46

Correspondence.BRITISH MEDICAL BENEVOLENT FUND.

Ie Audi alteram partem. I

To the Editors of THE LANCET.SIRS,—You have more than once allowed me at this time

of the year to plead the cause of the British MedicalBenevolent Fund, or rather of the sick and worn-out

medical men, the widows; and orphans, who are the clientsof this charity. The annuity department is the last refugeof the destitute aged, and there are now more than sixtypensioners receiving therefrom in monthly instalments f:20or X26 a year. There were, however, at the last election inNovember, more than this number of eligible candidates,and only ten vacancies. The donation department relievesthe urgent necessities of members of the profession whoare broken down by sickness or misfortune, and ofwidows and children left unprovided for, and it is the

only resource open to them, except private charity,in sudden distress or bereavement. It is upon this de-partment that the pressure is greatest, as will be seenwhen I state that the balance at the bank was over-

drawn at the last meeting of the committee in December.E1760 was voted to applicants during the year, an averageof ael60 at each of the eleven monthly meetings, the grants,like the annuities, being spread over the year, or a greatpart of it, in small instalments, except when there is urgentneed for the full amount, as on the death of a medical manor to avert ruin. No rent or salary is paid; all the officesare honorary, and the enormous correspondence required inascertaining the worthiness of applicants, verifying theirstatements, and in collecting the funds is undertaken by the elion, secretaries, aided by hon. local secretaries. Not theleast of our recommendations to the confidence and sympathyof the profession is the fact that Sir James Paget is Pre-sident of the Fund.

In asking for help, I may perhaps be permitted to remindmedical men that patients are often ready to contribute. ;Within the last few days I have received a legacy of £ 100 :bequeathed to the Fund because Professor Bell of Edinburgh]was one of our hon. local secretaries. Contributions will be 1gladly received by Dr. Phillips, 21, Upper Berkeley-street, 1hon. financial secretary; Edward East, 16, Upper Berkeley-street, hon. see. for cases; Dr. Johnson, 16, South Eaton-place, chairman of committee; or myself. 1

I remain, Sirs, your obedient servant, ’

34, Seymour-street, Portman-square,Jaii. 2nd, 1889.

W. H. BROADBENT,Treasurer of the Fund.

THE INFLUENCE OF ARTERIAL TENSION ONALBUMINURIA.

To the Editors of THE LANCET.SIRS,—I have been for many years, and I believe I am

still, the only supporter of the theory "that increasedarterial tension tends to prevent albumen from appearingin the urine, and, when albuminuria is already established,increasing the vascular tension tends to lessen it." The

widespread belief in the opposite theory is, I think, astriking example of the mistake of placing trust in thepost hoc ergo proptcr Iaoc method of reasoning, I cannot

agree with your correspondent, Dr. Willey, when lie writesthat in the majority of cases of post-scarlatinal albuminuriathe arterial tension is lowered. Ifind that, as pointed outby all writers on this subject, the arterial tension is raisedboth before and at the time the albumen first appears inthe urine. The increased tension, however, does not causethe albuminuria, nor does it increase the amount. Theincreased vascular tension and the albuminuria are bothoriginated by the presence of some abnormal or an excess ofsome normal substance in the blood. The increased arterialtension being an effort on the part of nature to remove thissubstance from the system, I believe in many cases thiseffort prevents albumen from appearing in the urine, andalways lessens the amount. To state that the increased ivascular tension in such cases causes the albuminuria seems

to me to be equivalent to asserting that nature is at fault.The way in which the foreign or excess of normal .substancein the blood produces albuminuria, whether by acting onthe renal nerves or by mechanically injuring the glomerularor tubular cells, or by exercising a toxic influence overthese cells, is not at present under consideration. The pointis that it does not do so by raising the arterial tension. Thesupporters of the theory that increased tension causes albu-minuria find it so inadequate that they have to supplementit by adding slowing of the blood stream as a frequent causeof albuminuria. I ask, Are the two conditions—increasedvascular tension and slowing of the blood strearn-foundpersisting together ? Why is it that albuminuria is some-times found associated with an increased, and at othertimes with a lowered, vascular tension ? The answer, Ithink, is that if the blood is normal in composition, and thekidneys are performing their functions in a healthy manner,lowering the vascular tension will cause albuminuria, whilethe blood is sometimes so loaded with excrementitiousmatter that, although the vascular tension and themetabolic and excretive functions of the kidney cells areactually increased, they are, as compared with the workrequired of them, below the norma. When Dr. Willeywrites that in cases of post-scarlatinal albuminuria withlow arterial tension he has observed a lessening and finaldisappearance of the albumen concurrently with the increaseof vascular tension, he confirms my previous statement,that " in cases of functional albuminuria I have frequentlyobserved that raising the arterial tension in any way thatdoes not at the same time increase to an equal or greaterextent the solid ingredients to be excreted by the kidneysdiminishes the amount of albumen found in the urine, and,if carried to a sufficient extent, causes it to disappear."The power increased vascular tension has of preventing

the escape of albumen from the kidneys, is well exemplifiedin cases of cirrhotic kidney. In this disease the urine con-tains little or no albumen so long as the increased vasculartension is maintained. For this reason, the diagnosis ofthe disease has to be founded upon other signs and symptomswhich point to there betng an excess of some substance inumc VIUVU umuuucu .1. VI. J.lu..Ul.1.VJ.B.1.U. rr mcm, however, the

heart’s action fails and the vascular tension lessens, there isa corresponding increase of albumen in the urine. Indiabetes mellitus the same series of events is observed : noalbumen is found in the urine until the disease has existedfor some time, and the heart’s action fails, and the vasculartension lessens. In diabetes insipidus, although the vasculartension is enormously increased, the urine is free fromalbumen. Albumen is not found in the urine of healthymen after running a three-mile race, but is present in theurine of a varying percentage of men after a day’s march.The vascular tension is undoubtedly enormously increasedduring all the first experiment; while, in the day’s march, itis probable that in the cases in which albuminuria is

present there is a weakened action of the heart and a

lowered vascular tension at the time the albumen passesthrough the kidneys, In intermittent albuminuria occurringin patients in the decline ot life, the albumen is generallypresent in greatest abundance in the urine secreted in theevening. The reason for this is, as I have found byexamining these cases, that their heart’s action is rapidlyweakened and their vascular tension lowered on restingafter even slight exertion, and this promotes the passage ofalbumen into the urine. In younger people suffering fromintermittent albuminuria, I believe that lowering of tem-perature plays a prominent part in lessening arterial tensionand causing albuminuria ; lience we often find the albumenin greatest quantity in such cases in the urine secreted ongetting out of bed, the exposure while dressing being sufli-cient to lower the vascular tension. Loweiing of tempera-ture and tension, I believe, accounts for the albuminuriaoccurring in some people after cold bathing. In cardiacdisease we do not find albumen in the urine until thevascular tension is lowered, owing to failure of action of thedisease(] organ. In attacks of Asiatic and British cholera,after the crisis the vascular tension is greatly lowered, thepulse in some cases being almost imperceptible. The urinesecreted at this time frequently contains a considerableamount of albumen. In the last stage of many wastingdiseases, when the heart’s action fails we find albumen inthe urine. It would be easy to adduce further instances tosupport the theory in which I believe, but regard for yourspace forbids. 1 am, Sirs, yours truly,

agard

Llanduduo, Dec. 1888. JAMES CRAIG.