional giddiness, fugitive pains in various parts of the body, and a sense of extreme languor and weariness, rendered his life miserable. For six weeks before he consulted me he had been taking a series of Turkish baths, and had dieted himself carefully, but notwithstanding his care the dyspeptic symptoms had continued, and his mental disquietude was more constant than before.

When I first saw him he was restless at night, but obtained a fair amount of unrefreshing sleep; his skin was rather dry, but perspired readily after exercise; his pulse ranged from 84 to 96; his appetite was tolerable, but not so good as usual; he ate meat twice a day, and was in the habit of drinking four or five glasses of sherry or an equivalent amount of claret, but he never drank beer; after each meal he suffered greatly from flatulence and drowsiness, and after breakfast experienced a sense of uneasiness about the head and of heat and weariness of the eyes. His bowels were somewhat torpid, but usually acted without the aid of medicine; his urine he said was right," and with the exception that it was frothy or strongly beaded it certainly did not present an unhealthy appearance. Occasionally it threw down a deposit of the lithates, but more commonly it was clear, pale, acid, of a strong urinous odour, sp. gr. 1026, and was free from sugar and albumen.

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Under the microscope a few octohedral crystals of oxalate of lime and here and there a few epithelial cells were visible, but they were scarcely more numerous than in healthy urine. On the addition of nitric acid to the extent of about one-third of the bulk of the urine a strong effervescence took place, and within twenty minutes after this had subsided crystals of nitrate of urea had formed to such an extent that the whole of the urine in the test-tube appeared to be converted into a solid mass. On some occasions the crystals of nitrate of urea did not occupy above half the bulk of the urine, but commonly they filled two-thirds of the space occupied by the urine. My friend Dr. Dickinson, who kindly examined a sample taken from the entire quantity of the urine (1927 c. c.) voided in twenty-four hours, reported that the day's excretion contained 53.9 grammes of urea, or nearly 21 grammes in excess of the average amount excreted within that period according to the observations of Dr. Parkes.

The next and only other case which I shall detail is of a very similar character. The patient, a gentleman closely engaged in the city, was 37 years of age, about 5 feet 7 inches in height, and 10 stone 2 lbs. in weight, of sallow complexion, but healthy aspect. He said he had enjoyed excellent health until the age of 29, when he had a severe attack of fever, which left him in shattered health and extremely nervous, Some months elapsed before he Legained his strength and was able to resume business, and he had suffered ever since, on slight occasions, from disturbance of the digestive organs, as evidenced by flatulence after meals, palpitation, colicky pain in the abdomen, and a tendency to acidity and diarrhoea. Accompanying these symptoms there was a distressing sense of depression, à disinclination to exertion, and inability to apply himself steadily to work. He was always tearing some impending calamity, some serious and irremediable bodily affliction, or some loss or inisadventure in business. His skin was cool and rather inactive; pulse 84. Tongue coated; bowels at one time costive, at another relaxed. The urine was frothy or firmly beaded, clear, acid, of pale sherry colour, sp. gr. 1028. It had a strong urinous smell, and was perfectly free from sugar and albumen. Nothing noteworthy was observed under the microscope; on the addition of nitric acid an intense effervescence ensued, and within half an hour crystals of nitrate of urea began to form and soon filled two thirds of that portion of the tube occupied by the urine. In this case as in the last, Dr. Dickinson kindly determined the amount of urea excreted in twenty-four hours by examining a sample taken from the entire quantity of urine (1359 c. c.) which had been passed, and he found that it amounted to 551 grammes, or 22.1 grammes in excess of the average. In four other cases, in which at my request, Dr. Dickinson determined the quantity excreted in twenty-four hours, it was found to amount to 42.5 grammes, 41.8 grammes, 39-06 grammes, and 51 grammes.

Now, all the instances which have come under my notice have had several features in common. With one exception, that of a lady, aged forty-three, the patients have all been males, varying in age from twenty-three to fiftyfour. Most of them have been essentially meat eaters, partaking sparingly of bread and other varieties of farinaceous food, but five of them ate ment only twice daily, and one, a member of our own profession, declared, not only that he never touched meat except at dinner, but that even then the principal part of his meal consisted of vegetable and farinaceous food. Without exception, the patients have been tolerably healthy in appearance, and often somewhat florid, though in some instances they have lost flesh slightly; indeed, their aspect has been so little indicative of disease, and their complaint of suffering has been so urgent, that any practitioner who did not examine the urine for urea would have surely regarded them as simply hypochondriacal. Usually the pulse has been quick and rather weak, and the patient's complaint has been of languor, flatulence, restlessness at night, and extreme nervousness. They have been afraid of encountering the rubs of everyday life, and in some instances have for the time lost their pleasure in society; they have eaten fairly, though with less than their usual relish, and the feeling of languor which has oppressed them, and of fatigue

which has followed even a moderate amount of exertion, has led to their abstaining almost wholly from exercise. They have usually complained of extreme depression in the morning, with a sense of heat about the eyes, muzziness in the head, and weariness after breakfast-feelings which have in some measure passed off as the day has advanced, and they have partaken, as usual, of stimulants. The condition of the urine has varied; at one time it has been scanty, and loaded with lithates; at another abundant, or even excessive in quantity, of a light sherry colour and strong urinous odour; and these alterations have been repeatedly observed in the same case at intervals of a few days, or even of a few hours. The pale and clear urine, of specific gravity varying from 1029 to 1032, and quantity from 32 oz. to 64 oz., is that which has usually contained the largest quantity of urea, and it has remained markedly frothy or beaded for twenty-four or thirty-six hours, just like diabetic or highly albuminous urine. Dr. Prout has stated that “urine containing a large proportion of urea is prone to decomposition, and generally soon becomes alkaline;" but in the cases under consideration the urine, even when exposed to the air, will remain acid and free from decomposition for two or three weeks in warm weather, and in cold weather will remain unchanged for as many months.

The method I have adopted in testing the urine has been to add to a small quanity of it in a test-tube about one-third of its bulk of nitric acid, and then to shake the tube until all effervescence has subsided. The tube is then left at rest, to allow of crystallization of nitrate of urea to take place. In cold weather this is commonly effected in twenty minutes or half an hour, and it will usually occur in about the same time even in hot weather if the test-tube is immersed in a bath of cold water.

It should, perhaps, be added that the tendency to a recurrence of this form of disease is very great, and several of the patients have consulted me in reference to the same train of symptoms on more than one occasion.

The treatment adopted has varied in its details, but that which has proved most successful is based upon the view which I take of the pathology of the disease, namely, that it is connected primarily with perverted nervous action, in consequence of disturbed assimilation. Neurine tonics, such as arsenic, quinine, strychnia, iron and zinc, together with the mineral acids, the shower bath, and the dripping sheet, are the remedies which have proved most successful in my hands, and when combined with alterative doses of blue pill and colchium will usually afford relief. In one or two instances, characterised by extreme irritability, the bromide of potassium, in conjunction with iron, has proved a more effective remedy, and occasionally the hypophosphite of soda has been serviceable.

The form of the disease which I have thus endeavoured to bring before the Society has not as yet received distinct recognition, though the peculiarity of the symptoms by which it is signalised are such, I think, as entitle it to be regarded as a special form of derangement. Except in Dr. Prout's classical work on Stomach and Urinary Diseases,' I find no mention made of it in any treatise on the urine published in this country. Even Dr. Prout regards it as very rare, and, while suggesting its close connection with diabetes mellitus. declares (p. 96) that" where he has seen one case of an excess of urea in adults he has seen twenty cases of diabetes. Dr. Parkes, referring to Dr. Prout's observations on these cases of azoturia, distinctly states, "I have never seen a disease of this kind." It is obvious, therefore, not only that this condition of the urine has, in many instances, escaped recognition, but that the form of derangement on which it depends requires careful investigation.

The symptoms by which it is characterised appear to me to necessitate a complete revision of the theory hitherto accepted respecting the cause of the presence of urea in the urine. Up to the present time it has been held that urea is formed principally, if not solely, during the destructive processes of assimilation as a result of oxidation of the tissues, and in confirmation of this opinion most authors have asserted that it is found in largest quantities after violent exercise and during the excitement of febrile disorders, when

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