ON TH E
ORB ID CONDITI ONS OF THE UR INE
D E P E ND ANT U P ON
D ER ANGEMENTS 0 F D I GESTION
BY
C H AR LE S H ENR Y R ALF E , M A
MD
‘
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C I
C LL T M
L LL E E P H S I I NS L N
E
I S I IN P H S I I N
E HE
PH SI L I
A US
F
EL
CO
OW 0 P T H E R OY A
L O N D O N B O O P I T A D ; L AT
L
GB B B N WI C E
A ND
T
G
O
AC
Y
O F
B B NI O B
R
E GE
V
a c a ooz. o r
C A
T
O P
Y
n
CA
G
B B I D GE
O ND O
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Y
C A
; A
S SIS
T A NT
.
O O G C AL C E B M I S T B Y I N
’
o n o n o u a m o u rn ] .
C H UR C H I
N E W B UR L I N G TON S T R E E T
1882
Y
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P HY
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S IH I SNP I L
E I
B B AHB N B
LOND ON
A
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M
C
A
O
D
TA
C AL
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TO
G E O R GE E D
D C L Ox ou
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R E G I US
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P R O F E SSOR
Bu
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,
LLJ) E u
OF
THE
n
TH E GE N ER AL
F O LLO WIN G
AR E
WI TH
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PA G E T
M D Ca naa n , F R S
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IVER SITY OF CA MB R I D GE
M ED ICAL C OUN C I L
I ’ H Y SI C I N T H E UN
OF
P R E SI D ENT
m
WA R D
PAGES
IN SC R IB E D
R E SPE CT AN D
E STEEM
PR E FAC E
IN
the pre s e nt work it is in ten ded to co nfine the
atte ntio n to those urin ary deran geme n ts which are the
result of chemical cha n ges occurrin g withi n the body
as distin ct from those morbid condition s of the urin e
which are directly associated with d isease of the ren al
organ s or of the gen ito urin ary passages or those which
like diabetes an d temporary albumin uria are the resu lt
of disturban ce of the circulatio n in the hepatic a n d
re nal vessels
D urin g the la st twen ty years physician s have paid
but little regard to these deran gemen ts which du ri ng
the e arlier part of the cen tury were the subj ect of ex
ha u stive rese arch a n d furn ished the materials for keen
discussion a n d con troversy
Three ca uses may be
assign ed for thi s n eglect I n the first place the atten
tio n of pathologist s has of late years been almost ex
elusively directed to histological research
S econ dly
owin g to the dom in a n t positio n uric acid h as as sumed
in humoral pathology there h a s been a ten den cy to refer
the e deran gemen ts to the same category an d to s pe ak
of them somewhat in discrimin ately as co nn ected with
gouty proclivitie s a n d thus to overlook some of their
L astly there is n o departmen t
d istin ctive character s
of clin ical medicin e which is gen erally so perfun ctorily
performed as the examin atio n of the urin e in disea se
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PR E FA C E
viii
As
a rule we are con ten t with determin in g the pre
se n ce or absen ce of albumen or sugar the n ature of
deposited matters, an d recordin g the specific gravity an d
,
,
reactio n without however referen ce bein g made to the
co nditions as regards time food &c at which the urin e
w a s passed
Wh il st it seldom ha ppen s tha t a ny attempt
is made to determin e the actual acidity or the a m oun t
of soli d matter passed daily yet it is almost en tirely
by this mean s that we can hope to obtain a n i n sight in to
the n ature of the metabolic ch an ge s o ccurrin g within
the body
But whilst this bran ch of u r in ary pathology has been
of
late vea rs physiological
com paratively n eglected
che m istry h a s made con siderable progre s s a n d this is
e specially the case with referen ce to the phy s iology of
digestio n N ot on ly have recen t di scoveries el u cidated
much that wa s obscure but th ey h a ve also Open ed up
I t is therefore with the aid that
n ew poin t s of v iew
physiologic al chemistry n ow a flord s us that it is pro
po s ed to pass un der review the fact s con n ected with the
subj ect of the morbid con dition s of the urin e depen dant
Much of the material of
on deran gemen ts of digestio n
which the pre s en t volume is comprised h a s already
appeared in the pages of the L an ce t duri n g the last
The en couragemen t the author received
five years
durin g their publicatio n in a separate a n d detached
form lead s him to hope that n ow they are arran ged in a
more systematic m an n er they may prove serviceable
towards the elucidatio n of these still diflicu lt problems
in chemical pathology
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Q UEE N
A N N E STR E E T,
C A VEND ISH S QUA R E W
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M a rcia 1 5 th, 1 8 8 2
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C O N TE N T S
C HAPTER
F OR MATION
D YSP E PSIA
R EMOVAL
AN D
AssocrATE D
OP
I
AC ID FR OM
B
TH E
OD
C HA PTER I I
WITH AN A C ID C OND ITION
PA G E
Y
1
O P TH E
UE I NE
20
C HAP TER
D
P SP E P sI A
THE
ASS O C
IATE D WITH AN
III
AL KAL I NE CO ND
OE
UR INE
36
C HAPTER
D
ITION
EE AN G EM ENTs
I
AS SOC ATED
(R ELATION SHI P
To
L
IV
WITH D E POS ITS
ITH E M IA AN D
0E
UB IC AC ID
65
GO IIT)
C H A PTE R V
D
EE ANC E M ENTs
0F
As soc I ATE D
WITH
D
EP os I Ts O F
OXALAI
’ ‘
E
LI ME
99
C H APTE R VI
.
D
E E ANGE M ENT s
OF
As soc I AT ED
WI TH EXC ESSI VE ELIM INATION
PH O SPH OB I O AC ID
116
A PPEN DI X
E FFE C T
TH E
OE
B I C AE EONATE
or
PO TAB H
ON
TH E
ACID
ITY
UE IN E
OP
1 37
b
C OR R I GEN DA
ga i n on p 16 the form ul a for Aci d S od i u m
C arbon a te a nd Norm a l S o d iu m C arb ona t e sh ould b e N a HgCO3 and
N 312H CO3 resp ect ively a n d n ot N a H CO a an d N 1 20 0 : as given
in the tex t
O n p a ge 3 7 secon d l i n e of form ul a f or = C2 H4 O (A ld ehy d e)
H 20 0 4 H 8 0 2 2 0 0 2 H 4 rea d = C2H O (A ld e hy d e)
H 20
C4 H 8 0 2
+ 2 0 0 2 + H4
a n d a g a in on n ex t l i n e f or 0 2 H 4O
(A ce tic A cid )
On
p a ge 1 1
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an d a
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0 2 11 4 0 2
rea d
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p a ge 8 3 foot note f or
gra i ns i n s tea d of 400 0
On
20 0
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free
i d ity
ac
of
L on don
p orter
,
rea d
MOR B I D
C O N D I TI O N S
OF
\
UR I N E
TH E
C H A P TE R
F O R M A TI O N
TH E
ON
AN D
TH E
A C ID
I
M O VAL OF
B O DY
R E
I
AC D
FR O M
an d
acid s alts are co ntin uou sly en terin g the
blood ( 1 ) They may be i n troduced into the body from
without in the food
The quantity however thus
derived un der ordin ary con dition s is comparatively
sm all sin ce n e arly the wh ole of the salin e con stitue nts
of the food are alk alin e or become so by con v ers io n i n
the syste m S till a s m all quantity of acid sodium
phosphate is d erived from the j uice of flesh an d this
pa sses n o doubt un chan ged in to the blood (2) A cid
too is gen erated in the alimen ta ry can al from ferm en
tative decomposition of the s a ccha ri n e matters take n
with the food or of the amylac eous prin ciple s th at have
been con verted into sugar I n he alth this ferm e nta tivo
process is mo st active at the lower part of the small
intestin e s a n d in the first portio n of the large i ntesti n e
(3) Lastly acid is generated in the tissue s of the body
Thus in a c on dition of inactivity the lymph fluid of all
tissues is alkalin e or n eutral ; on a ctivity be in g evoked
the reaction be comes a cid This is well see n i n what
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1
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F OR
M A T I O N AND
R E
M O VA L
follow s the co n traction of mu scle s in which the con
traction wave give s ri s e to s arco l actic carbon ic a n d
other v olati l e fatty acids a n d probably glycerim ph os
O f the s e acid s the carbon ic pas ses directly
p h oric acid
i nto the b l ood in a free state With regard to the
other acid s their distri bution a n d combin atio n with
the in organ ic bases likewis e s et fre e by the pro ces s of
ti s sue o x idation is s o h ighly comp l icated that l ittle is
k n ow n about them
I t is probab l e howe v er that the
lactic a n d other organ ic acids are c on verted in carbon ate s
probab l y acid ( b i carbon ates a n d that som e portion
of the pho s phoric a cid e n ter s the blood a s a cid s odium
pho s phate ; sin ce Ma l y * ha s con c l usiv ely determin ed
the pre s e n ce of acid s odium pho sphate a n d acid s odium
carbon ate
(bicarbo n ate) the latter a n acid s alt w ith a n
alkalin e reaction
I n spi te, however of thi s co n s tan t e n tran ce of acid
in to it the blood of the li vin g body is alway s alka l in e
n o doubt becau s e the chief acid s alt s odium bicarbon ate )
(
h a s a n a l kalin e reaction What the degree of alka l e s ce n ce
of n orm al blood is has n ot bee n deter m in ed but it i
probab l e that like the temperature a n d s pecific gravity
it h a s c ertain de fin ite l im it s w hich c an n ot be p assed in
either dire ction without c au sin g di sturban ce of healthy
n utritio n
I n fact great di ffi cu l ty is experien ced in
reducin g the alkalin e reaction of the b l oo d ? H oflm an n
w h o fe d pigeo n s for a con s iderable time on food yieldin g
on ly a n acid a sh (y olk of egg) f oun d that however
great th e ten de n cy of uric a cid a n d of the acid s alt s of
pho sphoric acid to c om bin e with ba se s yet the s e were
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U t u hu ge fi b di M itt l
S ii eb ild
R M ly Z f ii Phys C him i e 1 8 77
U b d U be g g
f ei e S ii
du ch d
n ers
n ism u s
1
'
B lu t
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a
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e
er
in d en
n
c
er
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er
H a rn
n
e
"
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Z
an
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e
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vo n
f iir
zu r
a
r
u ng
im
O ga
r
’
r
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r
e
r
,
n
a
B i ol og ie vii
rer
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r
a s a lk alis cli e
I
OF
AC D
FRO
M
TH E
B OD Y
3
.
n ot withdrawn from the alkalin e blood but wer e
eviden tly withheld to m ain tain its alka l in ity L a sca rf’“
by in troducin g dilu te d min eral acid s in to the stomach
succeeded in reducin g the a l kale s cen ce of the blood
but n ot con siderab l y a n d the con clu sion he arrived at
wa s that the organ ism retain ed free al kali with great
e n ergy
I n some of h is experimen t s the quan tity of
a cid in troduced in to the sto m ach would have made the
w hole an imal acid if it had bee n ab s orbed a n d excreted
a gain
From this L ascar inf ers that the organ ism
pos ses se s certain
regulative mechan is ms
whi ch
main tain the equi l ibri u m betwee n the acids an d al kalin e
bases in the system The s e experim en tal facts s ee m
to be born e out by what occurs in s cur vy
That
disease as has been well e stabli shed is brought about
by the prolon ged an d com plete withdraw a l O f the
o rgan ic v egetab l e acid s a n d their s alt s frO
m the dietary
o f those a if ecte d
The s e organ ic s al ts a s is wel l
k n own by oxidation in the blood yield alkalin e carbo
n ates
N ow, the alkalin e car b on ate s are the s alt s
chiefly co n cern ed i n main tain in g the alkale s cen ce of
the blood a n d it appears when the s e are largely wit h
drawn a s happen s when scurvy is in duced the proper
degree of a l kalesce n ce of the blood is main tain ed with
diffi cu l ty a n d in order to se cure it s ome other alkalin e
Thus I
s a l t is retain ed in s te ad of bein g excre te d
f oun d after the w ithdraw al of fres h vegetable food for
e ightee n days the total q ua n tity o f phosphoric acid
pass ed in the tw en ty —four hours wa s slight l y red u ced
w hilst the pho s phoric acid in combi n ation with the
alkalin e oxide s wa s reduced n early on e ha l f A gain in
a ca s e of scurvy it wa s foun d that the a l kalin e pho s
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Z ur
P fli ger,
a
lkalescen ce
des
B lutes
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‘
A rcli iv
fur
Phys iologi e
’
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F O R MA T I O N AND
4s
R E
M O VAL
pha te s
in creased rapidly on the resumptio n of an an ti
s corb u tic diet altho u gh the amoun t o f phosphoric acid
i n gested wa s the s ame in scor b utic a n d an ti s corbutic
ratio n s re spectively The s e two facts poin tin g to the
con clusio n that the alkalin e pho s phate s are retain ed in
the system when the alkalin e carbo n ates are with
*
w
n
n
n
i
n
s
dra
these are aga
upplied
a d di s charged whe
A ll experi m e n ts made on an ima l s with a vie w to redu ce
the alkalin ity of the blood or to n eu tralise it have
e n ded soon er or later in the death of the an im al a n d if
the proce ss h a s been a slow on e the defin ite patho
l ogical chan ges will be foun d to have occurred in the
blood a n d tis sues clo s ely resemblin g the chan ges foun d
in the bodies of patie n t s dyi n g from s curvy v iz dis
olu tion of the blood globule s ecchymosis in the heart
blood stain s in the m edia stin u m gums a n d mucous
s ur faces ; whilst the mu s cular s tructure o f th e heart
a n d the mu scle s gen erall
y a s w e l l a s the secretin g ce l l s
of the liv er a n d kid n eys becom e gran ular a n d even
d i s tin ctly fatty
L astly D r Gaskell 1 h a s shown
exp erim e n tally that a di l ute alkalin e solution act s upon
the musc ular tis sue of the heart so a s to produc e a
powerful con tractio n whilst dilute acid solution s pro
duce a n o ppo s ite eff ect a n d that the mu s cle of the
smaller arterie s are acted upon in the same way These
facts s eem to poin t to the co n clusio n that on e factor at
leas t upon which the con striction of the m uscles both of
heart a n d arteries de pe n d is the alkalin ity Of the fluid
s urrou n di n g them
I t i n ot un reason able therefore
to su rmi s e that variation s of the degree of alkalin ity
w ould n ot be un likely to lead to disturban ce s of circu
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i n qu iry
‘
L ew i s
,
1 8 77
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P th l g y
of
o o
a
S u vy
c
r
’
by
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1 J ou rn a l
'
int o
th e
,
of
Physi ology
’
,
vol.
iii
,
N o 1 , 1 880
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hor
the A u t
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OF
I
AC D
FR O M
TH E
B OD
Y
5
lation an d s o e ff e ct a seco n dary chemical in flue n ce on
n utrition as we l l as a direct on e
A cid is discharged from the blood by fo u r chan n el s
( 1 ) By the lun gs (2) the skin (3) with the gas tric
j uice a n d (4 ) by the urin e The escape of carbon ic
acid by the lun gs is eff ected by mean s partly mechani cal
sin ce c ar bon ic acid exis t s in the
a n d partly chemical
blood in two con dition s loose a n d s table By loo s e
carbon ic acid is m ean t that carboni c acid which is given
off to a v acuu m
a n d is physica l ly ab s orbed a s well a s
retain ed in so l utio n by the alkalin e carbon ates a n d
pho sphate s ; thi s loo s e c arbo n ic acid e scape s from the
lun g s in to the at m o sphere in obedi en ce to the la w of
pre ssures O n the other han d the stable carbon ic acid
is in combin atio n with s ome bas e a n d ca n o n ly be
the bloo d by s ome chemica l mean s
s eparated f ro m
H ow thi s dec ompo sitio n is e fi e cte d is n ot yet deter
min ed The am oun t of carbon ic acid exhaled by the
lun gs of a healthy adu l t h a s bee n s hown by D r E dward
S mith “ to average about 950 gramme s in the twe n ty
fo u r hours The rate o f excretion howe v er is not
bein g subj ect to extern a l in flue n ce s s u ch as
u n i form
the am oun t of bodily exercis e take n the n ature of the
food a n d the e ffe ct of the meal hours Thus D r Smith
h a s s hown that the in ges tion o f f ood produ ce s a marked
in creas e on the e l imin atio n Thu s in a mean of eight
expe rim e n t s he f oun d the rate of excretion before break
fa st to be
grai n s per min ute afte r breakfas t 9 grain s ;
before a m i dday dinn er th e excretion w a s 8 6 grain s
a n d w a s co n tin ued at the s am e rate per m in ute aft er
grain s per min ute
w ards ; before tea the rate w a s
afterwards it ro s e to
grain s D r S mith co n s ider s
it Tra s action s of Roy a l S ociety
1 8 60
E x p erim ents in
Respira tion
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F O R M A T I O N AND
6
RE
M O VAL
the fact that n o in crea s e occurred after the dinn er meal
in his case wa s owin g to his din in g before his usual
hour an d that the a ction u pon the respiratio n of the
previous mea l had n ot passed off I n some experiments
he mad e with D r Murie a n d Profes s or Franklan d a n
in crease was obser v ed This in crease i n the exh alatio n
of carbonic acid or to ex press it plain ly the a cidity of
th e breath af ter food i in terestin g whe n tak e n i n
conn ection with the fact that the opposite e fiect is
n oticed with res pect to th e urin ary secretion the
acidity of which is depressed by the in ge stio n of a
me al
I n a d di tio n to th e ca rb on ic acid p a s sin g off by th e
lu n gs about six gramme s of this gas are exhaled by
The swe at or fluid
the skin durin g the s ame period
perspiration h a s al s o a de cided acid reactio n which is
due to the pre s e n ce of formic acetic a n d butyric a cids
The quantity of a cid however discharged by this ch an
nel has n ot bee n deter m in ed it probably varie s gre atly
even in he a lth a n d a very c on s iderable amount is ex
creted when stro n g ex erci e is take n ; whil s t i n cert ain
d isea ses as acute rheumatism the quan tity disch a rged
by the skin is often e n orm ous
The gastric j uice is alway acid a n d its acidity h a s
n ow bee n in con testably proved to be due to hydrochl o ri c
acid— a t leas t R ichet ha s shown that in the fresh secre
tio n this is the on ly min eral acid pre se n t L actic
a cetic a n d bu tyric a cids are al s o met wi th i n ga stric
juice the result of fermen tative chan ges occurrin g i n
the stom ach I n certain m orbid con ditio n s which we
sh all con sider fu rther on they m ay be con siderably i n
exce ss of the hydroch l oric acid i n deed that a cid may
be very sca ntily secreted ! a n d thu s b y cau si n g delay
D u Su c G astri qu e che z l H om m e et les An i m a ux
Pari s 1 8 78
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F O R M ATI O N AND
8
R E
MO VA L
hi gh —
above 500— because the quantity of acid yielded
to the ether is s mall ; the co eflicien t for the organic
a cid s is low for the opposite reaso n The followin g ex a m
ple will ren der the matter clearer 100 grammes of water
contain in g 1 1 grammes of lactic acid a n d 100 grammes of
ether agitated with this s olution removes 1 gramme of
acid s o whe n we determin e the acidity of the two fluid s
we fin d th at of the wate r to be 10 a n d that of the ether
B ut suppo s in g the de gree of dilutio n to be ten
1
time s g reater than i n the fir s t c a se the n 100 grammes
of water which co ntain s
grammes of lactic a cid
agitated with a n equal weight of ether will yield to the
ether
gramm e an d retain 1 gramme the co efiicien t
therefore s aid to be 1 0 The co efli
of lactic a cid i
have been deter
cien ts of ma ny other organ ic a cid s
mined S ome of th e most import an t a s ha vin g a bear
in g on an imal chemistry are succi nic acid 0 = 6 be n zoic
acid
oxalic a cid 0 = 9 5,a cetic acid
SO
f ar a s con cern s on e a cid in solution the operatio n is
simple en ough but when we have to deal with a m ixture
of two or more we must hav e recours e to a s eries of
a gitation s with ether so that we may sepa ra te the a cid
which is the mo s t readi ly s oluble in ether from the on e
that is less so By such repe ated tre atm e nt of the
origin al acid solutio n with ether an d recordi n g the co
effi cie n t of partage after each operatio n we are able to
obtain the true co eflicien t of partage for each a cid
prese n t
The acidity of human gastric j uice varies co ns iderably
a c cordin g to the stateme nt s of diff eren t observers Thus
R ichet * from n umerous observ ations o n a patie n t after
gastrotomy gives the average a cidity as
with a
a n d a min imu m of 0 5 per thous an d
maxi m um of
0 p cit p 68
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OF ACID F R O M T H E
9
B OD Y
S chroeder? “ from observation s made in a female with
Schm id td from
ga tric fi stula records it a s low a s
experimen ts on dogs give s a n av erage of
a n d S za b o i
with the s am e an imals 3 per thous an d
The s e variation s
n eed n ot be co n sidered co n tradictory the acidity of the
gastric j ui ce n o doubt depen din g m uch on the n ature of
the phy sio l ogical s timulus that excite s it This suppo
sitiou receive s support from the ob s ervatio n s of S ch m idt
wh o foun d the j u ice of herbi v orou s an imal s had a low er
degree of acidity than that from carn iv orou s an im al s O n e
poin t however is certain that the acid is pre se n t in a very
dilu te state thu s con firmin g the re s ul ts obtain ed by
experim en t s with artificia l gastric j uice in whi ch a
degree of acidity of
per ce n t is foun d to be mo st
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efi e ctive
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With regard to the amou n t of acid withdrawn from
the blood by the gas tric s ecretion durin g the twen ty four
hours it is impo s sible to s peak with a n y certain ty sin ce
the quan tity of gastric j uice s e creted durin g that period
h a s n ever been definite l y a s certain e d
G rii n ewa ld § in a
d by him states it a s twen ty three imperial
c ase exam in e
pin t s but thi s wa s un doubted l y un der path o l ogi cal con
P arke s con sider s if we put it at twel v e pi n ts
d ition s
L ehm an n drawin g con
we s hal l be w ithin the m ark
clu sio n s from experi m e n t s on an ima l s co n clude s tha t the
secretion of ga stric j uice in the twen ty four hours
amoun t s to on e te n th of the whole weight of their body
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Su cc i h um a n i ga strici vis di ges tiva Dorpa t 1 8 5 3
L e ipsi g 1 8 5 2
1 B i dd er e t S ch m i d t D ie V e d a u u gssaf t
I B e itrage z r Ke n ntn iss d e fre ien Sauren d e s m e nschl M gen
Z e itsc h if t f P hy iOIOgie Chim i e i 1 8 77
f te s
B ea l e s Archive s of M ed ic in e vol i p 2 7 0
Med Tim es a n d Ga z ett e
G u ls ton ia n L ect u e on Pyrex ia
1 8 55 vol i p 33 3
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FO R M A T ION AND R E M OVAL
10
this per m a n w ould repres en t s omethin g like 14 lbs
av oirdupois Un fortun ately a s Richet well Observes
the data on which these ca l culation s are f oun ded are
very un certain sin ce it is extremely d ifli cu lt to determin e
the relati ve proportion of the tru e gastric s e cretion a n d
the mucus m ixed with it a n d als o to make allowan ce for
what pa sse s O ff acci d en tally duri n g the experime n t by
the pylorus a n d what is ab s orbed by the vein s of th e
stomach M oreov er e v en if the s e Ob stacle s should be
overcom e the in termitte n t n ature of the s ecretion
would m ake it d ifi cu lt to arriv e at very de fin ite co n
e l u sio n s
W e mu st n ow proceed to co n sider the man n er in
whi ch the hydro chl oric acid of the ga stric j uic e is
It is
s e arated in a free state from the alkali n e blood
p
o n l y recen tly that a n explan ation h a s been Offered to
accoun t for thi s seemin g paradox I n
in order
to elucidate this poin t I made in the laboratory of the
C harin g C ro ss H o s pital a serie s of e x perimen t s in
whi ch I f oun d by in troduc in g a n alkalin e solution
c on s i sti n g
of sodium bicarbo n ate ( 5 per ce n t ) a n d
n eutral s odium pho s pha te (5 per cen t ) i n to a small
U tube fitted with a diaphra gm at the ben d a n d pas sed
a weak electric curre n t through the s olutio n that in a
short tim e the fluid in the limb co n n ected with the
n egati v e po l e i n crea s ed in a l kalin ity whil st the fluid in
the limb co n n e cted with the positive pole be came acid
fro m the format ion of acid s odium ph o sphate
N o w on e
o f the chief s alt s in the blood is u n doubtedly s o d iu m o r
potas sium bicarbon ate — a n acid s alt with a n alkalin e
reaction a n d n eutral sodium pho sphate ha s al s o a n
a l kalin e reac tion
The deco m po sition which occur s
between them may be represen ted as follow s
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it
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2 9,
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O F ACID F ROM T H E B ODY
Ac i d S o d i u m
C a rbona te
S o di u m
Phospha te
N e u tral
.
Na
Na
,,
a
l So di u m
C a rbona te
.
H , 00,
,
N orm
11
A c i d S o di u m
P h osph a t e
.
.
Na
H , P0 ,
,
H3 P 0 ,
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.
The abo ve reaction explain s the pre s en ce of acid
s odium phosphate in urin e
To accoun t fo r the form a
tion of free hydrochlori c acid in the gas tric j u ice
sodium chloride is s ubs tituted for the n eutral s odiu m
pho sphate the decompo s itio n in thi s ca s e bein g
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S od i u m
Ca bon a te
S od iu m
Ch lori d e
A ci d
r
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Na H
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C O3
M a ly
Na
Sod i um
Ca rb on te
a
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CI
,
H y droch l ori c
N orm al
i
Ac d
.
N a } , C O3
.
H Cl
,
.
however wh o s ubs equen tly in v e stigate d the
h a s c o m e to the con clus ion
sub e ct with great ca re
j
that the hydrochloric acid is derived from th e decom
po s ition Of n eutra l s odium phos phate with calciu m
chloride thu s
it
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Ne utral S odi u m
P hos pha t e
C a l ci u m
C hlori de
.
T i cal c i c
Pho spha te
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r
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H y droc hl ori c
.
Ac
id
.
P0 , + 4 Na , Cl+ 2
H , 190 4 + 3 C a,
2
S od i u m
C h l o i de
r
it matters little which v ie w w e adopt
sin ce all the s a l t s n a med are pre s en t in the blood ; the
importa n t fa ct be in g that ou t of the body a w ea k
e le ctrica l curren t wi l l s epa ra te the acid from its b a se
W hether the deco mposition oc currin g in th e body is due
to th e s ame age n cy mu st f or the pres en t rem ain a
matte r of con j ec ture Still the experim ent of Profe ss or
D uboi s Reymon d made with an extremely sen sitiv e
ga l van omete r whi ch show s that there are n o tw o part s
of th e body w ho s e e l e ctrical con d itio n is pre ciselv the
sa m e an d th a t the difi eren ce s betw ee n them a re grea te r
P ra cti ca ll y
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Physiolog
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1 7 4, 1 8 7 7
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FO R M AT I O N AND R E MO VAL
12
in proportion to the difi eren ce in activity of the vital
proces s es which are bein g carried on in them m akes
such a n hypothe si s plau sible )“ whil st the i nterestin g
discoveries made by D r B urdon S an derson that
electrical disturban ce t ake s pl ace durin g co ntra ctio n of
the leaf of the D iom ea m u s oip u la or Ve nus s fly tra p
points to the s ame con clu sio n
Whate ver be the nature of a gen cy tha t efi ects the
decompo sition it must be a powerful on e to effect the
sep aration of hydrochloric acid from bases for which it
The decom
h a s such a stron g affin ity as soda or lime
positio n however on ce effecte d i n the blood there is n o
d ifi cu lty i n explain i n g the prese n ce of free hydrochl oric
a cid in the tom a ch sin ce Grah am showed man y years
a go that this a cid po ses se s high difiu sive power and
passes from a mixture through a dialyser with gre at
rapidity
A cid al s o le ave s the body by th e urin e sin ce the re
actio n of healthy human urin e collecte d durin g a period
of twen ty four hours is always a cid This a cidity is
reckon ed a s oxalic acid that is to ay i n dete rminin g
the amoun t presen t we use a s olution of sodium hydrate
standardised so that each cubic centim etre represe nts
The degree of a cidity of th e
01 gramme Of oxalic a cid
twe nty f our hour s uri ne in w ell fed a dults is ge n er ally
equivalen t to two gra mme s o f ox alic acid
N ow although the re a ctio n of healthy huma n uri n e
collected throughout the twe nty four hours is acid yet
if separate s amples of the uri ne p assed durin g this period
be taken c on siderable v ariation s i n the ch ar acter o f the
re action w ill be observed The con stan cy with which
these variation s occur under diflerent diu rn al physio
D r Poore Te xt book of E l ec tricity in M ed ici ne and S urgery
S m ith E lder and C c 1 8 76
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O F ACID F R O M
TH E
B O DY
13
logical co ndition s wa s first studied by D r Ben ce Jon e s
That physician poin ted out that the acid reaction of the
urin e in creases an d dimin i sh e s i n versely with the s e cre
tio n of the gastric juice H e foun d by examin in g the
m i n e at short in terv als duri n g the day that an in crease
of acidity wa s Ob s erved in the urin es passed before meal s
an d that a declin e in the acidity occurred shortly a fter
food had been take n a n d acid wa s co n sequen t l y with
d rawn from the sy s tem
its maximum dec l in e bein g
attain ed in about three hours when the acidi ty begin s to
rise I n s ome in stan ces n ot merely wa s there d epres
sio n of the acidity but the urin e became n eutral an d
even alkalin e The s e Observ ation s of D r Ben ce Jon e s
have bee n r epeatedly con firmed by sub s equen t in vesti
gators an d the ebb a n d flow in the in ten sity of acid re
action of the u rin e to which the ter m a lka line tid e has
been apt l y applied is a recogn is ed physio l ogical fact
though explan atio n s d iiferen t from that ofiere d by D r
Ben ce J on e s have bee n ad v an ced to accoun t for the phe
Dr R oberts )“ for in stan ce is di spo s ed to a ttri
n om en o n
bute th e o ccurre n ce of the al kalin e tide a fter m eals to a
differe n t cause — n amely to the e n tran ce of the n e wl y
F or if a s he s ay s the
di ge ste d food in to the blood
n or m al alkalesce n ce of the blood is due to the prepon
dera n ce O f alkalin e bas e s in all our ordin ary articles of
f ood a meal is p ro ta n to a do s e of al k ali w hich mus t fo r
a time add to the alkalesce n ce of the sy s tem an d con
D r Ben ce Jon es s view receive s
s equ e n tly of the urin e
con s iderable support from clin ical a n d phys iologica l
experie n ce S in ce in tho s e ca se s atten ded w ith frequen t
vomitin g of in ten sely acid fluid it has often been n oticed
th at the urin e pas sed im mediately a fter the ej e ction of
Mem oirs of the Man chester
A C on tribu ti on to Urol og y
1 8 59
L it a n d Phi l
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FO R M A T ION AND
14
RE
M O VA L
the fluid beco m e s alkaline the s ame effect is produced
in dogs experime n tally when poun ded gl a s s or other
in dige s tible substan ce is in troduced in t o the stomach to
provoke the s ecretion of the gastric j uice which is with
drawn a s s oon a s secreted b y wa shin g out the stomach
with water b y mean s of a stomach pump showi n g in
both i n stan ces that the alkalin ity of the urin e wa s
caused by the withdrawal of acid from the stomach an d
n ot b y the addition of a l kali to the bloo d
That the in
ge stion of food e s pecially vegetable food con tributes
in a s light degree in the production of the alkalin e tide
is v ery probable but that it is main ly con cern ed in the
phe n omen o n is ou t of the que s tion otherwise the alka
linity of the urin e would be in di rect proportion to the
quan tity of food i n ge s te d which is certainly n ot the
cas e In deed the acidity of the urin e ca n be depre s s ed
a n d eve n ren dered a l kali n e otherwi s e than by the with
d ra wa l of acid from the s tomach or by the in ge s tion O f
food An d it is thi s circum sta nce hitherto u n explain ed
t h at h a s ren dered man y phys iologis ts un wi l lin g to accept
D r Ben ce Jo n es s a s a complete solution of the phen o
m e n on
D r H erm an n W eber “ s ome years ago obs erved
tha t Whils t breakfast decidedly had a n i n fluen ce in
lo werin g the acidity yet w he n he wen t without that
mea l the acidity wa s still l e s sen e d though n ot to so
great a degree Thi s Obs ervation of D r W eber I have
repeated l y been able to con firm the mere act of risin g
a lway s producin g a decided depre s sio n in the a cidity of
the urin e The u se of the cold douche or sweatin g in
the vapour bath both have the same eflfect quite in de
pen de n tly of food or the activity of the stomach
There is an other chann e l however by which acid is
P ro fessor Pa rk e s O n th e Com position of the Uri ne in H eal t h
a nd D i sea se
p 55 C h urchi ll 1 860
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16
F O RMA T I O N
AND
R E M OVAL
occas io n ally to a n exce s s of acid s alt s of hippuric
an d uric a cids I have already (page
whe n speakin g
of the prese n ce of free hydrochloric acid in the gastric
jui ce showed how the s eemin g paradox o f the s eparation
of a n acid s e cretion from a n a l kalin e fluid like the blood
A n d I poin ted out in the cas e of
ca n be explai n ed
urin e that it wa s the resu l t of the decompositio n of
a s alt with a n alkalin e reaction but havin g a n acid
con stitution like s o dium or potas sium bi carbon ate
with an other alkali n e s alt the n eutral s odium phospha te
thus
and
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Ac
id
C arbon te
a
Na H
,
,
N e u tra l
.
C O3
P
hospha te
Norm a l
C a b on a te
r
.
1‘Ta 2, C O3
N a z, H , P O 4
id
Phos pha te
Ac
.
Na
,
.
H 2, P 0 4
.
M aly i“ be l ieve s that acid sodium phosphate a s well
a s hippuri c a n d uric acid exi sts in a free s tate in the
blood a n d that the reaction o f that fluid rem ain s
alkalin e on accoun t of the prepon deran ce of alkalin e
H e ha s shown that if a n alkalin e mixture con
s alts
tain in g n eutral s odium pho sphate a n d acid s odium
phosphate be placed on a dialy s er the acid salt pa ss e s
in to the s urro u n din g dis ti l led water ; he n ce he co n s iders
the excretion of acid urin e through the ren al paren chyma
to be s im ply a proce ss of dialy si s
Maly s explan ation has the merit of simplicity but
it does n ot wholly a ccoun t for man y of the phe n omen a
con n ected with the variation s in the reaction of the
urin e If on the other han d th e vie w that the acidity
of the urin e is caused by the reactio n between acid
s odium carbon ate an d n eutral sodium pho s hate be
p
accepted it will explain a n other paradox which has
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cit.
I
OF
AC D
17
F R OM T H E B O DY
bee n Observed by Be n ce Jon e sfi" B en eke +Par kes 1 an d
myself § to oc cur after the admin istration of the
bicarbon ates (acid carbon ates ) of ammo nia pota sh a n d
soda un der certa in co n ditio n s viz causin g of a n in
creased acidity of the urin e Thi s poin t will however
be more fully referred to whe n we con sider the action
o f alkalin e remedie s in the tre atmen t of d yspep sia
S o lo n g as the discharge Of acid from the system
passes ofl regularly a n d i di stributed in n orm a l pro
portio n am on g the secretio n s co n cern ed in its rem oval
its pre se n ce o n the mucous surface s with which it comes
in con ta ct is un felt
When however the production of
a cid is excessive or the distributio n of the acid amon g
the various secretion s is irregular so that on e be come s
more highly charged with acid than the others the n
the seco n dary effects due to acidity make thems elves
These when the formation of acid is o n ly
m an ifest
or is on ly temporarily in duced by
s light l y in exce s s
ca s ual disturban ces may be limited to s light heartburn
in the cas e of the stomach s ome itchin g or n ettle ra s h
of the skin a little bro n chial catarrh or some degree of
irritability of the urin ary pas sage s Whe n howe ver the
f ormation of acid is exce s sive or lon g co n tin ued the
secon dary disea se s it giv es rise to become formidable
in their n ature
A tta cks of acute dys pep s ia ae com
pa nied with paroxysms of pai n cra m p vomitin g a n d
diarrhoea so severe a n d Often s o lon g con tin ued a s to
reduce the patien t to the utmost stage of prostration
I n tractable skin diseases like lepra psoriasis a n d
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Phi loso phi cal Transacti on s 1 8 50 p art :2 p 673
1 A rchiv des Wisse nscha f tlich en H e i lku n de 1 8 5 4
p 444
zu r Urol og ie
I C om p osition o f th e Urin e in Hea l th an d D isease p
L an ce t Nov 9 th 1 8 78
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FO R MAT I O N AND
18
R E
M O VA L
czema severe asthmatic paroxy sm s a n d chro n ic bro n
chitis freque n t attack s of
gravel a n d other re n al a n d
urin ary affe ction s E xcessive fo rma tion of acid deter
min ed probably by certain textural a n d n eurotic co n di
tion s is very likely the cau s e of the s evere in flam m ation
of the structures in a n d aroun d j oin ts such a s we witn es s
In deed a n
in gout a n d in attacks of acute rheumati s m
over acid state may be con sidered a predi spo sin g a s w ell
a s a n e x citin g cau s e of both the s e diseases s in ce the n utri
tio n of the tis sue s un doubtedly become s impaired ‘“ by the
supply of faulty n utri tive material a n d so the co n dition s
whi ch favour a n attack of acute gouty or rheumatic
i n flammatio n are de v eloped
The s e are the mo st palpable a n d direct man ifesta
tion s of a n outburs t Of a n over acid state but there are
m an y other ailmen t s s uch as palpitatio n s a n d flutterin g
of the heart ; exaggerated puls ation s of la rge arterie s ;
irre gularities a n d in termi s sion s of the p uls e ; achin g
pain s in the l imbs ; bur n in g patche s n euralgia me
grim ; ve rtigo ; n oi s e s in the ears ; de pre ss ion of spirits
sleeple s s n es s & c
which man y writer s de s cribe a s
arisin g from irregular man ifestation s of the gouty state
a n d which D r Mu rch ison
d with a n equal show of reas on
refers to di s order of the liver but which without com
mittin g our s elves to a n y de finite theory may be con
ve n ien tl
y con sidered a s ari si n g from a n accumulatio n
of acid in the sy ste m when they occur in perso n s who
have n o claim to be con sidered gouty n or in whom a ny
e
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Thi s is well sh o wn in cha n ge s wh ich ta ke p l a ce in s cu rvy a
d isea se cl osel y a ll i e d in m a ny resp ects to g ou t a n d h eu m a tis m
a n d whi ch devel op s a f t er th e w ith d ra wa l for s om e l en g th of ti m e
f om the bl ood of th e a lk a l in e sa l ts su ppl i e d b y ve ge t a bl e f oo d
O n F u n ction a l D era n ge m en ts of the
1 C rooni n L ectu res
L i ver
1 8 74
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OF ACID FR O M T H E
19
B OD Y
marked disturban ce of hepatic fun ctio n is n oticed O ne
poin t that should be con sidered with referen ce to these
affectio n s is their extreme motility— the paroxy smal
n ature of their o n set the sudden n e s s w ith which they
disappear or tran fer themselves from on e regio n or
organ to an other These sudden chan ges aff ord a d
dition a l s upport to the view that these deran gemen ts
are caused by chemical alteratio n s in the quality of the
blood sin ce we n otice similar variation s within physio
logica l limits in the secretion s of variou s organ s a certain
ebb a n d flow as it were depen de n t on con dition s a flec
tin g their fun ctio n al activity A n d when we proceed to
refle ct on the v astn e s s a n d complicity of the chemical
circulation goin g o n in the body a circulatio n the im
portan ce of which wa s little con sidered till Professor
P arke s drew atte ntio n to it in the G u lston ia n Le ctures
of
we ca n hard l y wo n der if a pathological check
occurrin g to the eliminatio n of matters ready for their
discharge by their n atural p assage causes a n outbreak
in an other directed by the same i nfluen ce that regulates
the delicate chemical variation s whic h take place within
physiological limits
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Tim es an d
1 855,
vol.
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C HAPTER II
Y A sso c I A T E D W I T H A N ACID
O F UR I N E (A C I D D Y sP E P s I A )
D Y S P E P s I A U SU A L L
D
IT I O N
C ON
mucous membran e of the stomach furn ishes two
secretion s : on e which is con tin uously secreted durin g
fastin g a l kalin e in reaction thick a n d te n acious in con
the other the gastri c j ui ce thin limpid a n d
s isten ce ;
acid which is o n ly s ecreted when a stimulu s is applied
to the walls Of the organ I n hea l th the quan tity of
gastric j uice secreted from the walls of the s tomach
apparen t l y depen ds more on the gen eral requireme n t s of
the sy stem than upon the quan tity of the food in tro
d u ced i n to the dige s tive cavity
I n di s eas e both the
quality a n d the quan tity may be co n sid erably altered
The ob servation s of D r Beaumon t on the stomach of
A lexis St M artin showed th at in febrile co n dition s of the
sy stem o cca sion ed by whatever cause the villou s coat
become s red a n d dry a n d the secretion s become di mi
n ish e d a n d whe n thi s co n ditio n is c on sid erable n o gastric
j uic e wi l l be evoked by the alimen tary stimul us These
observ ation s of D r Beaum on t hav e been con fi rmed by
B lon dlot a n d 0 1 Ber n ard
O n the other han d it has
been sho wn experime n tal l y that u n der certain n ervous
in fluen ces the secretion is con siderably in crea s ed The
con ditio n s un der which thi s takes place are n ot howe v er
well un derstood because the chann el by which they are
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21
DYSPE PSIA
AC D
conveyed ha s n ot been defin itely determin ed Bern ard i“
foun d that section of the v agi durin g digestion caus e d
the redde n ed mucou s surface to be come pale whils t irri
ta tion of the n erve s or eetio n of the fourth ve ntricle
above their origin produced di latatio n of the gastri c
v e ss el s a n d in duced a n abun dan t s ecretio n Of gastric
j uice Rutherford ? al s o foun d tha t the ga stric mem
bran e flu shed durin g digestion becam e pale whe n the
vagi were cut a n d that stimul atio n Of the c en tral e n d
of either n erve caused redde n in g of the gas tric mem
bran e whils t irritation of the peripheral en d produced
n o co n stan t e flect
L astly it has been foun d that when
all the n erves that supply the stomach have been di vided
ga stric juice of n ormal acidity a n d dige stive pow er will
s till be secreted whe n a stimulu s is s upplied to the
mucous s urface Of the stomach alkalie s a n d dilute
alcoho l bein g amon g the m ost poten t which s hows that
the n erve ce n tres on which the secretio n depen ds exist in
the wa l ls of that organ F rom a con s ider ation of the
foregoin g facts it is probable therefore that whe n hyper
occurs pathologically it is con n ected wit h
s ecretion
either direct or reflex irritation of the s e n er v e cen tres
This may be produced either by a morbid con dition of
the blood s uch a s may re s ult from a n exce s s of acid
developed or retain ed in the s ystem in a gouty state
or the tain t of malarial pois on or by actual dis eas e of
the stomach itself especially those form s in which the
d ee p er struct u re s are in volved or by di s turban ce in the
other organ s co nv eyed to the nerve cen tres of the
stomach by reflex ag en cy
C h om eli h a s d escribed an acute a fi ection which he
L ec t S y st
vol ii pp 4 38 a n d 4 61
xx v i 1 8 70
1 R u th erford Phi l Tra n s
Paris 1 857
x D es Dysp ep s i es p
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22
AC D
D Y sB E B srA
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terms la dysp ep sie a cid e gra c e
in which it would
almo st seem as if the whole body turn ed acid The
dis ease apparen tly commen ces like a n ordin ary attack of
gastri c catarrh but so severe are the sym ptom that the
patien t speedily becomes pro s trate a n d has to keep his
bed There is frequen t vomitin g of acid matter tin ged
with yellow coloured bile the saliv a is acid a n d the
s ourn e s s of the breath s o marked that the air of the
cham ber becomes tain ted with it There is ob stin ate
con s tipation Af ter a time the character of the vomit
chan ge s from yellow to gree n bile which after pe rsis tin g
a con siderable n umber o f days moderates the pulse
however in creasin g in frequen cy with us ually a con
A t this period cer
s id era b le elevatio n of temperature
tain n ervous symptoms develop headache accompan ied
by hallucin ation s pas sin g gradually in to coma in which
in the maj ority of cas e s the patien t dies
The duration
of the disea s e wa s from thirty to fort y days
Gb om el
first n oticed the aff ection after the cholera epidemic of
Dr
1 8 32 but sin ce then he h a s repeatedly s een cas e s
W il s on F ox “ also relate s that durin g the cholera out
break in L on don in 1866 he wa s struck with the fre
quen oy Of subacute in flammatory affection s correspon d
in g in their symptoms to those of em ba rra s ga s tr iqu e
freque n cy durin g the
a n d he al s o n oticed a s imilar
autumn of 1 8 71 a year in which cholera was prevalen t
L ast autum n I saw a
in E urope but n ot in E n gla n d
case which ra n a cour se very s imilar to those described by
C h om el a n d as it presen ts features of in terest I briefly
summarise some of its characteristic detail s
A gen tleman about fif ty years Of age a ban s te a m
an d of robu st habit a n d who at the time his il ln e s s com
m ence d was in good health wa s s eized on e n ight
(O ct
D i seases of the S tom a ch p 1 00 3rd edit 1 87 2
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24
I DYSPEPSIA
AC D
morphia was given three times a d ay He wen t on in
this state for a fortn ight or three weeks from the com
m e n ce m en t of the il l n e ss
durin g which time he had
been quite s en sible ; on the twen ty first day howe v er
his n urse reported that he had pas s ed a re s tle s s n ight
a n d in the morn in g durin g her abse n ce he got ou t of
bed a n d wa s un able to get back again O n her return
she foun d him talkin g excited l y a n d fan cyin g th ere
were people in the room &c F or s ome reas on or other
the usual dose of morphia had been withheld the pre
cedin g n ight
O n gi vi n g him thi s he becam e quieter
a n d with a s econ d do s e he becam e quite ratio n al
The
vomitin g which up to this time had been glairy a n d
colourle s s on ly s ometimes tin ged with bile n ow became
darker a n d by the twe n ty fourth day distin ctly con
ta in e d blood
The abdome n wa s flat n ot ten der on
moderate pre ssure n or wa s pain at all complain ed of
The emaciation w a s con siderable ; the skin har s h a n d
d ry an d of a yellow brown i sh hue ; te mperature usually
below 9 8 F but occasion ally towards e v en in g run n in g
up to 1 00 F or 1 01 F The amoun t of vomit dis
c harged durin g the t we nty fo u r hour s n early filled a good
s ized was hhan d basin
Turpen tin e wa s n ow given a n d
after a fe w doses the blood dis appeared from the vomit
an d
the sickn e ss gradually dimin i s hed the ton gue
be came clean er the urin e m ore plen tiful On N ov
2 0th the thirty f ourth day of the illn e s s he wa s able
to sit up for a few hour s a n d had n ot been sick for five
days H e wa s still kept on milk diet a n d the turpe n
tin e m ixture give n o nce or twice a day From this he
con tin ued to make s atisfactory progre s s a n d when see n
six m o n th s afterward s wa s in very good health
I n thi s case it is difli cu lt to dete rmin e precisely the
co ndition which led to this prolon ged attack of acid
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25
I DYSPEPSIA
AC D
vomitin g D urin g the first week of the illn ess the
patie n t see m ed to be sufferin g simp ly from a n attack of
acute gastric catarrh A fter the relap s e of the ten th
day the character of the vomit wa s en tirely diffe re n t to
what wa s n oticed at first a n d there s eemed to be more
con stitution al disturban ce Wh il st the c ase wa s in
progre s s I thought that possibly the s evere attacks of
gastric catarrh had evoked s ome late n t organ ic mi schief
a n d that the irritatio n of the n erve ce n tre s in the walls
Of the stomach was the cause of the d ischarge of acid
The complete re covery O f the patien t n egatived th i s
hypothe s i s
It seem s therefore the attack may be
referred to a gouty con dition or a n outbur st of a n
o v er acid state of the sy stem
V omitin g of acid fluid s ometimes occur s in per s on s
who hav e been e x po s ed to the in fluen ce of malaria e v en
after other evide n ce s of ma l arial pois on in g have pas s ed
away D r F en wick fi“ wh o wa s the fir st pre cisely to n ote
this con dition rem arks that the vomitin g at first on ly
trouble s the patien t early in the morn in g but by
degree s it becomes more con stan t occurrin g directly
after every meal I n the s e case s the appetite is al ways
bad there is loss of flesh the s kin sallow a n d
the lips blo odle s s ; when the n ature of the malady is
recogn i e d it w ll b e foun d to yield to quin in e or ars eni c
i
A cas e that I saw for the late D r M urchiso n in
1 8 77 may b e referre d to this cause
A n A merican
lady s tayin g at the L angham H otel was seized on e
mor n i n g with a rigor whi ch wa s s peedily followed by
s weatin g con curre n tly with the o n s et of the sweatin g
she complain ed of in ten se pain in the epigastrium a n d
the retchin g of a n extremely acid fluid when ever she
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O n A trophy
of
D i g estive Organ s p
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the
1 73
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S tom a ch a n d Nervou s
C h u rchi ll 1 880
,
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Aflection s
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of
the
26
I DYSPEPSIA
AC D
oved in bed or attempted to take food or d rin k
There wa s n o eviden ce of either biliary or re n al colic
A s the pain wa s s evere a sixth of a grai n of morphia
w a s i nj ected s ubcutan eou sly
This relieved the pain
The n ext day
a n d in a few hours the vom iti n g cea s ed
quin in e wa s pre s cribed a n d there wa s n o recurren ce Of
the pai n or v omitin g S he in formed me she had had
s imilar atta ck s before that they w ere always u s hered in
by fit of shiverin g fol l owed by sweatin g a n d that in the
S tates she had s u ff ered from s evere attacks of pron oun ce d
in term itten t fever
The v om itin g of a n acid fluid is us ually a di stre s sin g
accompan im e n t Of can cer a n d u l ceration of the stomach
It is derived apparen tly from two s ource s on e from
hypersecretion of the gastric j uice (hydrochloric acid )
from dire ct irritation of the n erve ce n tre s Of the stomach
the other fro m acid derived from ferm en tative chan ge s
occurrin g in that organ (lactic acid) Both a cid s are
usual l y prese n t together but sometime s on e pre
pon derate s more at on e time than an other Thus D r
Goldin g Bird" state s th at in a case of scirrhous pylorus
he foun d at on e time a quan tity of free hydrochl oric
acid in on e pin t of vomit equal to twen ty two grain s of
the pharm aceutical acid with a n organ ic acid s u fiicien t
in quan tity to n eutrali s e seven grain s of pure potas h
At an other time the hydrochloric a cid had n early disa p
p ea red a n d the quan tity of organ ic acid in each pin t
required for saturation n early seven teen grain s of the
alkal i
N au s ea or vomitin g ge n erally aris es at some period
durin g pregn an cy M o st frequen tly it o ccur s of a
morn in g or im mediate ly after takin g food but in s om e
case s in addition to thi s disturban ce in the morn in g or
F
Urina ry Dep osits p 1 62 F ifth e dition 1 85 7
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I
AC D
27
DYSPEPSIA
at meal times there is more or less heartburn an d
flatulen ce throughout the day a n d in s evere cas es the
vomitin g become s in ce s s an t W hen the sick n e s s occurs
o n ly in the morn in g or come s on when a n attempt is
made to take food the vomit usua l ly con si sts of mucus
an d acid fluid evide ntly derived from hyper s ecretion of
the ga stric j u ice W he n the vo m itin g is more freque n t
a n d there is much flatulen ce
lactic a cid derived fro m
fermen tative chan ges will also be presen t Sim ilar
disturban ce of the gas tric fun ctio n the eff ect of refle x
n ervou s in fluen ce is met with in organ ic disease of the
uterus a n d other organ s I n phthi si s vomitin g of s our
fluid accom pan ied with more or les s pain n ot in fre
quen tly occurs to ward s the en d O f the disease I n the s e
cas e s the w alls of the stomach see m to have un dergon e
atrophi c chan ge s a n d the vomitin g h a s been attributed
to thi s co n dition but as D r Budd * poi n ted ou t o n e
circumstan ce in compatible with the idea that the
vomitin g is altogether due to the s e chan ges is that the
chan ges of structure foun d after death do n ot n eces
s a rily corre s po n d in degree with the severity or duration
O f the ga s tric symptom s
Man y form Of kidn ey
dis eas e s uch as chro n ic in terstitial n ephriti s tubular
nephriti s a n d s uppurativ e n ephritis are freque n tly
atten ded w
ith n ausea if n ot actual vomitin g I n the s e
cas e s
a s in phthi si s
there are us ually chan ge s to
be foun d in the mucou s membran e of the stomach
which s ome authors co n sider suffi cie n t to accoun t for
thi s symptom It must be born e in min d ho we ver
that n au sea a n d vomiti n g when pre s en t are often quite
early symptoms a n d di s appear for lon g in terval s
perhaps only to be observed again toward s the termi
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O gan i c a
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1 8 55
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nd
F u ncti ona l Disorders
of th e
S tom ach p
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1 8 7,
28
AC
ID DYSPEPSIA
ation of the case The acid of the vomit thrown up
durin g the sickn e ss caused by the passage of biliary
a n d re n al ca lculi h a s been s hown by man y observer s to
be hydr ochl oric acid the aci d of the gastric j uice
my frien d Mr M Beck ha s in for m ed me that
a nd
patien t s sufferin g from chro n ic bladder affectio n s are
frequen t l y troubled with s o ca l led bil ious attacks
R eflex vomitin g of a n acid fluid is v ery comm o n in
childre n in who m irregu l ar secretion of the ga stric
j uice see m s very readily excited w he n teething or suffer
in g from in testin al w orm s a n d Budd * h a s poin te d out
that youn g chil dren wit h tuberculous dis eas e of the
l un g or with in fla m mation Of the brain suffer from
thi s ga stric dis order more frequen tly than grown u p
per s on s l abourin g un der the s am e diseases
O ther form s o f n er v ou s di s tu rban ce have a powerful
in flu en ce on the secretion of the gastric j uice amon g
w hi ch may be men tio n ed sudde n emotion s of grief fear
or an xiety overwork in tellectu al or physical or the
exhau stion con sequen t on too prolon ged fastin g b y s te
I n the s e case s we have ofte n to
rica l con di tion s & c
deal appare n tly at on e tim e with a con di tion of in creased
at an other time of dim in i shed secretio n It is perhaps
thi s irregula r perform an ce of the gastric fu n ctio n that
a ccoun ts for the an omalous dy speptic symptoms these
c as e s so frequen tly pre s e n t
I n typical cas e s when the symptoms are well de fin ed
there is usu ally n o difficulty in determinin g whether
the acidity ari s e s from exce ss ive or irre gular s ecre
t ion of the gas tric juice or from fermen ta tive chan ges
takin g pla ce in the alimen tary can al Profe s s or W il s o n
F o x f has very con cisely stated the chief poin ts of dis
4“ O p c it
p 1 99
f D i sea ses of the Stom a ch p 22 Third e dition 1 8 72
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AC
ID DYSPEPSIA
29
tin ction betwee n them in relatio n to flatulen ce pain a n d
vom itin g Thus in hyper s ecretio n little or n o flatulen ce
is complain ed of whilst in acidity arisin g from fermen ta
tive ch anges it is a di stin ctive symptom Pain too is
less urge nt in the latter con dition than it is in the former
when it is often so severe a s to give rise to the suspicion
Of the existen ce of organ ic mischief It diff ers also in
character
I n hypersecretion it occurs on a n e m pty
stomach a n d is ge n erally relieved by takin g f ood ; it
varie s in in ten sity from a feelin g of cravin g or gn awin g
to an in ten se con tin ued burn in g se n sation behin d the
stern um I n ferm e n tative dy s pep sia the discomf ort
sets in some time after a mea l a n d is characteri sed
more by a feeli n g of disten sion a n d weight th a n
actual pain ; when pain is felt it is ge n erally of a colicky
n ature an d re f erred to the in te sti n e s rather than the
stom ach * A ctual vomitin g of acid fluid is common in
case s of hyp ersecretion whil s t in acidity arisin g from
fermen tation on ly a s light regurgitation usually occurs
I f how ever vomitin g doe s take place the m atter s
ej e cted will be foun d to co n tain a con siderable quan tity
of organ ic acid chiefly lactic acid a n d occasion al l y torulae
a n d s arci n ae a n d it will occur s ome tim e after a me al
I n hypersecretion on the other han d the vomitin g
Often takes place on a com p l ete l y empty stomach or is
provoked when on ly a s mall quan tity Of food is taken
I t is prob a b l e th a t the p res en ce for a s h ort ti m e of even a
con s i dera b l e qu a n tity of a ci d in th e s t om a ch d oe s n o t ca u s e p a i n
S in ce a D r B n ce J o es ha s sh o wn w h e n 8 1 gra i ns or eve 1 62
gra in s of dry ta rta i c a c i d a re tak en in f our or si ou n ces of w a ter
th e aci d h u rts the m o u th a n d u pp e p a rt of the food t u b e a d th en
i se to
cease s to b e fel t for th ree h ours or m ore w h en it g ives
gripin g n d col i cky p a i n The p a i n a tte nd an t on h yp e ecre tion
see m s to ori g i n a t e in th e n erve cen tres th em selves a n d p rec e de s
a pp a ren tl y the disch arge of a ci d
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A C ID D Y S PEP S I A
3O
This acid pyro si s mu st not however be co nfou n ded
with that form of pyro si s or water bras h i n whi ch
the fl uid poured out is n eutral or alka lin e an d which is
probably derived from exce ss ive s e cretio n by the salivary
glan ds B oth form s of pyro s is however may be prese nt
togeth er the patie nt complainin g of the dis ch a rge of
watery fluid at o n e time a n d of acid at an other
The rea ctio n of the uri ne too exhibits difi erent cha
In acidi ty aris in g from
ra cters i n the two co n ditio n s
fermentative chan ges the n atur al reactio n of the urin e
is d imi ni shed or may even b ecome a lkalin e with a te n
deney to depo sit oxalate s or pho spha te s In hyp er
s ecretio n however the general ch a racter of the twe n ty
four hour s urin e is to increa s ed a cidity and the deposi
tio n of uric acid an d u ra tes If however, i ndividu al
s ample s of the ur in e be ex amin ed it will be fou n d tha t
great variatio n s in the rea ction ta ke s place withi n short
period s of time— the urine at on e time bein g in te n sely
acid an d at an other neutra l or alka lin e the latter con
ditio n bein g frequently a ccompan ied by co n siderable
diure si s Thu s i n a lady who snfi ers severely from
attack s of megrim a ccompa nied by the vomiti n g of a
glairy acid flui d I h a ve freque ntly n oticed afte r an
atta ck ha s j u st pas s ed off the urin e to be W
e an d
depo sit pho sph a tes whilst urin e s ecreted be fore an d
durin g the attack s will be highl y acid an d turbid with
urates Similarly i n a gentlema n who su flers from
frequent attack s of paroxy smal scia tica each attack la st
i n g from two to three hour s a simila r variatio n in the
reactio n of the urin e is frequently n otice d I t h a s
already been ob se rved tha t irregular s ecretion of the
ga stric j uice is very re a dily excited i n children (p 28)
s o we al so fin d the reactio n of their uri n e u n dergoe s
frequent chan ges i n the character of its reaction, eve n
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32
A0 11) n r sr nrsm
”
disappears an d the patient alway s looks biliou s
In
thi s form of biliou sn ess the liver is probably n ot con
cern ed The copiou s di scharge of bile doe s not aris e
from its excessive s ecretion but simply from the empty
in g of the gall bladder in duced by freque nt vom iting
the s allown ess or slight j aun dice bein g the re sult of
duoden al catarrh excite d p artly by the acid an d partly
by the stra inin g in the act of retchin g
I n formin g a n opin io n a s to which form of acidity we
have to deal with in a give n ca se we mu st remember
that th e o n e is very likely to pro duce the other Thu s
if irritatio n cau sed by hyper s ecretio n is lo n g co ntin u ed
co ndi tions aris e which, by impedin g the dige stio n of foo d
favour fermentative chan ges ; i ndeed the over acidity of
the gastric jui ce it self issuffi cie nt to arre st the digestio n"
of a lbumin ou s su b tan ces whil st the irritation c a u sed
by the frequent pourin g out of a highly acid secretion
a n d th e pre s ence of un dige s te d a lbumi nou s fo o d produce s
at len gth catarrh of the mucou s membrane of s tomach
o n e of the most potent factors in the productio n of
fermen tative dyspepsia O n the other han d if the
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d or n eu tralisa tion a rrests
ca n be sh o w n b
th e
y a v e ry s im p l e ex
Place som e fin ely m in ced m u scl e or b oil e d fibrin a bou t
p erim en t
a s m u ch a s w ill lie on a th ree p en n y p ie ce in th ree te s t tu b e s a b 0
F ill e a ch tu be two th ir ds fu ll o f a rtificia l gastric j u ice
p er c e n t
A dd to a a f ew drops of s tron g hy d roch lor ic a cid N e u
acid ity )
tralise b with sod iu m carb on a t e sol u tion 1 per ce nt L ea v e c u na l
te re d Plac e the th ree tubes in wa ter b oth at te m p 40 C ; d ig estion
will a lon e p roceed in test tu be a (N B — I f the m ixtu re in test
tu be a ac id ifi e d b y the add ition o f h y droch loric acid be d il u te d w ith
w a ter a n d if the con tents of te st tu be 6 be a ga in re n d ere d of th e
sa m e a cidity th ey w ere befo re n e u tra l isa tion dige stion w ill p ro cee d
sh ow in g d ig e stion h as only been a rre ste d not d e str oy e d b
y the pre
s en ce of too m u ch acid or b y n e u tra l isa tion )
Th a t the pre sen ce of too m
a ction of the gastr ic j u ice
h
a ci
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A C I D D YSPEP S I A
33
acidity i n the firs t i nst a nce is due to ferme ntative
cha nges brought abou t by impeded digestion hyper
s ecretio n of ga stric j uice will at last often be ev oked
from the disturbance of the n erve centre s of the stoma ch
produced by the irritation of the products of ferm en
tative chan ge
I n thes e mixed cas e s it is often very
diffi cult to decide which is the origina tin g con dition a
point however which it is imp ortant to dete rmi ne if we
wish to do more than pa lliate the more urgen t symptom s
We s hould th erefore in a ll case s determin e the na ture
of the acid pre sent in the vo mit This can be do n e
either by chemic a l a n a ly sis a len gthy an d tediou s
process or by ha vin g recours e to R i chet s method of
s epar a tin g the a cid s by ether a n d determin in g their cc
e ffi cien t of p a rtage
If thi s is high we may be sure that
hydrochloric a cid is p red omin a n t if low tha t the a cidity
is due to the pre s en ce o f organic acid s
If the p a tien t
d oe s n ot vomit or a t the mo s t is o nly troubled with sou r
ri s in gs the acidity is proba bly chiefly ca u sed by ferm en
ta tive chan ge s
F or the relief of the pain an d vomitin g which re s ult
from the acidity of hyper se cretio n opium or m op hia a re
the chief remedies When the dis order s eems to a ri s e
from direct irrita tio n of the n erve centre s of the stoma ch
it s elf four or fi ve drop s of liquor opii or a n equal qua n tity
of liquor mo rphi as a dmin i stered with bi smuth o n a n
empty stomach genera lly s uc ceeds in calmin g an d
regula tin g the dige stive fu n ction s before many do ses
Wh en the dis turba n ce is the re s ult of
a re taken
reflex irrita tion an in j ectio n of m o rphia (gth gra in) is
more effica ciou s tha n the a dmini stra tion of the drug by
the mouth Wh en the hyper secretion seem s to depen d
upo n the a ccumulati on of a cid in the sy stem a gouty
malaria &c morphia or opium s hould be give n
state
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34
AC I D D YS PEP S I A
check the immediate urge n cy of the symptom s whil s t
appropriate step s shoul d be ta ke n to relieve the system
of the ca u se of the disturba nce In the vomitin g of
pregnancy R in ger “ reco m men ds the admini stra tio n of
drop do ses of ipecacuanha win e every hour or three
time s a d a y Ipecac uanha too he rem a rk s is s o me
ti m es effective in checkin g the vom i tin g from ca ncer of
the stom ach a n d succeed s sometim es after more com
mouly u sed remedies ha ve failed Tincture of bella
donn a in twenty drop do se s three tim e s a day h a s al s o
bee n foun d ervicea b le in the vomitin g of pregnan cy
Liquo r a rsen ica lis i n d r o p d os e s o n a n empty stomach
often prove s very s erviceable in the late vomitin g of
phthi sis I n a patient of min e i n whom it wa s tried
after other re m edi es had fa iled the relief that speedily
followed its admin i st ra tion wa s very marked O xide
of zi nc oxa la te of ceri um an d n itro glycerin e a re
remedi e s o ften u sed in sympathetic vomitin g their
action however is un certa in ; whe n admini stered they
m a
y be adva nt ag eously combi n ed with bella d onn a
The a p plica tion of a mustard plaster over the epi
ga striu m h a s often a m a gical effe ct in stoppin g the
retchin g a n d vomitin g When the exce ss ive or irregula r
i c juice seem s to depe n d o n min or
s e creti on of g a str
forms of nervo us di tu rb a n ce such a s the exhau stio n
dependent o n overw ork hy steria &c great bene fit will
often be deri ved from the u se of the douche especially of
s e a w a ter or a cou r se of brin e b a ths a t D roitwitch or a t
Soden
The application of a cold compres s at ni ght
over the a bdome n ha s also a wo nderfu l e ifect in regu
latin g an d calmin g function al di sturbance both of the
st om a ch a n d liver
The diet s ho uld be nutriti o u s ea sy
of dige stion ; an indi gestible meal or even a s in gle tough
*9
H an db ook of Th era p e u tic s
E ighth E d ition p 40 9 1 880
to
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A C ID
35
n r s r nr s m
mor sel ofte n excitin g a s evere attack of pain an d
vom itin g The interval s between the meal s should not
be too prolonged nor should the stomach be over
loaded a t any meal A little food should be taken the
la st thin g at nig ht an d immedia tely o n wa kin g i n the
morning A lcohol a n d coffee a s articles of diet are to
be a voided though iced champ a gn e with A pollin ari s
water or a cup of stron g coffee will often sta y the
when the v omitin g is severe C o nsiderable
st omach
be ne fi t is often obtain ed by the u se of alkalin e minera l
wa ters between the attacks by persons who snfler from
thi s form of acidity
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C H AP TER
111
D YS PEPS I A U SUALL Y A S S O C IA T E D WI TH A N EU T RAL 0 1
AL K AL I N E C O N DIT I O N O F UR I N E (FLA T U LE NT D Y S
'
As Frerich s“ h a s well ob s erved , though yea st
are continually bein g t a ken with the food a s in bad beer
or bread an d are thu s bro ught in co ntact with the
s accharin e an d a lbumi n ou s m a tters of the food which
are capable of fermentin g in the stomach fermentatio n
does not occur un les s an other co nditio n is added The
ferment must ha ve time a n d Opportun ity for developin g
itself Un der ordin ary circum stan ce s it is s o rapidly
removed from the s tomach t ogether with fermen table
materi al that the proce ss ha s n o time to comme nce
The condition s therefore tha t fa vour the developme nt
of fermenta tion a re tho se whic h retard diges tio n
either by mecha nically obs tructin g the on ward pas sage
of the food or from a n a bn orma l co nditio n of the
dige stive s ecretions or the in digest ible n a ture of the
food it self From experi m ents we learn that un der
norma l circumsta nc es the gas es fou nd in the stomach
co nsist of oxygen n itrogen a n d carbonic acid, but n o
hydrogen which we would exp e ct to fi n d if the gas e s of
the s tomach i n health were formed by lac tic ac id ferm en
Med Tim es a n d Ga zette 1 8 61 vol ii
R ep Clin
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F LA TU LEN T DYSPEP SIA
37
It is probable therefore that of the gas e s
obtained from the stomach un der n ormal con dition s
the first two are derived from the air swallo wed with
the food whilst the latter is derived by diff u sio n from
the blood I n the small in testin e however acetic a n d
lactic acid ferme n tation commen ces a s is shown by the
prepon deran ce of carbon ic a cid gas a n d the pre s e n ce of
h y droge n fi“ The steps that occur in thi s process of
fermen tation are well shown in the followin g table
t ake n from Professor E wald s work on D ige stion
ta tion
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0 6H 120 6 S u ga r
2 (C ZH GO) A lcohol
O
C ZH SO
hyd e)
C 2H 4O O
20 0 2
.
2 (0 3H 60 3) L a ctic A cid
.
OZK 4O (Ald e
11 20 0 411 8 0 2
20 0 2
.
H4
(B u tyric A cid)
0 211 40 (A cetic
A cid)
.
The occurren ce of this lactic a n d butyric acid fer
men tation in the small in te stin es i n health s uggests a
wa y in which the carbo hy drate con stituen ts of the food
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-
The foll owin g
ta b le g ives th e result of Pl an er s analy si s of
Wi en er
th e g ases of stom ach a n d s m a ll i n t e sti ne resp e ctively
Sitn er Ma the m n a tu rwiss C l a sse B d x l ii
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St
S
om a ch .
m all in tes tin e.
Ga s
Me t
B
Meat
co2
25 -2 0
32 -9 1
40 1
686 8
663 0
.
a
.
0
H
read .
'
Nil
79
N il
.
-
Trace
V g t bl di t
e e a
e
e
.
38
F LAT ULEN T
DYSPEPSIA
may become con verted into fat ; for by this lactic a n d
butyric acid fermen tation the sugar is con verted in to
members of the fatty acid s eries The exten t however
to which thi s fermen tation is c arrie d in health is
probably small sin ce if it occurred largely in the in tes
tin e we should a s Professor F o ster " ob s erves have a
large quan tity of free hydroge n excreted by the lun gs
which is n ot the cas e The ferme ntative
or bowels
chan ge s reach their highe st poin t in the large i n te s tine
in spite of
s o much s o a s to ren der its con te n ts acid
the alkalin e chara cter of the secretion from it wall s
H ere in addition to hydrogen we have a c o n siderable
quan tity of marsh gas (OH4) developed with sul
h
u rette d hydrogen (H 28 ) from the de c ompositio n of
p
the albumin ous a n d other sul phu r yieldin g elem e n t s o f
the food
In diseas e however exce s sive fermentative chan ge s
of the food may occur leadin g to the production of
en ormous quan titie s of gas a n d the formation o f various
in termedi ate products as we have seen s uch a s alcohol
aldehyde a n d acetic acid on the on e han d a n d of lactic
S ometimes it is a large
a n d butyric acid on the other
quan tity of gas that is formed at an other time a n
exce s s of a cid Thus E wald l sp eak s of a patien t wh o
pithily observed that there wa s sometimes a vin egar
factory a n d s ometimes a gas work s in hi s in s ide
in
fact at on e time alcoholic fermen tation led to the
formation of a cetic acid at an other the butyric acid
fermen tation produced hydrogen a n d carbon ic acid It
is often diffi cult to distin guish clin ically betwee n the
difl eren t form s of fla tu len t disten sion which a rise
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Text B ook of Physiol ogy p 242
1 L ectu res on Di g estion Prof C
Will i am s Norgate
D r R S a u n d by
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M
A
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i ll an C o
E wald Transla ted
a cm
1 8 81
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by
F LA T U LEN T DYSPEPSIA
so that food remain s un dige sted for a con s iderable
time A s aton ic d y pep sia is the mo st frequen t of all
form s of in digestion so it is the most easily recogn ised
The broad flabby ton g u e thin ly covered with white
fu r with its edges in den ted by the pres s ure of the
teeth ; the feeble action of the heart the lo s s of
appetite a n d f eelin g of weight a n d di sten s io n h a rdlv
ever amountin g to act u al pain ge n erall y referred to
the che st rather than the epigastrium a n d experien ced
the s our ri s in gs a n d er u cta
s hortly after takin g f ood
tion s from the stomach occurrin g from two to three
hour s after a meal whil st fla tu len t disten s ion of the
bow els is more or les s con stan tly presen t givin g ri s e to
tightn ess a n d sore n e s s o v er the
s e n satio n s of weight
w hole abdomen but m ore especial l y distre s sin g in the
right a n d left hyp ochon d riac regio n s form a collection
of s ymptom s w ith w hich we are o n ly too familiar
C on dition s of the n ervou s sy stem a s is well kn o wn
have a powerful in fluen ce on the dige stive process It
is theref ore n ot s urpris i n g to fin d whe n in n ervatio n is
impaired that dyspepsia frequen tly results I n some
in stan ces n ervou s disturba n ce has te n s the pas s age of
alimen t through the in te stin e s so that in thi s form of
dyspep s ia we have diarrhoea s hortly after food in stead
of acid eructatio n s flatulen ce a n d vomitin g I n the
maj ority of cas e s however the proces s of digestion is
re tarded a n d fermen tative chan ge s en sue A s a rule
the fla tu len t dy s pep sia ari sin g from n e rvo u s in fluen ce s
is les s pron oun ced a n d more variable than in ato ni c
dyspepsia though if the dis turban ce be lon g co n tin ued
e specially if caus ed by exhau stion from un due me n tal
strain or depre s sin g moral in fluen ces a co n dition of
ge n eral debility will in ti m e be in duced A poin t of
interest to be observed in the dyspepsias arisin g directly
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41
F LATU LEN T DYSPEPSIA
from disturban ce of the n ervous system is the rapidity
with which the ton gue of te n be comes coated wi th den se
fur a n d a s rapidly clean s on the subsiden ce of the
excitin g cause Flatulen t di sten s ion of the stomach
a n d in te s tin e s ofte n arise in n ervous state s of the s y stem
apparen tly quite in depen de n tly of a n y ferm en tative
chan ge s o ccurrin g in the alime n tary can al In deed it
is quite impo ss ible to accoun t for the en ormous quan tity
of
ga s which con sists largely of carbon ic acid often
di s charged through the mouth on a perfectly empty
stomach by hys terical a n d hypochon driacal patien ts
except on the suppo s ition that it is d iffu sed from the
blood C ertain n euro se s of the v aso motor s yste m leadin g
to udden in creas e of the salivary gastric a n d in testin al
s e cretio n s w hi ch are di s charged by vomitin g a n d purg
in g mu s t n ot be con foun ded with acid eructation s a n d
yeasty diarrhoea re sultin g from fermen tative chan ge s of
S u ch discharge s are observed in the cris es
th e food
ga s triqu es w hich are a ss o ciated w ith ataxic phe n omen a
in which the fluid the
a n d in p yros is or water bra s h
reaction of which is n eutra l or alkalin e is poured ou t
by the s alivary glan ds or from the mucous surface of
the sto m ach probably both
A s a rule however
dys pep sias ari sin g from di sturban ces of the n e rvous
system are depen den t ge n erally o n a co n ditio n of hyper
s ecretio n a n d the ferme n tat ive chan ge s arise secon darily
ou t of that con ditio n
I n organ ic d i s eas e of th e stomach acid fermentatio n
is always pre s en t in greater or les s degree a ccordin g to
the situation of the le sion T hu s in di seas e a flectin g
the body or cardiac en d of the organ the food may be
retur n ed so quickly that ferm en tati v e chan ge s have n ot
tim e to take place whilst in cas e s where the ob structio n
exists at the pyloric orifice the most s evere forms of the
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42
FLAT ULEN T DYSPEPSI A
affectio n are met with a n d the quan tity of a cid matters
returned from the sto m ach are often e normous Thus ,
i" relates a ca s e of a w om an sufferin g from
u
i
nc
k
e
Q
dilatation of the stoma ch the re su lt of stricture of the
pylorus, i n whom the stron g acid vomit amounte d to
3000 cc (about 5 pin t s ) in the twen ty four hours
In
ca tarrh al state s of the sto m ach whils t the process of
digestion is impeded by the scan ty se cretion of the
gastric juice an unh ealthy mucus is pour ed out whi ch
rapidly decompose s a n d its elf un dergoin g ferme ntative
changes , a n d which is often ejected from th e stom ach
This however must be distin guis hed from the insipid
fluid retched up in the morn in g in c atarrhal co nditio n s
Thi s fluid a s Frerichs h as
resultin g from alcoh ol
shown is n ot formed in the s tomach but is due to the
in creased secretion from the salivary glan ds an d the
s aliva swallowed durin g the n ight is simply hawked up
i n the morn in g , con verted how ever in to s trin gy ma sses
by the action of the acetic acid formed by fermentatio n
A n other cause
on the muci n co n tain ed in the sali v a
giving rise to fermen tative ch an ges is a n a n omalous
co n ditio n of the digestive se cretion s Thus in the ca se of
the g astric j uice , it h as be en shown that too much acid
though it hin ders lactic acid f erm en tatio n furth ers the
developmen t of yeast fun gi an d alcoholic a n d acetic acid
ferm e n tation
F ermen tative chan ges m ay als o com
men ce in the m on th ; this u sually depe nds upo n an acid
fermentation of the bucca l an d oral mucu s , but in some
cases appe ars to be due to actu al acidity of the p arotid
s aliva ? The influen ce tha t di min ution or i n cre ase in
the s ecretion of s aliva has on the gen eral health cann ot
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“
Correspon den zb latt f sc h we i z A erste, ’ 1 8 74 , Ja h rg 4, No 1
1 Astu sch a wsky, R ea ction d es Pa roti s S p ei chel b ei gesam den
Menschen ” ‘ Cen tralbla tt f d Me d
1 8 78, 25 7
at
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DYSPEPSIA
F L ATU L E N T
be stated with certainty but if a it ha s bee n stated
the alk alin e saliva is a po werful stimuli for the secre
tio n of the gastric j uice then a de fi cien cy in its quantity
or perversion i n its quality a n d its re a ction are prob ably
n ot without i n fl u e n ce o n the s ecretion of the latter flui d
whilst such alteratio n s must result in imperfect con
version of the amylaceou s prin ciples in to sugar an d
thus lead to acidity an d flatu len ce B ile exercises an u n
doub te d an ti ferme ntative actio n whilst also it in duces
i n crea sed peri stalsis of the in testinal wall s D iminution
of the secretio n would therefore allow ferme n tative
chan ges to take place more readily than would be other
wise the c ase D ogs in whom biliary fi stula ha ve bee n
established pass much oflen sive fla tu s The cfi ect that
di se ase of the pan crea s or deran geme nt of its secretio n
ha s i n the productio n of di s orders con n ecte d with
digestio n has yet to be studied ; there ca n be n o doubt
however tha t a ny distu rb a n ce of secretion of a n organ
which ha such a powerful a ction o n starch fats an d
albumin s mu s t make itself felt There is o ne point
however co n cernin g the p an cre atic juice we must n otice
a n d th at is its prolo n ged actio n on albumin ous matters
leads to the formation of putrefactive products Thus
tryps in by its actio n on albumin ous matte rs co nverts
them i nto two forms of pepto n e— anti pepto ne an d
hem i pe pton e *
The former un dergoes n o further
change but the other after a longeror shorter time
breaks up in to other bodie s such as leucin a n d tyrosin
& c a n d by prolo nged action i n n eutral or feebly
alk aline so lution s into ammon ia sulphuret ted hydrogen
hydro gen an d carbonic ac id S o tha t if the peptones
are retain ed for too lon g a time unabsorbed in the
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it
Kii hn e
H eidelb
.
,
u nd
Lea,
“
U be
e
Na tural Med ic
.
r
d ie A bson deru n g
Verha n dlu
n
g
en,
’
i
,
H ft 5
.
d es
.
Pan creas
.
”
44
F LA TU LEN T
n x s rn r s m
upper part of the s mall inte s tin es flatulen ce ma y
be cau sed by the contin u ed actio n of the pan creatic
j uice
A mon g the cause s leadin g to fermen tative chan ges
must be men tion ed the di et of the in dividua l In
man y case s food is taken in such exce ss that it is n ot
ab sorbed a n d it then un dergoes putrefactive chan ges
in the alimen tary can al
A s much as thirty poun d s
of a half putrid ma ss has bee n got rid of by purgative s
P arkes in stan ces a case of thi s kin d a s oc currin g a m on g
s ome co n victs in A ustralia wh o received from s eve n a n d
a quarter to s even a n d a ha l f poun d s of f ood daily ;
dy spepsia ob stin ate con stipation d iarrhoea skin dis
ease s a n d Ophthalmia were the re sult That a too
free con sumption of saccha rin e a n d amylaceo u s article s
of diet will i n duce thi s form of dy pep sia there ca n be
n o doubt sin ce s im ple ab stin e nc e from such articles o f
diet is often suffi cien t to remove the dis order Milk
c on tain in g as it doe s the very eleme n t for lactic acid
f ermen tation is a frequen t ca u s e of this form of
dy spep sia In ordin ate te a drin ker s al s o su fler greatly
from flatu len t dy spepsia ; thi s is caused partly by its
in fluen ce through the n er v ous system o n dige stio n
partly by the dilution of the digestive secretion s by a n
in ge stion of a n over abun danc e of fluid by the a ction
of its tann in o n the albumi n ous prin ciple s a n d
lastly
though n ot lea st by its bein g a vehicle for a con siderable
quan tity of milk a n d sugar A lcoho l likewise by
in ducin g ga stri c c atarrh is on e of the mo s t active
f actor s in the production of thi s for m of dyspepsi a
F ood of a bad quality itself un dergoing ferme n tative
chan ges at the time of in gestion s uch a s bad bread
bad beer an d the like in troduced into the stomach is a
cause n ot to be overlooked Whilst in relatio n to food
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F LA TU LEN T DYSPEPSIA
45
we must in sist upon its u fli cien t mastication a n d upon
regular a n d well arran ged m eal times A su flicien t
tim e bein g allowed between each meal for its proper
digestion but n ot so far prolon ged a s to in duce exha u s
tion L astly climate is a n importan t con sideratio n in
these cas e s patien t suff erin g from fla tu len t dyspep sia
bein g greatly ben e fited b y re siden ce on dry soi l a n d in
s heltered s ituation s
Thus Prout h a s observed that
certain seas on s a n d certain malarious district s more
than others aggravate the ten den cy tow ard s s accharin e
mal assimil ation probably by the in duction of a catar
rhal state of the dige stive organ s S ome of the mos t
sev ere an d ob stin ate form s of this disorder I have met
with have been in patien t s who have resided in malarious
d istricts an d at s ome time or other have s n fi ered from
its in fluen ce
S in ce fermen tative chan ge s give rise to the develop
men t of fla tu s a n d acid the disturban ce s we m eet with
in thi s form of dyspepsia are caused by the presen ce of
the s e abn orma l product s of dige stion a n d the effort s
made to expel them I n the m aj ori ty of in stan ce s
almost immediately on takin g food a sen se of w eight
Then the feelin g of weight
a n d fuln ess is experie n ced
is exch an ged for tearin g twi stin g s en s ation s a n d cramp
l ike colicky pain s S evere pain ho wever a n d te n dern e s s
on pre s sure are n ot c om p l ai n ed of u n l es s there is a l s o
organ ic di s eas e of the stom ach
The heartburn is
accompan ied by eructation s of ga s a n d risin gs of s ou r
acid fluid a n d un digested por tion s of food ; actual
vomitin g is rare except in cas es of pyloric ob struction
S o great occa sion ally is the acidity of the s e regurgitated
matters that they set the teeth on edge like the
sharpe st lemo n j uice a n d as Trou s seau observe s wi l l
often cover copper vessels in to which they are placed with
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F LA T ULEN T DYSPEPSI A
4-6
a coatin g o f lactate or acetate of copper In o rdin ary
cases of flatu lent dyspep sia the ga s is u sua lly carbo n ic
acid , an d the sour ri s in gs will be foun d to contai n both
la ctic and ace tic ac id on e or other predomin atin g
In severe cases
accordin g to the n ature of the ca s e
of catarrh especially when much un w holes ome mucus
is secreted by the walls of th e s tomach, the lactic acid
fermentation is carried on to the productio n of butyric
acid which be in g vola tile imparts its peculia r r an cid
odour to the breath ; this is particu larly n oticeable in
Inter
th e ca ta rrh al con dition in d u ce d by alcoholism
mediate products of acetic a cid fermen tatio n are also
frequently foun d i n the ej ected matters , such a s alcoho l ,
aldehyde an d ace ton e I n the cas es in which these
products are observed a n algoid growth kn ow n by the
name of sa rcin a is ge nerally met w ith This growth ,
however, has n o eff ect in producin g those abn orm al
decomp osition s of the con ten ts of the stom a ch , an d its
presen ce merely in dicate s th at con ditio n s f avorable for
its development exists in the stoma ch
The disturban ces caused by fermen tative chan ges i n
the stom ac h are n ot lim ite d to tha t orga n The a cid
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products formed in it together with the u n digested
residue of th e food pa s s o n in t o the in testin es an d
excites m ore or le s s pain an d diarrhoea A gain fer
m en ta tive ch an ges m a y o ccur chiefly in the intestine s
an d only a slight de gree in the stom a c h I n thi s ca se
which is as socia ted with a greater or less degree of
chronic i ntestina l catarrh a con stipated conditio n of
the b owels generally exis ts ; for though there m ay be
freque nt loo se , slimy an d ofi en sive di s charges from th e
bowels yet a purge n ever fails to brin g away a ccu m u
la ted masses of faaca l matter The whole of the intes
tin al tra ct may be affecte d or o nly p art of it
S o me
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48
FLATU LEN T DYSPEPSI A
a persis tent dcposit of oxa lates as sociated with peculia r
train of n ervous symptoms is ge nerally met with
C
h
a
pter
This
co
n ditio n of dimin ished a cidity
V
see
(
)
of the urin e cann ot I think be a ccoun ted for by D r
B en ce Jon es s“ hypothes is that w hen the conte nts of
the stom a ch are mo st acid the re a ction of the u rin e is
least a cid becaus e in these cases the acid is n ot with
drawn from the system bu t is formed in the stom a ch
itself Nor can I acce pt Dr R oberts s view e n dorse d by
D r W ilson Fox that the alk a l in ity is due to the a dditio n
to the blood of the alk aline ba s e s of the food sin ce in
these ca ses there is n o eviden ce that more food cont ai n
in g alk aline bases is either in gested or absorbed tha n
I n deed so far from there bein g
in a he althy con dition
any evidence tha t more s olid matters are pa ssin g in to
the system the Opposite is gen erally observed O n e
poin t that I have n oticed with regard t o these urin es is ,
that they eflervesce stron gly o n addition of a cetic or
nitric acid den otin g the pre s en ce of carbo n ates These
carbonates are tho s e of the fixed a l kalies p ota sh an d
soda sin ce the blue reaction given to red litmus p aper
is persis te nt an d n ot e v an e s cen t as would be the ca e
if alkalescence was cau s ed by ammon ium c arbon ate
The alk aline co n di tion therefore of the urin e i n ca ses
of flatulent dy spepsia I believe to be due en tirely to
the excessive elim in ation of the carbon ates of sod a an d
pota sh an d this exce s sive elim in atio n is brought about
by three co ndition s— (a ) gen eral debility an d the
feeble ness with which the re spiratory act is performed
le ad in g to the acc umulation of ca rbon ic acid in the
sy stem W ith regard to thi s poin t it is interestin g to
n ote that urin e alkalin e from the presen ce of carbonates
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0 n the Alka l es cence of
of
D iseased Stom a ch
”
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Ui
Med
r ne
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-
from
C hir
.
Fi x ed Alkal i in som e ca ses
vol x x xv p 4 1
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F LA T U LEN T DYSPEPSIA
49
the fixed alkalies is fre q uently met with in patien ts
con vale s cin g from acute diseases
(b ) D imin i shed
which is the freque n t result of the
s ecretio n
of bile
d u ode n a l catarrh produced by the irritatio n of the acid
co n te n ts of the stomach b ein g poured i n to the in testin es
gives ri s e to a n accumulation of alkalin e carbon ates in
the b l ood the bile bein g the chief s ecretion by which
a lkali n e s alt s are removed from the body ; f or though a
por tion of them are un doubtedly reab s orbed into the
blood fro m the in te stin es a con siderable proportion of
them are dis charged with the fa ces
O bstr u ctio n
therefore to the dis charge of bile leads to their reten tio n
in the blood a n d con s equen tly bein g elimi n ated in
(c ) The acids formed
g reater quan tity by the kidn ey
by fermen tative chan ges bein g of the fatty a cid s erie s
these o n en terin g the sys tem are oxidised into carbon ic
a cid a n d thi s u n iti n g with the base s of the alkali n e
o x ides form carbo n ate s of these bodie s an d by in crea s in g
the alkale sce n ce of the blood will dimin is h the n atural
acidi ty of the urin e a n d eve n re n der it alkalin e
The irridescen t film con si stin g of crysta l s of ammo
n ium magn e s ium phosphate ofte n f oun d on the surface
of uri n e of pers o n s su ffe ri n g f rom fla tu le n t dy s pepsia
is due apparen tly to the pass age o f urin e alk ali n e from
fi xed alka l i i n to a dirty chamber pot a n d h a s n o
F or if we take a sample of
s pecial clin ical sig n ifican ce
n orma l urin e of acid reac tio n a n d di vide it in to two
portio n s a n d place them both i n beaker each of which
co n tain s a drop of stale urin e a n d then re n der the
portio n in on e of the beakers alka l in e with liquor
p ota s sae ureal decomposition will s et in very much
e arlier in the beaker co n tain in g the alkali s ed urin e than
in the o n e permitted to retai n its n ormal acid reaction
a n d cry stal s of triple phosphate speedily for m
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4
FLAT U LE N T D YS P E P S I A
50
Ca ses
f fla tu len t
o
dy sp ep sia
con dition of
CA S E 1 — A
m
a lka lin e
with
a ssocia ted
i n es
.
gentleman a ged 60 cons ulted me durin g
He
D r Murchiso n s a b s en ce fro m town (Augu st,
s tated that durin g the pa st four mo n ths he had lo st
fl e sh an d had s u ffered cons iderably from mu scular
p ain s especia lly in the thigh with a sen se of inde
G ene ra l ap pearan ce worn ; com
s cribable wea rin es s
plexio n sallow ; con jun cti v a; slightly yellow C omplai n s
of palpitatio n of the heart an d shortn ess of bre ath
B owel s co n stipated much fla tul en t disten sio n ; troubled
with frequent micturition a n d is frequen tly awoke
early in the morni n g for this purpose P hy s ical exa m i
natio n elicited that there wa s n o disea se of the he art
a n d lun gs The liver wa s of n ormal dime n sio n an d
there wa s n o pain in the epigas tric or right hypo
The u rin e wa s clear slightly acid
chon dria c regio n
whe n pa ssed but became alkalin e o n bo ilin g an d threw
down a filmy cloud of pho sphates whi ch redi solved
with co nsiderable e flerve scen ce o n the a ddition of dilu te
acetic acid The sp ecifi c gravity wa s n orm al 1020 n o
albumen n o sugar a n d there was n o exce s s of either
alk alin e or earthy pho s phate s nor a ny tra ce of ammonia
The alkale s cen ce was thu s s olely d u e to the pre sen ce of
carbon ate s of potas h a n d s oda H e wa s ordered two
drachm dos es of C arl sbad s alts twice a week an d to
take a mixture con ta in in g ten drop s each of dilute
hydrochloric acid an d tin cture of nux vomica
On
A ugu st 23rd he called a n d s a id that s hortly after com
He
m en cin g the treatme n t he began to feel better
h a s lo st the wo rn expres sion of counte n an ce an d his
The sens e of we a rin e ss backache ,
com plexion is cle a rer
an d mu scular pain have di sappeared an d he ha s regain ed
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F LAT UL E NT
51
nx srnrsra
ome of his lo st weight H is urin e is n ormal i n all
respects an d the te n den cy to frequent micturitio n h a s
quite sub sided H e c o n sider s him s elf quite well
A dvi s ed him to co ntin ue the u se of the C arl s bad salts
for s ome time lon ger but to leave 0 1? the acid mix ture
Sa w him four years afterward s he had been free fro m
the symptoms ever si nce
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C A SE 2 — A
lady aged thirty six the wife of a school
master H a s lately been v ery anxiou s about her hu s
ban d s health a n d that of her on ly c hild H a s lo st
fl es h co n siderably of late Su fi ers much from mu s cular
pain an d e sp ecially in the legs ; much b a ckache
B owel s co ns tipa ted ; suffer s much fro m fla tulen ce
Worn anxiou s a ppearance ; complexio n sallo w bu t
conj un ctiva clea r N o enla rgeme nt or te ndern es s in
the epi gastric or right hyp ochondria c region H eart
a n d lun gs hea lthy Urin e n eutral in reactio n ; the
quantity pa ssed in twenty four hours amounts to 800
centime tre s ; specific gra vity 1 020
The phos phoric
acid a bout n ormal in quantity bein g 2 2 gra mme ;
uric acid
gra mme N o a mmonia present There
P ho spha te s were thrown
wa s n o sugar ; n o a lbume n
down on boilin g but were redissolved with vio lent
The
eflerve s cence by the ad d itio n of dilute acetic acid
patien t wa s ordered two dr a chm do s e s twice a week of
C arl s bad s alt s and a mi xture con tain in g te n mi n im do ses
of dilute hydrochloric acid a n d tincture of nux vom i ca
The p a tient improved ma teria lly un der this treatment
but not so rapid l y a did C a s e 1 I t wa s not till she
wa s able to lea ve home with its cares a n d an xieties for a
while tha t the im provement in her con ditio n bec a me
perman ent
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C A S E 3 — A C ambridge graduate,
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a
ged thirty
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five,
52
FLA T ULE N T
n x srnrs m
fellow of his college wh o for s ome mo nths previously
had been e n ga ged i n arduou s mathematical studies
H a d su ffered for six weeks from despon den cy a n d a
s e ns e of i n de scribable wearin e ss backache a n d mu s cular
pains chiefly i n the legs H a s lo s t fl esh B owel s co n
flatulen ce M icturitio n
s tip a te d ; s uffers much from
frequen t is rou s ed ofte n in the night time to pas s water
Fears that he is s ufferin g fro m diabete s
O n phy sical
exam in atio n his orga n s w ere foun d hea lthy
Urin e
n ormal i n a ppeara nce slightly a lkali n e i n reactio n
throwin g down o n boilin g a clo ud of phosphate s which
cleared up with con s iderable efferve s cen ce o n the additio n
of dilute acid P ho s phoric ac id n or m al i n qua ntity
N o c a rbo n ate of ammo nia
N o albumen n o s u ga r
O rdered two dra chms of C a rlsb a d salt s two morni n g s
i n the week and a mix tu re with ten min im do es of
dilute hydrochloric acid a nd n ux vomica In three
wee k s time he reported him s elf quite well
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C A S E 4s — A
gentleman aged sixty whom I saw durin g
D r Mu rchiso n s ab se n ce from to wn H a d spent m an y
years of his life i n I ndia in a C ivil Service appointmen t
H a s lately bee n lo s i n g flesh an d s uff erin g much from
weari n ess with mu s cu la r pain s in limbs B owel s can
s tip a ted
with co ns iderable fla tu lence
S allow co m
plexio n micturitio n frequent U rin e alka lin e ; phos
pha tes norm al no suga r n o albumen n o carbo n ate of
ammo nia O n boili ng the uri n e dep o sited pho sphate s
which cleared up with eflervescen ce on the addition of
d ilute hydrochloric acid O rdered C arlsbad alts a n d
a mixture with d ilute hydrochloric acid and n ux
vomica A fortnight afterwa rd s he reported hims elf a s
much better an d i n a mo nth he wrote to say he wa s
quite well
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FLA T ULE NT
53
n r srnrs m
I have al so n oticed s imilar conditions in six other
ca se s but as they all prese n t the same features it is
u nneces sary to quote them in detail There wa s los
of weight wea rin e s co n stipation , fl atulen ce, freque nt
mictu rition more or le s s sallowne s s of complexion
Urin e a lkali n e , n eutral or fa in tly i a cid , efierve scin g o n
the a dditio n of dilute acid with n o increased elimina tio n
of pho sphates nor any tra ce of a mmo nia or ammo n ium
carbonate They all rapidly im proved un der the sa me
trea tment
I n the ten ca se s un der my ob s ervatio n the alkales ce n ce
of the uri ne was clea rly due to the pre sen ce in exces s of
the carbon ates of soda an d potas h, an d to n o other
c a u s e since the blue colour on the litmu s paper rem a in ed
perm a nent an d ther e wa s n o a mmon iacal odour ; an d
the inf eren ce m a y fairly be dra wn that the dy speptic
s y m pto m s, i n the ab s e n ce of a n y other deter m in able
co ndition, were conn ected with the pre sence of thes e sal t s
a b n orm al quan titie s in the blood
With regard to trea tme nt th e chief obj ect is to
prevent the decompos ition of the organ ic matte rs of the
food in the alim e ntary ca nal Thu s when the disorder
o ccur s in delicate peo ple with feeble digestio ns we
e ndeavour by stimula tin g the ga s tric secretio n an d b y
givin g to n e to the mu s cular wall s of the digestive tract
to en s ure th e s olutio n of the albumin ou s co n stituen t s
a n d the o nward propul s io n of th e food ge n erally befo re
fermenta tive chan ge s can occur The former indica tio n
is probably be st e ff ected in the m a j ority of ca se s by the
a dmin i stratio n of an a lkali before meal s , s in ce C la ude
Bern ard ha s shown that s ma ll amounts of diluted
a lk al i in troduced in to the e m p ty s tomach will provoke a
di s cha rge of ga stric j uice more th an sufficient to
neutralis e it I n the cas e of liquor potassez it is
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F LA T ULE N T D YS PEP S I A
54
proba ble the alka li acts sim ply a s a direct stimulu s to
the m ucou s m embran e but when the a lkalin e bicar
b on a tes are take n in additio n to thi s a ctio n it is
probable they a dd to the a cidity of the sy stem bein g
themselves acid s alts and so improve the quality of the
ga stric secretio n
This actio n of the alkali n e bic a r
b on a tes is n ot however ba sed solely u po n a co nsidera
tion of their chemic a l con stitutio n but fro m the effe ct
their a dmini stra tio n h a s on the reaction of the urin e
Thus D r Be n ce Jon es in a p a pe r read before the R oya l
Society 1 850 showed co n clus ively from a s erie s o f
obs erva tion s that la rge do ses of s es quicarbo na te of
a mmo n ia n o t o n ly did not dimi n is h the acidity of the
u rine but actua lly i ncrease d it a s he fou n d that the
d a y whe n mo s t se s quicarbo n ate of a mm o n ia “ wa s ta ke n
th e a cidity was higher than it h a d b e en any p revious
day and that the a cidity wa s s till very high on the d a y
foll owin g its di sconti n uance F our years later a s imilar
obs erva tio n wa s made by D r W F B en eke lr with
regard to the efi e ct of bica rb ona te of s oda An d lastly
P rofe ssor P a rke s I in sta nce s a cas e of rheumatic fe v er
in which the acidity of the uri n e o n the d a y follo wi n g
the a dm inistra tion of bica rbon ate of potash wa s con
sid erab l
y higher tha n o n the day before it wa s take n
A s the que stion is of co n siderable imp o rta n ce wi th
regard to treatment e specia lly of tho s e affe ction s which
are under our consideration I will briefly give the
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l
d ca rbon ate I t con
ta in s the e l e m en ts of on e m ol e cu l e o f n or m a l ca rb ona te a n d two
B y e x p osu re to a ir it d ecom pos e s an d
m ol e cu l e s of a cid ca r b onate
is con v erte d w h olly into a c id c a rb on ate
1 A r ch iv d es Wisse n s ch a ftl ich e n H e il k u n d e 1 85 4 5 S tu d ie n
zu r Ur ol ogi e
p 44 4
I Com position of the Ur in e in H e al th a nd D is e as e p 2 9 7 1 8 60
S e sq u ica rbon ate
o f a m m on ia
is h a f
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FLAT ULE N T D Y S PEP S I A
56
of the urin e can b e be st a ccou nted for lies a s I have
alrea dy stated in their chem ica l con s titutio n the
a lk a lin e bicarbon ate s bein g a c id s a lt s
N o w the acid
rea ctio n of the u rin e is gen erally con sidered due to the
decompo sition tha t occur s between a n a cid or a n acid
s alt an d the n eutr a l ph osph a te of s odium i n the blo o d
acid so dium pho s phate bein g formed which pa s s e s out
with the urin e
N ow on e of the chief a cid sa lts of the blo o d is
undoubtedly bica rb onate of p ota s h or s oda an a cid sa lt
with a n alka lin e reaction The decompo sitio n which
re s ult s betwee n thes e two sa lts m a y be repre s en ted a s
follow s :
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d
N e u tr a
A ci
C a rb on a te
r
—
A
—
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fi
N a H ZC O3
l
Ph osph a te
-
r
N o rm
a
l
C a rb on a te
.
Acid
P h osph ate
.
—
A —
r
fi
N a 2H CO3
w
‘
N a zH PO4
We theref ore need n ot be
r
—A
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fi
N a H 2P 0 4
.
urpris ed to fin d the
admini stration of a n acid sa lt if it pa sse s una ltered
from the tom a ch into the blood cau sin g an in creas e i n
the a cid ity of the urin e A n d thi s is i n deed what
happen s when a do se of bica rbo nate of p otash a n d so da
is take n i nto the stomach before me a l s for then the
m ucou s membr a n e u n der n ormal co n ditio n s bein g either
n eutral or a lkalin e the bica rb on ate is ab sorbed n n d e
compo sed into the blood a n d ca u s e s that increa s e i n the
a cidity of the urin e whic h h a s bee n n oted
O n the
other h a n d when the sa lt is ta ken durin g dige s tio n
the acid conte nt s of the stoma ch decomp o s e it ca rbo nic
a cid is libera ted which e s cape s by the mo uth whil st
the alkalin e ba se s pa s s into th e system an d ren der it
a n d co n sequently the urin e more a lkalin e
With the alka li is gen era lly a s sociated som e vegetable
bitter N u x vomica or its alkaloid strych nia is the o n e
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FLA T ULE NT
57
n v s rnrsn
u sually selected servicea ble i n almo st every form of
in digestion it is particula rly v a luable in the fla tu len t
dy spep sia a ri sin g from a s ta te of gen eral weakn e s s an d
debility I ts extremely bitter ta ste excite s the ex cretion
of saliva an d thus a ids in the co nvers io n of the sta rchy
ma tter of the food It a ls o po s s e ss es anti s eptic p ro
B y its actio n through the n ervous s ys tem it
perties
gi v e s to n e to the mu scular wall s of the dige stive tra ct
an d thus en sures the on wa rd propul sion of the foo d
before fermentative cha n ge s o ccur
The increa s ed
mu scular co ntractility it imp a rts aids in overc omin g
the a tten da nt con stipation a n d i n exp ell in g flatu s N u x
vomica is u sually well h om e but it sometim es cau s es
head a che a n d a feelin g of fuln es s an d irritation i n the
sto m a ch
In this cas e c al umba may be advanta ge ou sly
u b stitu te d
Should there be much an m m ia ir on m u s t
b e given though it is generally tolerated with difficulty ;
the be s t way to admin ister it so a s to cau se the lea st
dis tu rban ce is in the form of s teel win e diluted w ith
wate r taken o n ce a da y a t dinn er time If the adm in is
tra tion of the alkali before meal s doe s n ot excite a
su ffi cie ncy of gas tric juice pep s in an d hydrochloric acid
The hydrochloric
should be admin i stered durin g meal
a cid should n ot however be give n i n too c o ncen tra ted
a form The strength of the acid s olutio n which i n
a rti fi cia l gastric dige s tion is fou n d to be m o st active
con ta i n s 0 2 per cent of rea l hydrochloric a cid This
degree of dilutio n ca n be obta in ed by pre s cribin g te n
drop s of the dilute acid of the P harm a copce ia to be ta ke n
i n two an d a half ounce s of wate r (an ordina ry win e
glas s)
When the dy spep sia a rises from n ervou s di sturba nce
an d there is little or n o debility a n d we have n o rea s on
to s uspect deficien cy of the ga stric secretio n acids take n
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F LA T U LEN T D Y S PEP S IA
58
e little time before meal s a re in dica ted C ombin ed
with n ux v omica they a re p a rticul a rly valu a ble in th os e
ca s e s when the p a tie nt h a s bee n lo n g in a depre s s ed
s tate h a s s u ffered mu ch fro m ca re a n d a n xiety or h a s
been o v er worked
E ither hydrochlori c ph o sphoric
a n d nitric acid s a re u su a lly a dmini s tered s ome ca s es
s eemin g to be m ore be n e fited by on e a cid th a n by
a n other
A ltho ugh ou r phy s io logic a l a n d chem ical
kn owledge re sp ec ti n g the a ctio n of acids wi thin the body
d o e s n ot e na ble u s a s yet to in dica te with precis ion the
c a s e s which w ill re ceive the most ben e fit from the admi
n istra tion of a n y s p eci a l acid o r gi v e a re a s o n for its
em ploymen t s till s peakin g broa dly we m ay sa y hydro
chloric a cid s eem s best suited to th a t cla s s o f ca s e s i n
which the dy s pep sia is a ssocia ted with a n a lkali n e or
feebly a cid sta te of the urin e un a tte nded with exec s
s ive d ep os iti o n o f p h o sp h a tes w hil s t p ho s p horic a cid
s hould be pre s cribed in th os e c a s e s where with a lk a li n e
urin e there is a tolerably con sta nt dep osit of pho spha te
of lime or triple phosph a te fi“ N itric or nitro muriatic
acid on the o ther h a n d s eem s mo st ben e fi cial in tho s e
c a ses in which the uri n e is ac id a n d h a s a te nde ncy to
depo sit oxal a te s an d ura tes or in whi ch s udde n a n d
freque nt chan ge s in its re a ctio n o ccur especia lly if the s e
depo s it s or chan ges are appa rently a s socia ted with a n y
di sturba n ce of th e hep a tic fun ctio n
C at a rrh of the stoma ch an d in testi ne s m a y be either
s om
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v a lu e of p h o sph oric a cid in th es e ca s es s ee m s to d e pen d
on th e f a ct th a t e q u a l q u an titie s o f p h osp h o r ic a cid h a v e a gre a t er
effe ct in ren d erin g th e u r in e a cid th an eith er hy d r och lor ic or n itric
p r oba b ly bec a u s e th e tw o l a tter com b in e w ith b a s e s to fo r m n eu tra l
sa l ts w h il st th e for m er a p p e a r s in th e u r in e a s a n a c id s a l t th e
restor ation of the n or m a l rea ction of the u rine in th is c as e pre
v en tin g the d eposition of ph ospha te s
The
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FLAT ULE NT D Y S PEP S I A
59
a ca u s e or con seque nce of ferment a tive dy spep s ia F or
the tre a tment of this conditio n nitrate of bis muth is
the m o st effi ca ciou s drug we po ssess It should be
given i n l a rge do ses (twenty to thirty gra in s) o n an
empty s tom a ch The powder is more effi ca ciou s than
the liquid preparation s It i well e specially if consti
p ation exi st s to give with it s mall do s e s of some ap erie n t
s a lt s uch a s s ulphate of magn e s ia or s ul ha te of so da
p
N itrate of pota sh i n fiv e grai n do se s may al so a d va n
ta ge ou sly be a dded to the bi smuth mixture if the
ga striti s be of a s ubacute type N u x vomica is a ls o
very servicea ble i n chron ic ga stric c a tarrh e sp ecia lly a s
D r R in ger h a s poin ted out whe n this con ditio n a ri s e s
from mecha n ic a l ob struction to the circula tion su ch a s
occur s in chronic bronchiti s dilated heart or cirrho si s
of the liver I n the s e ca s es a s well a s in chron ic a lco
holic ca ta rrh there is ge nerally associated a n a bun da nt
flux of ga stri c or inte stin al mucu s which unle s s re
moved a dd s to the exi sting trouble by it self un dergoin g
F or thi s purp o se the sy ste
fermentative chan ges
matic employme nt of sma ll dos es of C arl sbad s a lt s will
be fo un d of the greates t ben efit
A te a spoonful o
the sa lt di s solved in from ten to fi fteen ou nce s of hot
wa ter a s h ot a s the patient ca n bea r it shoul d be taken
every other mo rn in g a n hou r before breakfast This
dilute warm sa line solution s eems to have the power of
dissolvin g an d removin g a con siderable qu a ntity of thi s
a b no rm a l mucu s a n d carryin g it off by th e bowel s the
m otion s co n t a in in g n ot on ly faecal matter but a n o fi en
s ive an d glutin ou s lookin g s lime which ofte n a dhere s
m o st ten aciou sly to the s ides of the cha mber ve ss el
The cold wet com press is als o a powerful a gent i n the
treatment of suba cute and chro nic gastric ca tarrh
in deed its employment is advantageou s i n fia tu lent
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FLAT U LE N T D Y S PEP S I A
60
dyspep sia from whatever ca u se it ari s e s It should n ot
be a pplied durin g full dige stion but towa rd s the en d
of the p r oce ss about three hours a fter a mea l Thu s
if the princi pa l me a l of the d a y be ta ke n at seven i n
the e v en i n g it m a y be a pplied at h a lf p a st te n or
eleven o clock before the patien t retire s to res t In the
m aj ority of ca s e s it can be bor n e the wh ole n ight
patients un der its in fluence e nj oyin g soun d rep os e
who s e res t had previou sly been di sturbed by bad
drea ms or distres sin g restlessne ss With delic a te a n d
feeble per son s it is a s well at fi rs t to lim it the perio d of
a pplic a tion to three h o ur s
Thi s can be don e if the
com pre s s be a p plied the fir st thin g in the m o rn in g the
p a tient s sto ma ch being stayed with a s mall cup of tea
a n d a pie c
e of toa st to p reven t exhau stio n W hen the
compre s s is remo v ed the skin should be gently rubbed
with a ba thing glove or a soft Tur k is h towel I n a ddi
tion to relie v in g abd om ina l plethora it increas e s the
peri sta ltic action of the in te stin e s an d thu s aid s i n
expellin g fla tu s an d overcomin g co ns tipa tion Whe n
ferm entative ch a n ge s a re a cons equen ce of o b structio n
to the on wa rd pa ssage of the food s uch a s re sult s i n a n
extreme degree from ste no s is of the pylori c orifi ce our
treatm ent is of n eces sity limited to relie vin g the dis
tre s sing symptom s c a u s ed by the exce ss of a cid the
develop m en t o f sa rci n ae a n d the fla tu len t dis ten sio n
D rs R i n ger an d M urrell l have recently a dvoc a ted the
u se of glycerin e for the relief of fl a tulen ce a n d a cidity
They ba s e their recommend a tio n on the fa ct tha t it
reta rd s some form s of fermentatio n a n d putrefa cti on
n otably of nitro genous sub s tan ces E xperiment s? s how
that 2 to 3 p er cent of glycerin e added to milk will
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L a n ce t, Ju y 3, 1 8 8 0
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D r E Mu n k , Virch ow s
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Arch iv
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1 8 79
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F LA T U LE N T DY S PEP S I A
dela y lactic acid fermen tation from eighteen to twenty
f o ur hour s a n d it i s a well a scerta in ed fa ct th a t glycerin e
pres erves mea t so completely that afte r im m ersio n for
D rs
s ome mo nth s it is still fre s h a n d ca n be e a ten
R in ger a n d M urrell recommend it to be t a ken i n tea
spoo nful do s e s either i m medi a tely
before with or
directly after food Their ob servation s were ma de on
s tom a ch
flatulen ce an d they obta in ed sa tisfa ctory
re sult s for tho ugh it o nly partially s u cceeded i n som e
cases where o ther remedie s a t on ce cured in others
it speedily a n d completely s uc ceeded whe n the se failed
O win g to its s olubility they do n ot thi n k it in flue n ce s
the formation o f win d in the colo n except when give n
in large do se s when it act s a s a s li ght l a xative a n d so
expel s the putrefyin g m a ss which forms the win d My
own experien ce p oin t s to the con clus ion that its a d m in is
t ra tion is m o st ben e fi cial i n ca s e s of ordinarily delayed
digestion but that it is of little va lue i n s evere c a s es
G lycerin e however is a n ex cee din gly va lua ble me n struum
for the a dmin i stra tio n of other m edicin e s we ca n there
fore u se it i n all ca s es obta inin g the bene fit it u n
doubtedly con fer s in many in stances without in a n y
way in terferin g with the employme nt of oth er remedies
in c a s e s where its efficacy is doubtful
Thu s bi smuth
may be a dmin i stered bef ore meals p ep sin dur ing m ea l s
a s a n a ntisp a s modic
a n d a few dro p s of chloroform
after meals in a tea sp oonful of glycerine C ha rcoal is
u sef u l in a ll ca ses of fla tulence an d a cidi ty a n d its
benefi cia l eflects a re well m a rked in inte stinal fla tulen ce
I
a s s ocia ted with ofi e n s ive s mellin g ev a cuati on s ; thu s
have empl oyed it with con s idera ble s uc cess in relievin g
the fla tulen ce which i n so me ca se s is a very distress
in g sympto m in chronic dy sen tery ; it a ls o h a s a
marked cflect in di m ini shin g the foetor of the stool s
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62
FLA T U LE N T
n x sp np sra
charcoal i undoubtedly more eflica ciou s than
anim a l a n d it is be st ad m in istered in a dry s ta te in th e
form of p owder A co nvenient mode of admin i sterin g
it in thi s form is to strew a te a s poo nful thickly on the
cen tre of a s lice of very thin bread an d butte r the n
rollin g this up tightly compres s in g the edges to preven t
the e s ca pe of the charcoa l a n d s wallowin g it with a s
little m a s tication a s po s s ible Whe n the fla t u lence
chiefly occurs in the sto m a ch the charcoal s hould be
taken imm ediately before food ; i n intestin al fla tulence
immediate ly after
C rea sote a n d carbolic ac id a re often employed for
th e relief o f flatulen ce
D r S an som who h a s in tro
d u ce d the u se of sulpho carb ola te s h a s shown tha t
they effectually arres t fermenta tio n ; te n or fifte e n
grain s of s ulpho carbolate of soda may be admin i stered
either immediately before or after food
D r R in ger
h a s poin ted out that the s ulpho carb ola tes m a y be
adva n tageou sly employed i n ca se s whe n the patient
co mplain s of pain ofte n mos t m arked o n on e s ide of
the a bdo m en generally the left s ide un der the ribs
Thi s p ain which is te mpora rily relieved by the eructa
tio n of a little win d soon returns , an d m a y en dure
ma ny ho ur s This pain D r R i n ger think s is of n eu
ra lgic ch a ra cter an d is excited by fla tu len cy
I n s evere ca se s of flat ulen ce an d acidity I h a ve foun d
con si dera ble be ne fit re s ult from the u se of turp en tin e i n
from ten to fif tee n drop doses ta ken shortly afte r fo od
B y ac tin g a s a stimula nt to the mucous membran e of
the sto mach an d in te stin e s it increases the qua n tity a n d
improve s the quality of th e s ecretion a n d dimin i s hes
the cata rrh of tho se organ s It check s the forma tio n of
sa rcin ae
In the maj ority of ca ses it has a laxative elf e ct,
an d t hus relieves con stip a tio n without recour se bei n g
Vegeta ble
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F LA T ULE NT D YS PE PS I A
64
person s sufferi n g from this form of d y spep s ia an d they
are often particula rly s usceptible to its influen ce whils t
from a p urely medical point of view they are distinctly
better without it In ca s e s however where there is a
co n sidera ble degree o f ato ny a t a bles po o nfu l of bra n dy
dilute d with two ta blespoonfuls of water may be given
with advantage at the prin cipa l meal of the d a y s in ce
d ilu te alcoh ol in modera te qua n tity is a s B ern a rd h a s
a very effi cie nt stim u lan t of the ga stric
s ho wn
O nly a sm al l qua ntity of fluid should by taken at meal
time s a n d therefore the sa me bene fi t is n ot deri ved
from the emplo yment of t a ble waters a s is obtain ed
fro m their u se in ca s e s of dy speps ia a rising fro m un due
s ecreti o n of a cid ; a sm all tu m bler however of A pp oli
n a ri s wate r take n with dinn er is ofte n of di stin ct s ervice
pro ba bly from the fact of the co n s idera ble proportio n of
chlo ride of s o d ium it co ntains F luids a re best take n
about two h our s a fter foo d when they d ilute the acid
tha t may be formed an d help to remove the pro duct s
of dige s tion from the stoma ch F or thi s purpo se th e
na tura l eff erves cent a lka lin e w a ter s m a y be employed
They a re ho wever mo st ben efi cia l in ca s e s when the
fla tu len ce is limite d to the sto m ach a n d a re of little u s e
in reli evin g in te stin a l fl a tul en ce whil st in tho s e c a ses of
i nte stina l dy spep sia which a re a s sociated with oxa luria
they are d istrin ctly in j uriou s
F la tulent patient s a re decide dl y wor s e in wet cold a n d
ra w we a ther or whe n they cha n ge from a d r
y s oil to a
da mp situa tion Tho s e re sidin g o n wet clay s oil or in
m a rshy districts should therefore p a rticu la rlv a tten d to
the s ubsoil drain age of their hou se s a n d the u se of the
c old c ompre s s when ever the weather chan ge s from fin e to
wet wi ll protect them from bein g over s ens itive to cli
m a tic vici ss itude s
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A C ID
65
C H A P TE R I V
D E R AN G E M E N T S A S S O C I AT E D WI TH D EP O S I T S O F
A C ID
U R I IC
AL T H O UG H ,
prior to the di scovery of uric acid by
Schee le in 1 776 man y phy sician s“ taught that gout
w a s produced by a m orbific m a tter re s ultin g from the
coction s bein g i m perfectly performed in the p rim e
vine a n d in the s eco n da ry a ss imila tin g proce s s e s still it
wa s n ot till twen ty ye a r s la ter that the probability of
there bein g a connection between uric a cid a n d go ut
Indeed a t first uric acid wa s s olely
w a s eve n hinted at
regarded a s a con creting acid formed i n the kidn ey
which boun d together the ea rthy matter s of the urin e
and so engendered ston e Thi s view wa s expres sed by
the term lithic a cid — a term which is still employed
clinically though its chemical compo sition a n d rela tio n
I n 1 793
s hip is be st e x pres e d by the title uric acid
however Mr Murra y F orb e s f poi nted out that this
u b stan ce wa s dep o s ited i n other p a rt s of the bo dy
beside s the uri na ry p a ssages an d thi s he thought
s howed th a t it wa s c o ntain ed i n the ge n eral fluid s of the
body and not merely formed in the kidneys B u t
though thi s obs ervatio n wa s s hortly a fterward s c onfi rmed
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Trea tis e on Gou t 1 68 5
Th om as Syd e n h a m
1 Tre atise u pon Gr a v e l a n d u p on Gou t with a n E xa m in a tion of
A u stin s Th e ory of S ton e an d D isser ta tion on B il e a n d on Sol v e n ts
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66
AC I D
UB I C
by th e an alyse s of Wo ol a ston in 1 79 7 of gouty tophi
which he foun d compo sed of ura te of soda it wa s n ot
till Dr Garrod in 1 848 brought forward before the
R oyal Medi ca l an d C hirurgical S oc iety the re sult of
his ob servatio n s ba sed o n chemical a nalysi of bloo d
an d urin e in gout a n d rheumati sm that the fact
that in true gou t a n exce ss of uri c acid exists in
the blood pri or to an d a t the period of the attack
The facts then brought for
wa s fir st dem on s tra te d
ward ha ve bee n s in ce fully confi rmed a s to their accu
racy an d although D r G arrod doe s n ot m ain tain they
are in them s elve s s ufficien t to expla i n all the phe no
m en a of gout s till h is re s earche s have thrown co nsider
able light on the path ology of the dis ea se Sin ce D r
G a rrod s ob s erva tio n s h ave bee n p u bli s hed there h a s,
however been a tendency on the part of some writers to
exten d D r Ga rrod s guarded statement s with regard to
uric acid an d they ha v e a ssign ed to it a pla ce in patho
logy which is not yet wa rra n ted by phy siological an d
chemical obs ervatio n n or even I vent u re to thi nk by
clinical experien ce A lready a reactio n has set i n
again st th e doctrine s enuncia te d by th e mo st a dvan ce d
members of this s chool of humora l patholo gy an d which,
like mo st reaction s m a y in turn beco me extreme , an d
ign ore many importa nt poin ts in co nn ection with the
pathological rela tions of uric a cid which have bee n
fairly establi s hed
From the circum sta n ce that uric a cid is a di ureide
tha t is b y oxidation a molecule of uric acid can be split
u p i n to a molecu le of a n o n nitrogen o u s acid a n d two
molecule s of urea it h as been as sumed that whe n th e
proce s s of oxidation is imperfectly performed wi thin the
body u ric acid will b e foun d in exce ss in the blood ; an d
this assumption ha s been fu rther stren gthen ed by the
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U R I C AC ID
67
supposition that uric acid is on e of the sub stan ce s
through which each particle of albume n passe s before it
N ow whilst uric acid m a y
is thrown out of the body
fairly be spoke n of as a le s s oxidis ed product of proteid
metabolism than urea yet there is n o evide n ce a s Pro
fe ssor F o steri“ poin ts out to show that it is a n ece s s ary
anteceden t of the latter In deed we have in creasin g
eviden ce to s how that the probable an tecede n t s of the
urea in the blood are partly the kreatin formed in
mus cle an d elsewhere a n d partly the leucin a n d other
The phy
like bodie s formed in the alim en tary can al
al variation too of the quan tity of uric acid so
s iologic
far a s we ca n j udge from its excretion by the urin e
depen ds le s s on the n ature of the food than upon Special
con dition s of the i n tern al o rgan s than is the ca se with
urea a n d this al so poin ts to a n origin slightly divergen t
from th a t b od y Thu s Profe s s or P arke s ? foun d after
fou r day s of n on m itrogenou s diet t hat trace s of uric acid
could a l way s be foun d in the urin e which s ee m s a n
ad ditio n al argum e n t again st the origin of urea from
F or why Professor P arke s ob s er ve whe n
u ric acid
all the n itroge n was cut O E a n d con s eque n tly the ox y
gen wa s in relative ex ces s should n ot al l the uric acid
have been con v erted in to urea if that wa s its usual
origin in the body ? It is n ot however so con verted
but pas se s ofl p a r?p a ssu w ith the urea a s if furn ished
by special cells Profe s s or P arkes h a s al s o poin ted out :
that the comparative con stan cy in the amoun t of uric
acid excreted within n arrow limit s a n d the wan t of
co nn exion betwee n its chan ges a n d the chan ges in the
urea in health an d disea se seem to o ffer extremely
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B ook of P hy s iol ogy ,’ p 3 5 3
L a n cet, ’ v ol i, p 7 22 , 1 8 74
Tex t
I Com position
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ill an
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1 8 78
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68
U R IC ACID
stron g arguments again st the supp o sitio n that the
latter body is largely derived fro m the former A gain
the fa ct that in birds an d reptiles uric acid repla ce s
urea ha s be en urged in s u pport of the ins ufficien t
oxida tio n theory s in ce it ha s been urged th at bo th
have to econ o m ise oxyge n the bird for the du e
performan ce of its ac tive vital fun ction s the reptile
imperfectio n s of the
on a ccount o f the structur al
respirato ry apparatus With regard to birds however
we h av e n o proof wh atever of their need to eco n omise
oxyge n ; in deed the fact of the ri ch n ess of their bl oo d
in red corpus cle s poin ts to a n oppos ite con clusio n The
final c auses of the divergen ce in the s e cases Professor
F or ster seem s to thin k are to be sought r ather in the
fact that u rea is the form be st adapted to a fluid and
uric a cid to a s olid excrem en t L astly it must be
born e in min d that uric acid a n d its s alts are by far th e
most in soluble of all the organ ic products met with in
the body so th at un le s s s ome special provi sio n was sup
plied for its pro m pt removal a s is the cas e with birds
a n d reptiles by their volumin ous ki d n ey s a ny co n sider
able temporary exce s s would espe cial ly if the excess
was attribute d to imperfe ct oxidatio n lead to depositio n
in the textures of the body
These con sideration s certain ly do n ot give supp ort t o
those who ha ve given to uric ac id a n un due promin e n ce
i n humoral patholo gy an d who have based their hyp o
theses on the suppos ition th at uric acid is on e of the
substan ces through which every p article of albume n
p asses before it is th rown out of the body an d th at
when oxidation is impe rfectly perform ed there is a pro
duction of in sol u b l e uric acid a n d urates in ste ad of
urea In deed they poin t rather to a n opposite co n clu
sion , that uric acid in the human body in health an d
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UR IC ACID
69
eve n in dis ea s e is formed in o n ly very min ute quan ti
ties a n d that whe n it is depo sited from the urin e or in
the tis s ue s the fact of the occurren ce of s uch depo sit
may be gen erally referred to its in s olubility rather than
to its exce ssive productio n in the sy s tem Thus in the
maj ority of ca se s where freque n t a n d eve n persi ste n t
d eposit s of uric acid a n d urates are met w ith in the
urin e we are often un able to sho w that they are in
absolute exce ss whil st on the other han d it h a s been
repea tedly demon strated that n o absolute in crease doe s
o ccur in a ve ry l arge proportion of c as e s an d that the
precipitation depen ds solely upon chan ge s in the ch a
ra cter of the urin e s uc h as i n creas e of its den sity or
a cidi ty or bo th combin ed the result of s ome deran ge
men t of the digestive organs or from catarrhal or other
Whil st in
m orbid con dition s of the u rin ary passages
those c as e s in which a con s iderable quan tity of uric acid
is sudden ly di s charged w e ge n erally have suffi cien t ev i
den ce to s how that the deposit ha s bee n acc u mu l atin g
for some time previou sly in the urin ary pas sage s a n d
d oes n ot repre s en t the amoun t separated from the sy stem
within a period of t we nty four hour s A gain in tho s e
cas es where a n absolute in crease of uric acid excreted
in the twen ty four hours urin e does occur it will be
gen era lly foun d on in quiry that other urin ary con sti
tu en ts are likewi se bein g elimin ated in exces s n otably
the urea a n d pho sphoric acid The circumstan ce s un der
which this elim in ation occurs hav e received but little
atten tion ; they seem to depen d in man y cas e s on dis
tu rb in g i n fluen ces which apparently have a more pro
foun d origin than m ere dis turban ce of the hepatic fun c
tion s to which they are gen era l ly referred I n cases
where the con dition is temporary the in crea s ed elimin a
tion may often be referred to disturban ce of the n itro
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70
u m c nc m
gen ous equilibrium i n duced by the employmen t of a
too highly an im al ised diet by n ervous influen ces or
temporary disturban ce s in some fu n ction of the organ ism
The se cas es in their general ch ar acters correspon d to the
con ditio n de s cribed by Murchison un der the term
lithm m ia thou g h i n creas ed elimin a tion of uric a cid is
sole urin ary characteristic n or fun ction al
n ot the
deran gemen t of the liver n ece sarily th e sole ca u s e of
the d is order I n ca es ho wever where the dis charge of
uric a cid i n exce ss is more or less per si ste nt in a urin e
of high average s pe cifi c gravity whilst the urin ary secre
tion is n ot dimin i shed in quan tity it is to be feared
that the con dition is a prelude to some serious organic
mischief— ofte n phthisis and as Prout pointe d out of
uterin e can ce r It is a con ditio n whi ch is often foun d
precedin g or altern atin g with s a cch arin e diabetes and
atte n tion h a s recen tly been drawn to the cons iderable
increas e of pho sphoric acid discharged d aily with the
u rin e in these
C on siderable clin ica l importan ce
has been attach ed to the fact of uric acid deposit s thus
altern atin g with sugar as in dicatin g a n alliance of this
form of diabete s with the gouty state Without deny
in g that such is the case in some in stan ce s I would
howe v er poin t ou t th at the s e depo sits of uric acid are
often more appare nt than real an d depe n d r ather on
the chan ges in the urin ary s ecretio n its elf than on any
chemical tran sformation with in the bo d y Thus whe n
sugar is abun d an t there is u sually a correspon di n g
i ncreas e i n the quan tity of water di sch a rged so that the
relati v e quantity (per ce nt ) of uric acid is lessen ed if ,
however the quan tity of sugar become s dimi nished the
the di s charge of water from the body i generally pro
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J L Tessier Du D iab ete P hospha tiq n e Paris
pa p er by a u th or La ncet March 1 2 th 1 881
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72
ACID
UB I C
times profuse a n d of low s peci fic gravity at other time s
& c a n d yet scurvy a n d gout
s can ty a n d con cen trated
are whe n developed di stin c t dis ease s
N ow although true s curvy has a l most disappeared
from civil practice a n d is only occa sio n ally met with
amon g the s ailor s of our mercan ti l e marin e still a s D r
E ade “ a n d others have sho wn in com pletely developed
f orm s o f it are by n o mean s of rare occurren ce though
a s D r Buzzard ? h a s poin te d out the true n ature of the
ailm en t is very often overl ooked A mon g the clas s of
per s on s who form the bulk of the out patien t s of our
ho spitals a n d dispen s arie s m ild s corbutic man ifesta tio n s
may be frequen tly n oted A t the L on do n Hospital
w here from a habit acquired at the D readn ought I
m ake it a rule to examin e the gum s of all patien ts at
the time I exam in e the ton gue a vi sit s eldom pas s e s
without a ca s e presen tin g itself exhibitin g suffi cien tly
characteri stic scorbutic symptoms This m an ifestation
o f a scorbuti c co n di tio n is not however by a n
y mean s
con fin ed to our poorer patien ts sin ce we fin d it deve
lopin g from tim e to time am on g tho s e of a better clas s
H ere it frequen t l y superven e s on som e chron ic a ffec
tio n thus for in stan ce a patien t with a weak a n d feeble
d igestion is afraid of takin g s ugar because it turn s a cid
a n d vegetables particularly potatoe s becau s e they cause
flatul en ce so fruit potatoe s a n d green v egetable s are
av oided Absolute deprivation of vegetable food how
ever is n ot re q uired to produce a ten den cy to s curvy
s ome per s o n s be in g n aturally predisposed towards the
di sease a n d are more readily a n d speedily affected by a
temporary withdrawal or a dimin ished s upply than
others ; these pers on s have wh at the old er write rs
L a n cet Jun e 1 880 ; B rit Med Journa l N ov 1 9th 1 88 1
1 Reyn olds Syste m of M ed icine Arti cl e S curvy p 7 4 5
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73
ACID
”
termed the scorbutic con stit u tio n I n man y in stan ce s
that have come u n der my observatio n of per s on s sup
posed to be gouty I have sus pected them to be really
n fle rin g from a n in co m pletely d eveloped form o f s curvy
a n d have n oticed a n almo st imm ediate alleviation of the
symptoms by recours e to lemon j u ice fi“ S o als o w ith
per s on s who have had syphi lis b u t who at the time
they come u n der observatio n are free from a n y appare n t
manifestation s of the disea s e a n d wh o often complain
of symptom s that close l y resemble tho s e experien ced by
gouty subj ect s so that if our patien t s memory is short
or there are difli cu ltie s in the way of direct in quirie s
we may read ily fall in to error
Thus in the cas e
of a lady wh o wa s sen t to m e in the s pri n g of la s t
year suppo sed to be su flerin g from some gouty
trouble her chief sym ptoms were periodical attack s
though n ot of very severe character fol
of j au n dice
lo wed by urticari a with dyspn oea irregular a n d weak
action of the heart shootin g pain s in the limb s &c
The urin e collected for the twe n ty four hours sho wed
that sh e passed 1 520
with a specifi c gravity of 1 029
or rather more than on e half again a s much solid matter
There wa s n o album en or sugar ; u rea
a s sh e ough t
gramme s ; phosphoric acid
grammes a n d the
urin e loaded with urate s Un der a suitable dietary a n d
alkalin e treatmen t the quan tity of urin e s an k to
with specifi c gravity of 1 0 2 1 a n d the excretion of
urea to 33 gramme s a n d sh e felt gen erally more com
forta b le a n d in three week s wa s decidedly better
A bout thi s time how ever she began to complai n of
pain over the inn er edge of the right tibia a n d s hortly
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Wh en p a tients a re fan ciful a s th ey of ten a e an d con tin u e
their n egl e ct of veget abl e foo d a n d ref u se to tak e l em on j u i ce the
la tter m ust b e prescrib ed for them
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U R IC ACID
after a n ode developed which required surgical treat
men t She wa s then placed for a time on full dose s of
io di de of potas sium with de cide d eff ect on the p erios
teal swelli n g D r F othergi l l
a s omewhat
s im ilar case of a patien t wh o sn flere d from intractable
in dige stion which did n ot yield to ordi n ary treatmen t
till a local malady a persiste n t pain ca u e d b y a p erios
teal thi cken in g led to the s upposition that the un der
lyin g factor wa s un recogn ised s yphilis
I o di de of
pota s sium relieved the pain an d the in digestion Sir
Jame s P ag et ha s also drawn atten tion to the s ame
poin t in a s peech made at N o rw ich at the meetin g
of the
Briti sh Medical A ssociation in 1 8 74 when
referrin g to the routin e adm in istratio n of b lu e p ill b y
the practition ers of former year s he s uggested that
s ome of the good e ff e ct s attributed to its whole s a l e
admin i stration may have been obtain ed by its action on
a po s ible syphi litic t ain t which had escaped the ob ser
vation of the practition er
A gain s trum o u s an d tubercular subj ect s are v ery
liable n ot on ly to depos it uri c acid a n d urate s from
their urin e but als o to excrete it in exce s s Thi s is
e s pecially the cas e with youn g children wh o often d is
charge co n siderable quan titie s o f red s an d an d are
con sequen tly frequen t victims to uric acid ca lcu lu s t I n
m an y ca s es these depo s it s depen d s olely on temporary
di sturbances of digestion causin g a too highly acid state
of the urin e but when a s is often the case the uric
acid is al s o fou n d to be actually in exces s a n d n o t merely
deposite d whils t the p ecific gravity is high a n d the
I n d i ge s ti on a n d B il iou sn ess p 1 2 4
L ewi s 1 88 1
1 D r W Roberts from a c on si dera tion of s ta tis ti cs from
n u m erous s ou rces st a t es th a t
th e f re q ency of s t on e is fa r the
g rea test u n der five years of a ge a n d n ext b etwee n ten an d fiftee n
Urinary an d Rena l D iseas es
yea rs
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75
ACID
1 mm
ure a als o is i n excess it is ge n erally foun d to precede or
acco m p any some s erious con stitution al dis turban ce !”
In a dults t oo with strum ous or tubercula r te nde ncies
we occa sionally fin d patien ts who have for some time
previously been subj ect to an oma lous affection s an d
pain s i n differe nt p arts of the bo dy accompanied by a
more or less persisten t depos it of urates or uric acid
Thus a p atie nt I sa w this summer who was troubled
with an exces sive secretion of viscid mucus i n th e fauces
a n d a t the ba ck of the n ose but who in all other re
spects ap pe ared healthy except that sh e compl a i n ed of
symptoms corre s po n din g to those so graphically de
scribed by D r Murchi s on a s characteri stic of litha m ia ;
so that had I n ot kn own the fam ily history I should
probably have regarded the case a s on e of fun ctio n al
derangeme nt of the liv er This patien t s mother and
a brother however had both died of caries of the cer
vica l verte brae a n d an other brother had un dergon e
amputation of the thigh for disease of the kn ee j oi n t
This patie nt improved con siderably on cod liver oil iron
a liberal dietary a n d a brief re siden ce at M argate — a
pla n of treat m en t whi ch would have aggr avate d the
symptoms h ad they b ew d u e to hepatic deran gemen t
It wou ld be po ss ible to mu ltiply examples but en ou gh
ha s bee n s aid I believe to a ll o w u s to i nfer that many
of those an omalous sym ptoms the exact clin ica l sign i
fican ce of which we are n ot yet in a positio n always
rightly t o determin e but we are perhaps to o ready to
refer to as depen din g on a gouty con dition are n ot
n ece ss arily p athognomon ic of that state but may in many
in stances be irregular man ife station s of other morbid
co n ditio n s S o that excess of u ric a cid i n the urin e
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th e ea rl y stages of ri ck e ts
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76
U R IC ACID
should n ot be regarded a s m erely the result of defective
oxidation or fun ction al di sturban ce o f an organ but
w hen that con dition is more or le ss pers is ten t a n d is
accompanied by an in crea se of the other solid matter s
o f the u rin e n otably of the urea a n d phosphoric acid it
den ote s a n i n crease of tis s ue metabolis m throughout
the body a n d will ge n erally be foun d prece d in g or
accompan yin g some grave con stitution al di s order
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The clin ical a n d pathological con ditio n s which lead
to the deposit of uric acid a n d its sa l t s from the urin e
or its ex ce s sive elimin ation from the urin e may be thus
briefly summarised
A
D eposits of uric acid or urate s n ot however
n ece s s arily elimin ate d in excessive quan titie s
1 Absolu te i n crea se in
The o ccas ion a l d ep os it of u ra tes oh
th e a ci d ity of the u ri n e
s erve d in w i n t er a ri s es f rom
thi s ca u se
The a cti on of th e sk i n be in g ch eck e d
th e a ci d ity of the uri n e i n cre ases durin g
co ld w ea ther
S im il arly in m a n y ex t en
s ive c u tan eou s d i s ea ses su c h a s ec z e m a
a n d p sori asi s u ri c a ci d d ep os its are of frs
qu ent occu rrence ; the se d isorders th ere
fore n ee d n ot b e a ttrib u te d to l ith aem ia
Al so in form s of dysp ep si a a sso cia te d
w ith irre g ul ar secre ti on of g a stri c j u i ce
A ci d Dys p e p si a p
The d ep osit o f u rat es fre qu entl y n o
2 Rel a tive in crea se in
t ice d du ri ng th e su m m er m on ths orig i
th e a cid ity of the u rin e
n a t e in thi s wa y the c u t a n eou s tra ns
p iration b e i n g in crea se d in h ot wea ther
the
u ri ne is m ore concentra t e d
S im il a rly in pyrex ia especia lly rheu
m a ti c fever an d in d iarrh aaa
Uric a ci d
d ep osits a lterna ti n g wi th su ga r are
o f ten cau se d in thi s wa
y ; si n ce a s the
s u gar d i sapp ea rs uri nat i on is
n ot so
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77
U R IC ACID
p rofuse an d a re l ative in crease of the
a c i d ity of the urin e occ urs
Thi s re l a
tive in crea se m ay n ot on ly b e ca used b y
a d i m i n u ti on of th e wa ter ex cre t e d b u t
from defici en cy of th e a lk al in e ph os
phates thi s con d ition is fre qu en tly m et
w ith in th e u rines of ill n ou ris h e d or
stru m ou s c hi ldren
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B U ric acid elimin ated in excess but n ot n ecessarily
deposited from the urin e
1 U ric a ci d in ex cess
C hiefiy in d i sea se s of the l iver su c h
u s u ally a tt en de d w ith a
a s a cu te yell ow a trophy
c irrh os i s a n d
d i m i n ution of th e other can cer I n scurvy a n ex cess of u ric a ci d
urinary con stitu en ts (tru e is gen e ra lly ob serve d w ith a d i m i nu ti o n
l ith aem ia )
of urea a n d th e a lk a l in e phosph a t es
2 U ic a c i d in ex cess
I n fun c ti on a l dera n g em en t s of the
l iver esp ec i a lly thos e brou g ht a bout b y
a tt en d e d w it h a n i n crea se
d istu b an ce of th e n it ogenou s eq u ili
of th e oth er urin a ry co n
b riu m
b y the in gesti on of too m u c h
s titu en ts *
a n i m a l f oo d
A s a con d iti on a n tece den t
to th e deve l opm en t of phthi s i s or ca n cer
an d som e ti m es of d i a b etes or prece d i n g
th e ou b tb ea k of su ch co ns titu tion a l
c on d iti on s a s sy phili s
scroful a
a n d of
gou t in its early a tta ck
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M odern theorie s as sign to uric acid a variable wile in
the pathology of the gouty state The s e theories may
be briefly con s idered un der three heads z— l st W hich
maintain s that the cause s which predi spo se to gout are
either such as produce in creas ed form ation of uric acid
.
.
these ca ses if th e urin a ry wa ter is i n crease d we h ave a con
d ition for whi ch we m a y very properl y u s e the term p olyuri a
w h e n on l y the so l i d con s titu en ts a re in crea se d th en the de si g n a ti on
b aruria sh ould b e em p loye d The term baru ia wa s fi st
i n t odu ce d b y th e l a te D r F ull er in d es cribi n g certa i n form s of
dy sp ep si a a ssoci a te d with ex cess of urea in th e urin e Med Chir
vol 1i p 4 5
In
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78
UR IC ACID
in
the system or lead to its reten tion in the blo o d a n d
that the caus es excitin g a gouty fit are th o se which
in duce a le s s alk alin e con di tion of the blood or whi ch
augment for the tim e the formation of uric acid or such
as temporarily check the elimin atin g power of the kidn ey
an d which regards the depos ited u rate of soda as the
cause an d not the effect of the gou ty i nflammatio n !
2 n d W hich rega rds gout as a tropho neu ro is a n d
looking beyon d mere chem ico pathoge n etic theories
as signs to uric acid only a s econ dary pos itio n in relatio n
to the prod uction of the di s eas e ? 3rd The in ge nious
hypothesis I which rega rd s gout as a mode of dec ay an d
which does n ot con s ider the pre sen ce of urate of soda i n
parts of the body remote from the c e n tre of circulation
and i n tis sues little v ascular a n d of low vitality as
necess arily im plyin g that uric acid is poured out to free
the blood from its presen ce but that rather it m ay be
taken a s an eviden ce of a kin d of degen eratio n or wan t
of tissue organ i s ation Views apparen tly o opposite
are really n ot co n tradictory— for though n o on e of them
is in itself suffi cien t to accoun t for a l l the phe n omen a of
gout yet collectively it is po s sible to co n struct a theory
that h armonises with mo st of the clin ical ph a ses of the
disease F or in sta n ce let u s suppose the first step in
the pathology of gou t to be th at of textural dege n eration
by which the tis sues an d blood become lo aded wi th eflete
products th at su ch predisposin g con dition s lea d at la st
to a disturban ce of s ome special trophic n erve ce ntre ,
ca used either by a dege nerative chan ge in its structure
or deran gemen t of its fun ction by the circulation through
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Garrod A Trea tise on G ou t a nd R h eum a tic Gou t 8 rd
1 876
e d iti on pp 2 74 2 7 5
1 D r D Duck worth Briti sh M e di ca l J ourn a l M arc h 26th 1 8 8 1
I Dr W M 0 rd Me dica l Tim es and Ga z e tte F eb 28th 1 8 74
Dr
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80
n a rc a crn
antecede nt of the pathological s tate What effect these
alte red con dition s have in brin ging about pri m ary
chan ges in the chem i cal quality of the blo o d which may
be suppo sed to be con cern ed in the production of the
dise ase, an d what the n at u re of tho s e chan ges are we
will n ow con sider
It h a s b een already observed that the premon it ory
symptoms of scurvy closely resemble tho se that ge nerally
precede an atta ck of gout There are the s ame fugitive
an d erratic p ain s in the limbs ten derness of the j oi nts
atta cks of dy spn cea 850 In deed the close resembla n ce
between gout rheum ati sm an d scurvy i n e arly stages of
the disea se has repea te dly attra cted the n otice of writer
o n the subj ect sin ce the time of Syde nham who first
drew a ttentio n to this poin t * N ow n o fact in medicin e
is perhaps more clear l y established than that the exclusive
cause of scurvy is the prolon ged a n d complete Wi thdrawa l
of succulent fruits an d vegeta bles from the diet ary of
those affected— the very article s of food co n cerned i n
supplyin g the blood with the alkalin e carbo nates to
maintai n its alkalin ity To D r Garro d l belon gs the
credit of suggestin g that the ca use of the disea se lay in
the dimin utio n or withdrawal of o n e of the alkalin e
con stitue nts of the blood s in ce in 1 848 he ma de the
observation that in s corbutic di ets pota s h existed in
smaller quantities than in an tiscorbutic o nes an d wa s
led from th at circum stan ce to dete rmine the a mount of
th at substan ce in the blood an d urin e of a p atie nt
Thus he says for ins ta nce where m a tter su ite d to
produce the gout is newly gen e rate d there a ppea r vari ou s sy m
p tom s which occa sion u s to s u sp ect th e s cu rvy till th e f orm ation
a n d a ctu a l a pp eara nce o f th e g ou t re m ove a ll d ou b t con cern i n g th e
d i stem per
D e R heu m a tis m o S ect 6 c a p 5
Na ture Cau ses and Preve ntion of S curvy
E d inb urg h
j
Monthly J ou rnal of Med icin e N ew S eri es vol ii p 457
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U R I C AC ID
81
‘
su fierin g
from scurvy a n d he fou n d it co n siderably
d imi ni shed ; an d from thi s ob servatio n he brought
forward a th eory th a t s curvy depen ded upon a defi cien cy
of this alkaline oxide in the s ys te m The re sult of
s ome a aly s es “ I have ma de confi rm th e fact ob s erved
n
by Dr Garrod that pota s h is dim in is hed in the urin e of
patie nts s uffering from s curvy a n d I ha ve further s hown
that i n order to mainta in the proper degree of alkales cen ce
of the blood the alkalin e ph o spha tes are retain ed in th e
s y s tem
a n d co n s equently become dimin i s hed in the
urin e although the qua ntity inge ste d w a s the s ame
The primary chan ge then in s curvy appear s to be a
chemical altera tio n in the qua lity of th e blood i n the
directio n of dimini shed a lka linity In go ut a diminutio n
of the alkaline reactio n of the blo od h a s been ob s erved
an d D r Garrod f h a s p ointed ou t th a with the exce ptio n
of colla p ed cholera a n d perhap s certa in cas e s of albumi
nuria the reaction of the blood is foun d to be n earer
the n eutral poi nt in s evere forms of chronic gout than
i n an y other dis ea se
Thi s dimini shed alkalinity of
the blood in the cas e of gout h a s manife stly a differe nt
origin tha n what h a ppen s i n s curvy ; there a s we have
s een it is the re sult of the withdr a wal of alkalin e s alt s
s upplied by fres h vegeta bles a n d fruits
I n gout the
di min utio n is cau s ed by the p os itive additio n of acid
an d acid s alt s either ta ke n in exce ss wi th the food a n d
drin k or retained in the sys tem the re sult of imperfect
eliminatio n in co ns equen ce of s eden tary habits or the
action of certa in meta llic poison s
O u r vie ws with regard to the nature of the acids con
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Inqu iry in to
L e w is, 1 8 77
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th e
Path ology
of
Scu rvy
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B y the
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l ds
R eyn o
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Sy ste m
of
M ed icin e
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a
rticl e
“
Gou t,
p 82 6
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Au th or
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6
”
vol.
i,
82
1 mm
A C ID
cern ed in the productio n of gout have been limited i n
recent year s s olely to a co nsideratio n of the co n ditio n s
which lead to an increa se of uric acid i n the sy stem
Y et clin ica l experie nce doe s n ot altogether support thi s
exclu sive v iew For if the acid s co ncern ed i n the pro
duction of gout were derived solely from the nitrogenou s
element s of the fo o d a n d tis s ue s the n by a rigid limi
ta tion of an ima l food withi n phy s iologic a l limit s we
m ight hope to che ck or c ontrol the progre s s of the
dis ea s e B u t gou ty p a tien t s complain th a t other a rticle s
of diet be side s the nitro genou s or tho se which like
alco h ol dis turb the fu n ction o f the liver an d a re thu s
s up p o sed to le a d to i n crea s ed form a tio n of uric a cid gi v e
the m a rthritic trouble a n d they will a ffi rm there is a s
mu ch gout in a plateful of a pple tart a s in a mutton chop
a n d in a few stra wberrie s a s i n a gla ss of port wi n e
It is p rob a ble therefore the in fluence th a t a n exce s sive
an ima l diet h a s in th e pr o ductio n of the gouty state
is not due so m u ch though it is i n p a rt to the actua l
i ntroduction of a cid in to the sy s tem either b y the
s m a ll quantity of a cid so di u m p ho sphate that exi sts i n
the j uice of flesh or fro m the increa sed manu f a cture
of u ric acid but to the i ncrea s ed tis sue metabolis m
that it i n duce s throughout the body an d which whe n
contin ued for any len gth of time lead s to dege n erative
chan ges
With rega rd to the habit u a l a n d exce ss ive u se of
a lc o holi c bever a ge s a n d their efle ct o n the productio n
of gout a lthough un doubtedly th ey cau s e more or le s s
dera n gemen t of the liver I d o not h old a s I believe
m a n y d o th a t thi s deran gemen t lea d s to in cre a s ed for
matio n of uric a cid (a t a ll e v ent s it h a s n ot bee n pos i
tively pro ved th a t it d o e s so) for if that were the c a s e
the n the high er the alcoholic va lue of the bevera ge
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UR I C AC ID
83
the greater wo u ld be the ten dency to the formatio n of uric
acid ; yet it is n ot the spirit drinker s who snfler fro m
gout The fact is I believe tha t a ll alcoholic beverages
co ntai n free acids a cid s alt s a n d s accharine material an d
th a t the s e are th e deleteriou s element s the win e s contai n
in g the m ost of thes e bein g the mo st decidedly gouty
Thu s we fin d of the win e s i n ordi n ary u se port a n d
a re
mo st rich in s accharin e ma tter s a n d
s herry
B urgun dy i n a cid s a n d a cid sa lt s b u t which co nta i n s
more s ugar than the lighter acid win es cla ret an d hock
o r L o n do n
Spirit s with the exceptio n of s weeten ed
gin which h a s a reput a tio n of bein g pro vocati ve of gouty
s eiz u re s
are n early a ltogether free from the s e su b
s ta n ce s
B u t beer s e s pecially L o n do n p orter co nt a i n
a s much at
oz of s ug a r a n d dextrin an d 2 5 gra in s
of free a cid i n ea ch pin t Thu s the lightermen wh o
un load the collier s in the Tha mes a re a s D r B u dd
pointed ou t som e ye a r s a go gre a t s ufferer s from gout
a n d a re grea t c o n s umer s of porter often dri nkin g a ga ll on
a n d a re
therefore inst a nce s
o f thi s fluid over o n e j ob
o f the devel opme n t of the di s ea s e un der the in flue n ce
of a mild a lcoholic drink but which is rich i n s uga r a n d
free a cid * It is the sugar intro d uced with the foo d a n d
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llowi
l e w h i h giv es th b solu te a m o t of lcoh ol
id
d
f ree
g r in a g ll o of L on d on p or ter por t w in e l ret
d a c h ri e
d w h i k ey re sp e ctiv ely h w s w h a t a a cid
g in
m i tu re p r te r re a lly is
Th e fo
ac
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C ons titu en ts in 1 g a llon
Al
l
coho
L on don p orter
Por t w in e
C la re t (m e diu m )
Gin (L on don)
Wh isk ey
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a
F
.
oz
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30 0
186
750
oz
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7
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e a ci
40 00
4 80
8 20
32
32
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Tr a ce s
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UR I C A C I D
84
drink tha t furnishe s mo s t of th e acid developed i n the
body a n d it is therefore the saccharin e ra ther th a n the
n itrogenou s eleme nts of the diet that require re strictio n
Sugar by ferme nta tio n i n the i nte s ti n a l can al yield s
lactic acid a n d thi s whe n ab s orbed into the blo od is
reduced to ca rbo nic a cid Whe n the qu a ntity in troduced
is n ot exce s s ive thi s carbo n ic a cid u n i te s with the a lkali n e
bas es sod a a n d p ota sh i n prop ortio n to form norm a l
c a rbona te s (Na 2H C o3) on e atom of a cid to two of alkali
but whe n a con s iderable qua ntity is p oured into the
circ ul a ti o n the am o unt of a lk a li n e b a s e s a re prob a bly
insufficie nt to furn i sh two a tom s of b a s e but o nly on e
to c o mbi n e with the carbon ic a cid s o we ha ve in stea d
the a cid ( b i ca rbo na te (N a H 20 0 3) an a cid s a lt with a n
alka li n e rea ction but which I have s how n (p 1 1 ) is
capa ble by de compos itio n with n eutra l sa lt s of form i n g
acid s alts with a cid rea ction s ?”
S eden ta ry h a bit s e s pecially whe n food is t a ke n i n
exce ss u n do ubtedly lea d to the a ccumulatio n of acid
in the sy stem
P rofe ssor P a rke s i n h is wo rk on
H ygien e f h a s give n a co n ci s e table s howin g the
e fi e ct exerci s e h a s on the a b s orp tio n of oxyge n a n d the
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I t is prob a b e the re a s on s om e fr u its, su ch a s str a w berr ie s,
a n d fr u it ta r ts, p r ov ok e a r th r itic pa in s in th e
gou ty is th a t the
h a rin e el em en t ta k e n w ith th em p re dom in a tes ov er the a lk a l in e
ba ses con tain e d in th e f ru it a n d the sa lts e nter the sy s tem as a cid
sa l ts r a th er th a n a l k a l in e
I n the ty p ica l a n tis cor b u tic f ru its a n d
v egeta bl es (l e m ons cre ss a nd ca bba ge) a l ka l in e ba s es a bou n d a nd
th e sa l ts d er iv e d f r o m th e m n o d ou b t e n ter the sy ste m a s n or m a l
n ot a cid ca rb on a te
th u s h elping the s er u m of th e b lood to re a in
g
its p r op er d eg ree o f a l k a lin ity
B y Ed A Pa r k es M D
l ate
1 P ra ctica l H ygie n e
Prof essor of Milita ry H ygie n e in the A r m y Medica l S chool Ne tl ey
F if th e d ition b y P r of d u C ha u m on t Pro fe ssor o f Mil ita ry H y ie n e
g
in Ar m y Me d Sch ool N etl ey p 4 1 1
L on don : C h u r ch ill 1 8 7 8
s a cc
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UR I C s on )
85
evolutio n of carbo n ic a cid which show s that o n a work
day 8 % oz of oxyge n were ab sorbed in exces s of a
A n d that 1 3 oz in exce ss o f ca rbo n ic acid
re st day
were evolve d o n the work day although the s o called
w o rk day in cluded a period of res t the work bein g
d on e only durin g workin g hour s an d wa s not excessive
The accumula tio n of carbo nic acid i n the blood would
a s I have alre a dy explain ed
increa se the acid sa lts
pres e nt i n the blood s in ce the free carbo nic acid woul d
take a portio n of the base fro m the n orma l carbo na te s
(Na ZH C os) to fo rm acid c a rbonate s (Na H zcoa) O ver
fa tigue from exce s s ive mus cular exertio n may al so lea d
to a n accumula tion of acid i n the sy stem o win g to the
wan t of a s uffi cie nt supply bein g brought to them to
burn the carbo n eleme nt s which s upply their force, an d
als o from the accumula tio n of the products of their
c o mbustion E xhau stio n of the n ervous sy stem fro m
over work proba bly acts in the s ame wa y a co nditio n of
general fatigu e bein g in duced which actin g through
the nervou s s y s tem o n the heart an d v i s ceral organ s
ca u s e s the blo o d to circulate less vigoro usly an d the
proce ss of re newal an d removal to become slacker a n d
s la cker
L astly the acce ptan ce of the view that the fir st step
i n the productio n of gout is due to s ome chemical al tera
tio n in the quality of the blo od chiefly i n the direction
of dimini shed alkalin ity wil l do much to es tablish the
pathological rela tio n ship between s curvy rheumatis m
an d gout a rela tio ns hip that ha s lon g been held by
man y to be pos sible ) ‘ Thu s s cur vy is in du ced by a
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Mr Jona th a n H u tch inson , in
M e d ical
p ap er re ad be fo re th e B r itish
e nu nciated a s erie s o f p roposition s,
a
A ss ocia tion a t R y d e
cl ea r ly sh o w in g th e re l a tions h ip a s w e ll a s the p oin ts of d istin ct ion
betwee n gou t an d rh e u m atism B rit Med Jou rna l A u g 2 7 1 8 8 1
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U R I C AC ID
86
diminished alkalin ity of the blood owin g to the with
dre we l of alka line base s supplied by vegetable food ;
the disease may be c on sidered a s an instan ce of the
acute effect of acid o n the ti ssue s generally the
appearan ce of pos itive sy mpto m s bein g rarely delayed
more than a few weeks a fter th e c o mplete withdrawal
of vegetable food O win g to this rapid development ,
the textural degeneration s met with i n this dis eas e are
marked re s emblin g tho s e that occur i n an imals when
atte mpts have bee n made to reduce the alk alinity of the
blood or to n eutrali s e it viz dissolution of the blood
globules ecchymo ses i n the heart , blood stain s in the
media sti num gum s an d muco u s surfa ce s, with fatty
changes in the mu scle s gen era lly an d in the se creti n g
cell s of th e liver and kidney I n gout the di mi nished
alkali nity is in d u ced by the po s itive addition an d accu
m u lation of acid an d acid salt s in th e blood
The pro
ce ss is a gradual o n e an d c o n sequen tly the degenerative
chan ges are n ot of the s ame a cute character an d are
limited to part s remote from the centre of circulation
a n d in ti s sues little v a s cular a n d of low vi tality
As a
consequen ce inflamma tion is rea dily excited in thes e
ti ssue s lea din g to a depositio n of ura te of soda This
deposit may ari s e either from the s pecifi c in flamma tio n
cau sin g in creased fo rmation of uric acid in the affecte d
ti ssues or with or without increa s ed formatio n chemical
an d vital cha n ge s m a y take place in the tiss ues them
s elves which lead to the depo s itio n of the u ra te s formed
in them which un der n ormal circ u m stan ce s would be
removed into the genera l circulatio n A ssociated with
thi s impairm ent of ti s sue there is a di sturba nce of in
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See also Tr ou sse au ’s
and
Tr ans
u m atis m ,
he
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b ser va tion s on th e pa ra ll e lism betw een
C l in L e ctu re s vol iv p 8 86 S d
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gou t
Soc
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88
UR IC ACID
it is deposited the fact of the occurren ce of uch d epo it
m ay be ge nerally referred to its in solubility th an to its
exces sive production in the sy stem our attentio n will
the n be primarily e n gaged in the discov ery of the cir
cu m stan ce s which brin g about the depo s it of this i n so
luble substan ce a n d our sub s equen t eff orts en ga ged i n
their rem o v al a n d in remedyin g the incon ven ie n ces
caused by its loca l accumulation an d deposit In short
if this view be acc epted uric acid will be regarded a s a
co nsequen ce a n d n ot a ca use of the m an ifold dis orders
to which it has been s aid to give rise Wh at the co n
dition s a re which lead to the deposition a n d excessive
elimin atio n of thi s s ub stan ce have bee n fully con sidered
an d a co nci s e sum mary given (pp
From a co n
sider ation of the s e it will be see n how varied our treat
me n t must be if we wis h s uccessfully to deal with this
m an ife ta tion of d isordered actio n withi n the sy te m
An d in order to d o thi s the urin e mus t be completely
an d thoroughly exam i n e d n ot merely with refere n ce to
th e absen ce an d pre s en ce of deposit of uric a cid a n d
ura tes b u t with regard to its quan tity its a ctual a cidity
a n d the amoun t of solid matte r passed da ily I t is by
this mean s a lon e that we can get an in sight in to the
n ature of the metabolic cha n ges occurrin g withi n the
body Whilst a more or le s s per s isten t ten de n cy to
deposit u rates or uric a cid should lead to a ca reful an d
fre quen t examina tion of every organ of the body an d a
clo se in quiry i nto the perso n al a n d fam ily his tory of the
p atient B elievin g a s I d o that thes e deposits are
a mong the earlie s t in dica tion s afi orded of disturban ce s
ab normally afi ectin g ti s sue m eta bolism with i n the body
I cann ot too earn e stl y in sist upon this point Un fortu
n at aly the fa ct that the s e depo s it s are so freque n tly
depe ndent on some slight disturban ce of digestio n ha s
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UR IC ACID
89
les s e n ed their valu e in the eyes of medical practition er s
a s a clin ical in dicatio n of importan ce
It should n ot be
forgotten :however that deposits resultin g from gastric
a n d hepatic
deran geme n t s peedily di s appear un der
appropriate treat m e nt whils t those depe n den t upon
gen eral c on stitution al di sturban ce are un us ually ob s ti
n ate a n d per si s ten t a n d as s ociate d with a n i n crease * of
the other urin ary con stituen ts It is o n l y h owever by
payin g atte n tio n to these details in their min ute st par
ticu la rs that w e gain a n y clue in to the co n ditio n s w hich
are leadin g to this m an ife station an d from a n atte n
tiv e c on sideration of them we shall learn how it is that
s ome yield to treatme n t by acids
others to alkalies
whilst an other group of cas e s are ben efited by to n ics
iron ar s en ic quinin e a n d cod liv er oil others by blue
pi ll a n d salin e aperien ts a n d s ome a n d tho s e n ot a fe w
or exceptio n al by an ti syphi litic treatmen t although
there may be n o outward man ifestation of the dis ea s e
a n d we are on ly guided to o u r co n clu s io n by the con
fes sion of the patien t
I n con clu s io n it remai n s to say a fe w word s with
regard to the treatmen t of gout a n d here again we are
co nfro n ted with opposed Opin ion s a n d diverse theorie s
We have two extreme s chools to di s crimin ate between
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Dun ca n drew m y attenti on to a re
m a rk a b l e i n s ta n ce of th is o cc u rri n g in on e of m y p a ti ents at th e
S ea m en s H ospit a l du ri n g th e p e ri o d h e w a s h ou s e phys i c i an th ere
An old m a n w ith s om e n ervou s a ffe ction o f sy phil iti c ori g in wa s
p a ssi n g a ve ry cons i dera b le a m o un t of u rin e of hi g h sp ecifi c g ra vity
H e wa s t a k in g a m i x t u re
w hi ch dep o s ite d red sa n d in a bu n dan ce
a n d th e l a tt er
of i od i d e of p ot a s si um a n d bi ca rb on a t e of p ota ss i u m
sa l t w a s i n crea se d ti ll th re e d rach m s d a i l y w ere g ive n w ith a v i e w
Thi s it n ever qu ite su ccee de d in
of ren d eri n g th e u ri n e a lka l i n e
e ffec tin g a n d th e ch ara ct er of th e u ri n e rem a i n e d u n a lt ere d ti ll a n
im p rovem en t in the p a ti en t s gen era l h ea l th took p l a ce
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My f ri en d, D
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90
ACID
u n rc
those who may be termed the a s cetic an d th ose wh o
a dvocate the ton ic treatmen t of the di s e a se I nte rm e
diate be twee n the se are a few who are con ten t to follow
the rules l aid down by Syden ham wh o whilst advocatin g
temperan ce b oth in food an d drin k poi nted ou t th e
d an ger of a too great abstin en ce an d who whilst allow
in g that win e might prove in jurious as an ordi n ary
beverage thought more dan ger aro s e from the exclusive
use of water The practice of the a sce tic school is ba sed
upo n the ass umption th at gout occur s from a n over pro
d uction a n d accumulation o f uric acid in the system ,
arises in part from a too free in dulgen ce i n the albu
min ou s con stitue n t s of the f ood a n d in p art from defeo
tive oxidation w ithin the body in which accordin g to
the ir views the liv er is largely con ce rn ed Hen ce they
rigidly limit the amoun t of an imal food an d forbi d alco
holic beverage s for fear of disturbi n g the function of the
liver As howe v er I have a l ready stated it is n ot the
albumi nous co n stitue n ts of the food that gouty per on s
chieflv compl ai n of as excitin g their gouty troubles but
the saccharin e whils t it is n ot the beverages co nt ainin g
the most alcohol that are provoca tive of gout b u t those
which are mo s t rich in s ugar con sideratio n s which
m ake it prob able that the n on n itrogen ous acids play a
p art of equal if n ot of more importan ce in the p atho
geny of gout than uric acid The as cetic plan of treat
men t is n o doubt a whole s ome di s ciplin e for those who
by in dulgen ce in the pleasures of the table are o n the
high road to acquirin g the dis ease ; but to those i n di
vidu als with f eeble co n stitution s the in he ritors of go u ty
troubles or tho s e wh o are al read y weaken ed by repeat ed
attacks of the d i s order to o great ab stin en ce un doubtedly
in creases the debility a n d ag gravates the ma l a dy The
a dvo cates of the tonic plan of tre a tme nt hold n e arly the
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92
UR IC ACID
coli fren ch bean s stewed celery seak ale l ava m ay all
be u sed W atercre s s should be ser ved at every meal
S weet fruits a n d cooked fruits wi th added sugar must
be forbidde n But the subacid frui ts may be employed
i n moderation but even thes e may occasion h eartburn
an d acidity a n d give ri s e to cramp P astry on accoun t
of its richn ess an d the s ugar it con tain s should be
abs ta in ed from but plain rice bread a n d butter an d
custard puddings with but little sug ar m ay be ea te n
each d ay at d inn er with ad v an ta ge S avoury omelettes
caviare olives & c n ee d n ot be forbidden if part aken of
in moderation With regard to the use of alcohol the
speci al requiremen t o f e ach patie n t mu st be take n into
con sideratio n It sh ould be taken in a s d ilute a form
a s possible a n d the bevera ge selected must also be com
It is impos s ible to decide
pa ra tively free from sugar
what wine will suit a gouty patien t best It ofte n
happen as D r P rout re m arked man y years a go th at
those i n dividuals who have lon g bee n accus tomed to the
use of the stron ger win e s a port a n d sherry or who
have bee n drinkers of ale often s uffer from p ain s i n
b ack an d gravel when they are fir s t pl aced upon light
win es such as cla ret hock a n d ch amp a gn es a n d this is
especia lly n oticeable in cold weather It is therefore
a s well to make n o sudden chan ge especia lly with
elderly people beyon d reducin g the quantity an d sub
s titu tin g a dry an d li hte r port or sherry if the t a ste
g
had previously been to wards a f uller an d m ore bodied
wine Wh en however the lig ht win es can be t ake n with
out occa sioning gravel or pa in s in the b ack the superior
growths of the light c larets s uch as St Ju lien an d S t
E stephe are preferable to cla ret s of the higher cla ss such
as L a R ose or L afitte Z eltinger a still M oselle is
also a win e that gouty per s o n s as a r u le are able to take
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URIC ACID
93
without discomfort A ll win es should h e dran k directly
fro m the cask or after they have bee n bottled som e
time
Newly bottled win es are most pernicious
A lcoholic beverage s s hould on ly be i n dulged in on ce
durin g the day a n d s hould the n be taken with the prin
cipa l
A s the diges tive power s are u sually
meal
e n feeb l ed in perso n s who hav e suff ered lo n g fro m gout
a little dilu te alcohol which as Claude Bern ard has
s ho wn is n ext to the s aliva the mo st efficie n t agen t in
stimulatin g the gastric secretio n should be take n at
the com me n cemen t of din n er The best form is a
table spoon ful of bran dy in half a tumbler of water or a
s poon f ul o f s herry in the soup
N o other alcohol should
be take n durin g din n er but afterwards a couple of
claret gla s se s of some light win e or two s ma l l gl a ss e s of
dry port or dry sherry If the patie n t is very weak a n d
the n ight s are sleepless a l ittle bran dy or whiskey m a y
be permitted before goin g to bed ; thi s is be st taken in
s o m e n atural alkalin e eflervescin
g water
The meal hours should be regular The fast should
be broken im mediately on risin g before the fatigues of
the toilette Then a light breakfas t con si stin g of a
poached egg or a rasher of ba con or a little fre s h fish
Tea is preferre d to co ffee or cocoa which are apt to dis
agree Grouty in dividuals should en deavour to acquire
a taste for takin g thi s beverage wi thout m ilk or sugar ;
after the s e s ubstan ce s have been di s us ed a short time
their addition be comes po s itively distasteful Lu n ch
should be a l ight meal— a ba sin of clear soup vermi
celli j ulien n e or croute aux p ot a few s an dwiches or a
slice of cold meat with s alad D in n er s hould n ot be too
late certain ly n ot later than seven a n d three good
hour s s hould be allowed to in terven e betwee n the com
pletion of the meal a n d the hour for retirin g to re st
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94
c a rs
ACID
Gouty person s are extremely s usceptib le of fatigue
a n d though exerci s e is n eces s ary for them as it is for all
the amoun t take n should be caref ully regul ate d The
be st form of exerci s e is tha t which c an be ta ke n o n
horseba ck n ext drivin g walkin g about three or four
miles da ily if it does n ot brin g o n arthritic pain s in the
limbs B athin g is a n exercis e w hich the gouty should
employ freely The bath should be take n te pid ( 78° F
°
sin ce h ot bath s en ervate an d cold ba ths
to 85
depress the system too much Sea water or a solutio n
o f se a salt is ben eficial an d the plea s an test form is a s a
douche A fte r the bath the limbs should be ge ntly
rubbed by a n atte n dan t wi th a soft towel an d the n if
the muscles are at all wa sted fro m di su s e of the limbs
they may be ge n tly gal v an ised L ate hour are to be
avoided an d cro w ded a s semblies The p a ssio n s both o f
the body a n d m in d s hou l d be kept in control
W ith regard to the medical treatme nt of gout
When gout develops in a fran k form the almost
un iversal co n se n su s of Opin ion is in favour of n on
interferen ce The pain s hou ld be soothed by simple
an odyn e fomen tation s or if very s evere by the i nte rn al
a dm inistr atio n of opium or by the subcut an eous inj ec
tio n of morphi a Whe n a s it Often happen s a fte r a
sh arp atta ck of fran k go u t has u b sid e d the pati en t
co n tin ues to be troubled with min or manif esta tion s of
the disorder a n d the j oin ts con tin ue p ain ful an d slightly
swolle n we are often called upon to relieve the patie n t
an d employ specific remedie s F o r this purpo se colchi
cum is the drug gen erall y em ployed I have however a
stro n g obj ection to the use of this medici n e a n d s in ce
the introductio n of the s alicvlates I have h a d n o occa
sio n to empl oy it except in a few cas es where patie nts
h ave alrea dy become so habituated to its u se that thev
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96
ne w
A
CID
B ath in E n glan d I n chronic gout the patien t is
hardly ever free from some man ife s ta tio n Of the dis
order whilst the paroxy sms of the di s eas e if n ot so
s evere are more prolo
n ged a n d more j oin ts are im p li
c a te d than when the attack is perfectly fra n k
It is
w he n gout a s sume s the chron ic form that the cripplin g
effect s of the disease become formidable It is in thes e
ca se s that the physician is called upon to exercise all his
per severan ce a n d in gen uity The sufferin gs of the
patien t are so c on stan t a n d the dan ger of vis ceral com
p l ication s arisin g are 0 immi n en t that the medical
atten dan t h a s to be ever on the alert either to relieve
im m ediate symptoms or to ward off those impen din g
A dded to this the crippled s tate of the patien t by pre
ve n tin g the proper amoun t of exercis e bein g take n the
digestive fun ctio n s become greatly dis ordered a n d
trouble s of the lower bowel superven e whil s t the patie n t
is fortun ate if the cas e is n ot complicated with gravel
s o that re n al a n d vesical sufferin g s a re n ot added to his
mi sfortun es When a ll the s e circumstan ces are co n
s id e re d it is really s urpri s in g the age s these patien ts will
sometime s a tta in fi“ The treatme n t o f these cases must
be based on general prin ciple s sin ce a n y special lin e of
treatme n t is sure in the l on g ru n to do more harm than
good It is often diffi cult to resist the appeal of the s u fier
in g patien t to be allo wed to try s ome far famed s peci fic or
eve n a n Ope n dose of colchicum but permis s ion is fraught
with dan ger sin ce visceral complication s are very liable
to be excited b y them a s a d in stan ce of which came
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p a tien t of m in e re cen tly d ie d a t the age of e i ghty two who
h a d sn fi ered from gout a n d ca l cul ou s d isea se of the k i d ne for
y
forty three years
She su rvive d h owe ver fo ur of the ph si cia n s
y
w h o attende d h er in su c cession vi z Dr Prou t Sir J a m es C le rk
D r B ri n ton a n d D r B en ce Jon es
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97
UR IC ACID
under my observatio n qu ite rece n tly A gentleman
aged six ty six who h ad s u fi ere d from periodic attacks
of gout for some years but which had la tely become more
freque nt the urin e at the s ame time con tainin g tr aces
of albumen had bee n warn ed a ga in s t the use of col
chiou m or qua ck me d icin e s c on tain i n g colchicum fou n d
o n e night his foot un usually pain ful a n d fearin g that
a n attack of gout w a s s uperve n in g which would preve n t
his attendin g a busin e ss appoin tm en t durin g the week
took without con s ultin g his medi cal atte n dant a whole
b ox of gout p
The j oin t att ack subsided but the
patie n t beca me so seriously ill that a m edical man had
to be se nt f or who foun d the patien t had acute
n ephritis the urin e loaded with album e n ; oedema of the
lun gs rapidly s u perven ed a n d the patien t n ot many
hours after he wa s first see n by a m edical m a n died
There is on e drug however which if j udiciously admi
nistered a n d carefu l l y w atched is of the greatest service
in the tre atme n t of chronic gout P aracelsus was the
first to employ Opiu m in the trea tm e n t of gout an d it wa s
his successful treatme n t of a rich prelate of the church
C an o n L ichte n felds for this d isease with this drug t hat
led to his bein g appoin ted Profes s or o f M edici ne to the
Un iversity of B asle Syden ha m wa s loud i n his praises
of this remedy for the relief a n d con trol of the disea se
Of la te ye ars however the practice of givin g opium for
the tre atmen t of gout otherwise than for the relief of
p ain has declin ed Thi s n o doubt is owin g to our bein g
m ore alive to the da n ger o f a n overdo s e provin g fatal if
there is an y kidn ey complication than our predece sors
Whe n however there is n o eviden ce of ren al complica
tio n we may give opiu m Un der its u se the p atien t suf
ferin g fro m chron ic gouty troubles m akes a de fin ite
improve m e nt The attack of pain in the j oints b ecom e
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98
ne w
ACID
less frequent an d less severe the patien t is not so rest
less fretful a n d irritable a n d the dige s tive fun cti on s
o fte n improve in a remarkable ma n n er I t i s a s well,
however to co mbin e some portion of the O piu m with an
aperient I therefore gen erally prescribe two sets of pills
those to be taken at ni ght combin ed with a little
colocyn th or rhubarb a n d those which co n sist simply of
half grain doses of compou n d soap pill (on e te nth grain
of opium) combin ed with a little n u x vomi ca or any
other medicin e I ma y desire to give with it fo r use in
the d aytime
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1 00
O XALIC ACID
lo gi cal con dition that they were so far from bein g
in v ariably associated with a train of n ervou s a n d dys
pepti c sympto m s that they were frequently m et with in
the u rin e of person s apparen tly enj oyin g robus t health
Hereupon a reaction en u ed a n d the opin ion gain ed
groun d that these depo sits had n o clin ical significan ce
whatever a n d it wa s eve n called in questio n w hether
the oxalic acid foun d in the urin e ever exis ted in or wa s
ex creted as such from the blood a n d it wa s sugge sted
that oxalic acid wa s merely a product produced by
In
chan ges occurrin g in the urin e after emis sion
E nglan d these views h ave been ad v ocated by B a sh a m fi“
Ben ce Jon es f a n d Owen Ree s : The latter gen tleman
goe s so far a s to regard oxalate of lime merely as uric
acid or u rate altered afte r s e cretion a n d state s that
he h a s e n tirely failed to detect the peculiar pathological
con dition s which have been s aid to con n ect them s elve s
with the so c alled oxalic acid diathesis a n d is c on vin ced
that it must be regarded a s a n acciden tal a n d u n im p or
tan t mo dification of that mo st sign ificant variation from
health which con s ist s in the excretion of uric acid or its
compoun d s in abn ormally in crea sed proportion This
relegatio n of crystallin e depo sit s of calcium oxalate to a
position of almost ab solute in sign ifican ce except with
regard to the qu e stion of the formation of calcu l i has
received very ge n eral acceptan ce with the profe ss ion
F act however are n ow k n o wn wh ich poin t to the con
clu s ion that oxa l ic acid is formed in the organ i s m a n d
excreted with the urin e a n d that uric acid though it
may be a factor is n ot the o nly s ource from which it is
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R
l D i sea ses p 1 8 7 1 8 70
1 L e cture s on the A pp l i ca tion of C hem istry
a n d Th era p e u ti c s
p 9 8 1 8 67
I Croon ia n L e ctures pp 2 2 99 1 856
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Pa thology
I
O XA L C
AC
1 01
ID
derived either by oxidatio n w ithin the system or by de
compositio n after it has been excreted
W hoever has been in the habit o f makin g frequen t
ob s ervation s a s to the character of urin ary deposit s will
have n oticed that crystals of oxalate of lim e occur m o st
frequen tly in two distin ct classe s of urin es The on e of
deep yellow or oran ge colour of high specific gravity
usually con tain in g a n exce s s of urea a n d phos phoric
a cid a n d turbid with mucus an d urates the other pale
of a C itro n yellow or gree n i s h hue of medium s pe cific
gravity a n d perfectly clear except a t the bottom of the
urin e glass where a s l ight cloud of m uc u s is collected
I n th e
a n d in w hich deposited oxalates will be foun d
fir s t i n stan ce which is the on e mo st frequen tly m et with
the oxalate Of lime may probably be o cca s ion ally formed
from chemical
in the urin e
u b s e q u en t to emission
chan ges takin g place in that fluid especially if it has
been kept s ome time s uch as decompo sitio n of uric acid
a n d urates
or by the oxidation
of the pigm e n tary
matters a n d m ucu s ( acid fermen tation ) I n the latter
case which is less frequen tly obs erved there is very
little reas on to doubt that the oxalic acid comes fro m
the blood a s I hope presen t l y to show A gain urin e s
s uch a s are described un der the fir st category are m et
with un der a variety of pathological con dition s — fre
quen tly durin g the cours e of most febrile di s eas e s in
pulmon ary an d cardiac affection s in which re spiration
is impeded a n d in di s orders of the hepatic fun ction s
I n the s e ca se s h ow ever the presen c e of oxalate of lime
crystals is by n o mean s con stan t ; sometimes appearin g
a n d di s appearin g without a ny apparen t reason or altera
tio n in the ge n eral co n dition of the patien t ; a n d lastl y
if these urin es be fil tered shortly after emis sio n whi l st
still warm , a co n siderable crop of oxalate of lime crystals
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O XALIC
1 02
I
AC D
will subseque n tly form On the Other han d i n the
secon d va riety filtratio n after emis sio n gre atly checks
the te nde n cy to sub s e q uen t formatio n of ox alate of lime
crystals thou gh there is a n abun dan t deposit from a
s am ple of the same un filtered
Un lik e the other form
the urinary phen omen a are usually very p ersi tent an d
the same ch arac te r of urin e is met with d ay after da y
whilst with it is as sociated a form of dyspepsia in ducin g
con siderable emaciation an d atten ded with i nten se n er
vous depressio n a n d hypochon dria s is Had these cli ni
cal disti nctio n s been in s isted on at first a discrep an cy of
opi nio n woul d pe rha ps n ever ha ve arise n Unf ortu
his supporters , findin g
n ately D r Goldin g Bird a n d
oxalate of lime as s ociated in s ome of their case with a
train of di tin ct a n d peculiar symptoms regarded the a p
pearan ce of these crystals in the urin e in every i n st an ce a s
ha vin g a far more exten s ive pathological significan ce than
they really had O n the other han d Dr O we n R ees a n d
those wh o advocated his vie w s remarkin g the number
less in stances in which o x alate of lime deposits are met
with i n the urin e without be in g able to conn ect them
w ith any special pathological con d ition s overlooked or
di sregarded the cas es in which these exception al co n
dition s ha d bee n n oted by other observers an d thus
c ame to rega rd the s e depo sits a s a c cidental an d u n im
portant an d indi ca tin g n othin g m ore than u ric acid or
u rate s altered after secretion
The view tha t oxalate of lime i n u ri n e wa s de rived
from the decompositio n of uric acid was b a sed o n the
hypothesis that uric acid con tai n s the eleme nts of oxalic
acid carbonate of am monia hydro cyanic a cid a n d
formic acid and that the decompo s ition could be e ffected
by simply he ating the urin e The decompositio n of
u ric acid , however , is n ot s uch a simple m atter a s is
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1 04
O XALIC ACID
from this source must be rare a n d exception al Uric
acid too after it is v oided in the urin e may po s sibly
un dergo decomposition but it ca n hardly be s upposed
that s uch a stable body un dergoes spon tan eou s chan ge
without some powerf u l oxidi sin g agen cies bein g at work
to produce the re s u lt yet in typical case s of oxaluria we
frequen tly d i s cover c ry stal s of oxala te of lime as soo n
a s t h ey have h a d tim e to settle a n d co l lect a n d yet h ave
place in the
n o eviden ce that a n y chan ge has take n
urin e sin ce its emis sion A gai n if uric acid by its
decompo s ition yie l ds o x a l ic acid so readily we s hould
expect to fin d it rapidly di s appearin g as the proces s we n t
on
but we have n o e v iden ce that this is the case or at
elapsed
a ll even t s till s ome co n s iderable time h a s
A gain with referen ce to D r O wen R ees s as sertion that
if urin e loaded with urates be heated a n d then allowed
to cool oxalate of lime will after the space of a few
hours be foun d in abun dan ce though n on e may have
bee n dete cte d before This ob servation however has
been qu e stion ed by P a rk e s j " R acle a n d N eu b au erj but
sti l l ad m it tin g it to be c orrect it is s ufficien t to remark
that the applicatio n of heat materially assi st oxidation
a n d a s oxalate of lime freque n t l y occur s i n fre s hly
passed urin e when there is n o deposit of urates a n d
heat is n ot applied a n d there is n o eviden c e of any
chan ge havin g taken place in the urin e itself to accoun t
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k es the statem en t Wh en uri c ac i d is im p erfec tly ox idised
it d ivi d e s i n to ox al i c a cid an d u rea
Fro m th e decom pos itions of
uric a ci d whi ch I h a ve given a b ove it w i ll b e seen tha t th e im p er
f ec tél/ ox id is ed produ ct s a re a lloxa n ure a a n d m es oxa l i c a ci d whils t
o x a l i c a ci d is only obt a i ne d b
y ox i da ti on b e i n g carri e d to its ul ti
m a t e s ta g e
O p cit p 224
Archives des Vere i n s
1 Lieb ig s Anna l en B a n d cvi p 59
B an d iv p 7
a so m a
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for
1 05
ACID
the formation of the crystal s it has but little bear
in g on the question
From a con sideration of the foregoin g I thin k the
con clusion may f airly be arrived at that the con dition s
un der which oxalic acid is formed from u ric acid in the
system are extremely limited a n d exception al I f oxalic
acid is formed d irectly from uric acid within the s ystem
it mu st be un der con dition s which promote in creas ed
oxidation within the body— such for in stan ce as pure
air exercise sea bathin g &c — con dition s which it n eed
h ardly be said are ge n erally re sorted to for its removal
I n the s e c on d place without de n yin g the pos s ibility of
oxalic acid bein g ultimately form ed in uri n e s from the
de compo s ition of uric acid I thin k we may affir m that
n o deposit of oxalate of lime occurrin g in urin e within
twelve hours after emis sion is due to that caus e
But it may be a sked if we thu s limit I may almo st
s a y di s card the uric acid hypothe si s H ow are we to
accoun t for the frequen t appearan ce of oxalate of lime
in the uri n e ? The reply is to be foun d in the fact that
oxalic acid may be derived from a variety of s our ce s
a n d is foun d in the urin e un der a variety of cli n ical an d
pathological con dition s
1 D irectly from food by the in gestion of s u bsta n ces con
ta in in g oxa la te of lim e — I t is a well k n own f act that
ox alate of l ime cry stals have been foun d in abun dan ce
in the urin e of person s wh o have attempted to poi s on
themselve s with oxali c acid ; a nd experimen ts)“ have
s hown that when n on poi s o n ou s do s es are taken about
twelve per cen t of the acid taken by the mouth appear s
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quote d b y B ea l e K i dn ey D i seases
p 38 1 Third e d ition See a l so exp eri
a n d Ca l cul ou s D i sorders
m en t s b y D r Dy c e Du ckw orth a nd D r L ea re d
St B a rthol om e w s
H ospita l Rep orts 1 866 an d Med Tim es an d
1 867
3“
B
u ch eim
an d
Piotro wsky,
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1 06
ACID
oxn m c
as a lime salt in the urin e
M any fruits an d vege
t ables such as rhubarb sorrel tomatoes on io n s a n d
turn ips con tain crystal s of oxal ate of lime a n d to m an y
person s in weak health in dulgen ce in such articles is
in varia bly followed by a n attack of in digestion an d the
app aran ce of cry stals of oxalate of lime in the urin e
e
It h a s ho we v er been urged that oxalate of lime can n ot
thus be ab sorbed from the in te stin e in to the sy stem a n d
pas s out un chan ged in to the urin e on accoun t of its
great in s olubility in water Reoob however ha s demon
s tra te d that the in solubility is exaggerated
a n d he
poin ts out that S torer in his D iction ary of Solubilitie s
give s the solubility of oxalate of lime in water as 3 3 6 16 6 6
This n o doubt appears mall ; but a s oxalate s are n ever
re cogn is able without the microscope an d seldom appear
larger than a blood corpus cle so that as R eoob argues
by takin g the spe cific g ra vity of a n average crystal a s
equa l to a cube of water N IW1: of a n i n ch in the side
si n ce cube s are to on e an other a s the cube s of their sides
it follows tha t a cubic in ch of w ater would be equal to
of the s e crystal s
a n d would therefore
accordin g to Storer d i ss olve
a n d te n oun ces of
w ater wo u ld di s s o l ve
of the s e crystals ; hen ce
a s we do n ot often meet with a larger proportion tha n
this in the urin e the amoun t of blood circulatin g in the
body is m ore con siderably more than s ufficien t to keep
thi s quan tity in solution U ri n e s con tain i n g oxalate of
l im e directly derived from the food are rarely altered in
their gen eral characters a n d the crystals ceas e to be
depo sited at n o v ery d i stan t period after their in gestion
N o sen se of discomfort may be occa sion ed by their
pas sage through the system at mo s t a mere passin g
attack of in dige stion or in crea sed urgen cy duri n g m ictu
rition if there be a ny u rethral or vesical disease caused
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1 08
ACID
ox x m c
i n crease of these products in the urin e This is probably
the most frequen t cause of the appearan ce of oxalate of
lime depos its in the urin e a n d they are met with un der
a v ariety of pathological con dition s freque n tly durin g
the cours e of most febrile dis eas e s in pulmon ary a n d
cardiac affection s in which re s piration is im peded a n d in
dis orders of the hepatic fun ction s a n d depre s s ed con di
tion s of the n ervou s sy stem The urin e s in the s e ca s es
are gen erally of a deep oran ge co l our of high aver age
s peci fic gravity with a n ex c e ss of urea a n d phosphoric
acid a n d are u sually turbid with m ucu s an d urates
while the depos its of oxalates are n ot u sually persi sten t
often dis appearin g for a few days to return again in
great abun dan ce The oxalic acid in this case probably
is from rea s on s already stated n ot derived from the
decompositio n of uric acid either in the blood or su b se
quen tly in the urin e after em i ss io n The m o st ration al
explan ation of its appearan ce bein g that the pro ces s of
oxidation w ithin the body u n der circumstan ce s of
in creased tis sue m etabolism is on l y sufficien t to reduce
a certain quan tity of n on n itrogen ou s fa tty acids formed
w ithi n th e body to their lowe st term of carbon ic acid
a n d con seque n tly oxalic acid which is o n e of th e series
appear s in the urin e
4 F rom the m u cu s of the u rin a ry p a ssa ges —C rystals
of oxalate of lime have been foun d in the mucu s of the
gall b l adder a n d in the grav id uterus a n d it h a s there
fore been sugge sted that the cry stal s that appear in the
urin e may hav e their origin in the mucus of the gen ito
urin ary passage s In s om e cas e s thi s is probably true
but in the maj ority of in stan ce s we have n o eviden ce
of a n y morbid
con dition of the urin ary pas sages to
accoun t for their appearan ce I t is probable how
ever that calculi composed of oxalate of lime result
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o xa n
e
ACID
1 09
from chemical chan ges takin g place i n the mucus o f
the urin ary pas sages for as Profe s s or Parkes h a s re
marked n o on e can ob s erve the en ormous amoun t
of oxalic acid i n calculi a n d believe that such abun dan c e
could ever come from the blood ”
A very i n ge n iou s
hypothesis h a s been advan ced by Meckelf to accoun t for
thi s for m ation of oxalate of lime in mucus by as sum in g
that the m ucous membran e of the urin ary pas s age s
become the seat of a s pecific catarrh In thi s catarrh
a tough adhesive mucu s is secreted which has a ten
den ey to un dergo acid ferme n tation a n d in which
oxalate of lime appears whe n s uch fermen tation occur s
A t fir s t thi s oxalate of li me mucus is of gelatin ou s con
sisten ce but gradually it take s u p more an d more
oxalate of lime from the decompo s ed urin e a n d thus
growin g more an d more firm a ston y con cretion is at
len gth formed The large a n d n umerous crystals of
oxalate of l ime so frequen t l y observed in the urin e of
pers on sufferin g from spermatorrhoea are mo st probab l y
derived from the mucus of the gen ito urin ary pas sages ;
f or if a patie n t sufferin g from thi s malady be d irected to
collect the urin e pa s sed at stool in a small ve ss el a n d
als o the s em i n al a n d mucous discharge which gen eral l y
f o l l ow s micturition durin g the a ct of defae cation s epar
ately in a te st tube or on glas s slide it will be foun d
that both the urin e an d the discharge con tain oxalates
which are moreover in timately mixed up in the latter
thus in di catin g a n in trin sic origin It is n ot improbable
that the oxala te of lime depo s i ts so frequen tly observed
in the urin e s of ataxic patien ts especially durin g the
so called u rin a ry crises may origin ate i n this way , owin g
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p 22 3
1 Tex t b ook o f Pra ctica l M ed ici ne
v ol ii p 74
cit ,
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by D
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F
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von
N ie m eyer
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1 10
ACID
ox a m c
to an ab n ormal co n dition of the mucous membran e of the
urin ary pass ages resultin g from disturbed innervation
5 F rom excess of a cid in the sys tem — B en eke has
poin te d out th at the in crea s ed productio n of lactic an d
butyric a cids i n the alimen tary can a l is freque ntly asso
sin ce as he thin ks the exce s sive
cia te d with ox aluria
f ormation of the e a cid s preven ts the developme nt of the
red corpuscles so th at oxidation is in su fli ciently per
formed A catarrhal con dition of the mucous mem
bran e of the inte sti nes he al s o poin ted out a s bein g fre
quen tly foun d ac compan yin g thi s con ditio n ; he does
n ot however, con sider it as bein g a pro xima te but on ly
a dete rminin g cause of the dis order Whilst en dorsin g
B en eke s st ate men t that deposits of oxal ate of lime are
met with i n perso n s suff e ri n g from dyspepsia atten ded
w ith excessive form atio n of la ctic an d butyric acids I
do n ot co n sider his explan ation to be the correct on e
sin ce in these ca ses I belie v e a catarrh al co n ditio n of the
mucous membran e of the dige stive can al to b e the
proximate cause which by hin deri ng the o nward pas
s age of the food favours f ermen ta tive chan ges a nd the
productio n of lactic a n d butyric a cids These acids
which are formed in small quan tities in the large in tes
tin e in he alth bein g absorbed in to the blood are n or
mally reduced to carbo n ic acid which un der ordin ary
circumstances passes ofi with the other carbo n ic acid
If however the pro
f orm ed in the body by the lun g s
c e ss of respir atio n be at all impeded some of the car
b onic acid may be elim ina ted by the uri n e combin ed with
the oxides of potash a n d s oda in the form of alk alin e ca r
b on a tes causin g a n al kalin e c on ditio n of that secretion
O r if the acids abs orbed from the in tes
(pp 4 7
A Form of D y sp e p si a as socia te d
The L ancet Jul y 188 0
w ith a n Alk al i ne C on dition of the Urine
B y th e Au thor
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1 12
A
m
0m
CID
oils ; situation s , in fa ct , in which catarrh al affectio n s of
the in te stinal can a l are likely to be en ge n dered
A lthough in bo th c on dition s the men tal s tate is more or
less affected still it assumes a diff eren t a spect i n ea ch
In lithaemia the patie n t is irritable fretful peevis h
but he is r arely
a n d di s con te nted with those arou n d him
at fault with himself or hypochon driacal I n ox aluria
however the p atien t is ge n erally amiable an d easy tem
pered with his relation s an d depe n den ts but is himself
filled with the deepest gloom an d foreb odin gs an d is
painful l y hypochon driacal In oxaluria the bowels are
irregular co n stipation at times al ternatin g with a
colicky diarrhoea of frothy yeasty ch aracter an d n ot in
freque n tly a ccompan ied with co n siderable dis charges of
blo od The urin e is usually of a pale greenish colou r
and the quantity passed in the twe nty four hours n ormal
i n quan tity an d spe cific gravity Its chief characteristic
is the deposit of cry st als of ox al ate of lime which a re
f oun d most a bun dan tly in the morn ing uri n e pas s ed on
Owing to the pre se n ce of the s e c rystals
first ri s in g
causin g irritatio n of the mucous membran e of the bla dder
micturition is frequen t an d urgent though the quan tity
Tra ce s of sugar are n ot
of urin e passed is n ot l arge
inf requen tly pre sen t an d s ometime s sugar for a while
repla ces the depo s it of oxala tes an d vice e ers d This
transformation has bee n accoun ted for by the hypothesis
th at whilst ox alic acid den oted a con dition of imperfect
oxidation s ugar represented a still lower The appe a r
an ce therefore of oxalate s with a dimin utio n of the ex
cretion of sugar h a s frequen tly bee n take n a s a favorable
however which I do
symptom of di abetes an opini o n
The urin e occas io nally
n ot thi nk altogeth er warra n ted
co ntain s a n exce s s of phosph ate of lim a though this
co n dition is not n early so frequ e ntly obse rved i n this
s
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O XALIC ACID
1 13
form of oxaluri a a s in the case where the deposit of oxa
late of lime re s ults apparen tly from i n creased ti ssue
metabolism a n d in which as has bee n already stated a n
in crea se of urea is also ge n erally n oted V arious reason s
have bee n as sign ed to accoun t for the a s s ociation s of
deposits of oxalate s with occa s ion al excess in the elim i
n ation o f phosphate of lime in the urin e
The most
probable explan ation is that it origin ates in two ways :
—a I n those cases where there is a n exce s s of urea the
i n crease in the elimin ation of the pho sphoric acid is the
result of the in creased metabolism of the tis s ues gen e
rally b W here the depo sit s of oxalate of lime are
a ss ociated with catarrh of the in testin al can al a n d the
f ormation of lactic a n d butyric acids is exc es s ive the
phosphate of lim e is derived n o t from the ti ssue s but
from the alimen tary can al the lactic acid havin g a
po werful solve n t action on this salt ; so that if it is
i n troduced in excess with the food a larger proportion
w ill be di ss olved ou t a n d pass in to the system than
would otherwi s e be the cas e In addition to th e men tal
depression already men tion ed patien ts sufferin g from
thi s for m of oxaluria are troubled with man y a n omalous
Thu s a
s ymptoms i n d icative o f n ervous di s turban ce
b u rn in g s en a tion is u s ually felt acros s the l oin s aecom
p anie d by a feeli n g of tightn es s an d draggin g roun d the
abdomen shootin g a n d burn in g pain s in the l ower lim bs
twitchin g of certain groups of m u scle s with often a
fee l in g of n umbn e s s deadn ess a n d coldn e ss in diff eren t
parts of the body The s e s ymptoms whe n presen t
together may lead us to in fer that the patie n t is s uffer
in g from a n early stag e o f locomotor ataxy a s wa s the
case with a n ou t patien t at pre en t un der my care at the
L on do n H o s pital when he fir st came un der obs ervation
The fact , however that other characteristic symptoms
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8
1 14
oxx m c
ACID
were absent a n d did n ot develop a n d that he im prove d
on a treatme n t directed to the relief of the dy s peptic
co n ditio n dis pelled a n y d oubts on that poin t
W ith regard to the treatmen t of the co n dition s we
have bee n de s cribin g In those ca s e s where the deposit
man ifestly arise s from the in gestion of articles of food
con tain in g cry s tal s of oxalate of lime it will be s uffi cien t
to poin t ou t what the s e are a n d to di s co n tin ue their u e
I f the depo s its ari se in directly from the food owin g to
in complete oxidation of the saccharin e oleagin ou s a n d
albumin ous prin ciple s it will be n ece s s ary carefully to
regulate the diet with regard to quan tity a n d quality
a n d to promote th e oxidi s in g processes withi n the body
by mean s of iron chan ge of air sea bathin g &c In
those ca ses where oxalate of lime deposits seem to aris e
from in crea s ed tissue meta b olis m as evide n ced by a n
in creas e in the am oun t of the urin ary co n stituents more
e spe cial ly the u rea a n d pho sphoric acid excreted daily
in quiry mus t be m ade in to the n ature of the con dition s
prod u cin g s uch di sturban ce a n d the treatmen t directed
accordin gly I n th e ca se of calculou s depo sits of oxalate
of lime it w ill be profitable to remember that the oxalic
a cid has po ss ibly its origin i n the mucus of the urin ary
passages a n d n ot n ecessarily in the blood a reflection
which ought to direct our atten tion rather to the tre at
men t of a n y local morbid con ditio n that may exist in
them than to the employmen t of remedie s design ed to
gen erally La stly with regard to
a ct on the sy stem
the s e ca s e s of dy spep sia associated with more or les s
per si sten t depo sits of oxalate of lime an d to which
alon e as I hav e stated the term oxaluria seems
applicable O u r effort at treatme nt must be directed
almost en tirely to the relief of the catarrhal co n ditio n s
on which the dyspeptic sympto m s depe n d
This is best
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CHA P T ER VI
DE R AN G E M EN T S AS SOCIAT ED W I T H TH E EXCE SSIVE
ELI M INAT ION O F P H O SP HO R IC ACID
amoun t of phosphoric acid p a ssin g out of the
system i n the cours e of the tw enty four hours averages
from
grammes to 3 grammes an d is distributed
am on g the four bases pota sh s oda lime an d m agnesia
in the propor tion of about two thirds combin ed with the
alkali ne oxides a n d on e third with the oxides of the
earths The alkalin e pho sphate s are extremely soluble
an d therefore are never depo s ited from the urin e On
the other han d th e earthy phosphate s are o nly soluble
i n acid olu tion s so that when the urin e becomes
n eutr al or alkalin e they are depo s ited Thus it h appen s
th at a deposit of the earthy phosphate s is by n o mean s
an indicatio n tha t they are in excess a n y more than the
f act that n o deposit is present is a n assuran ce tha t they
are bein g excrete d in n ormal amou nt S o lon g a s the
urin e rem ain s a cid a con s idera b le quan tity of pho s
phoric acid may be pa sin g out of the sy s tem without
givin g eviden ce of its pre s en ce whil st if the urine from
urs
an y cause become s alkal in e a deposit at o n ce oc c
alth ou gh the phosphoric acid may n ot be elim in ated in
excess I t is , therefore of the greate st importan ce to
determin e quantitatively the amoun t of pho s phoric acid
p a ssin g ou t of the system d aily in a n y doubtful ca se ;
TH E
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P H OS PH O R I C
A C ID
11 7
sin ce the depo s it s depen de nt upo n an alkaline conditio n
of the urine have rarely a gra ve import except tho s e con
n ecte d with the triple
pho sphate whilst persisten t
exces sive elimina tion with or without depo sitio n of the
ea rthy pho sph a tes is gen erally a ssociated with grave
co nstitution al di sturb a n ce
When human urine become s a lkalin e it is due to o n e
or other of the followin g c onditions :— 1 To exces s of
the fix ed a l ka lie s chiefly the alkali ne c a rbon a tes of
potash an d to some extent of alka lin e ph o sph a te s of the
s a me ba s e s
2 To the pre s e nce of volatile a lka li by the
formatio n of ammonia in th e urin e from decomposition
of the urea
The con dition s which lea d to the ex ces s ive eli m ina tio n
of the car bo nates of pota s h a n d s oda by whi ch the
a lka lin e co n ditio n of the urin e due to fi xed alka li is
almo st en tir
ely produced have been already discu ss ed
a t le n gth
a n d theref ore n eed n ot be
(pp 4 7
entered upon a ga in It is however n eces sa ry to p oin t
out that the urin e in the se ca s e s is n ot alwa y s distin ctly
and
a lk a lin e but o fte n n eutral a n d eve n fai ntly a cid
tha t n o depo sition of ea rthy pho sph a te s is ob served till
the u r ine is boiled when a white cloud of pho sph a tes
is precipitated
On te stin g the urin e n ow w ith litmu s
p a per it will be foun d to be di sti nctly a lkaline the heat
h a vin g expelled the carbo nic acid held i n s olution a n d
which gave to the urine its faintly a cid reactio n If a
few drop s of minera l a cid be added to the urin e with a
v iew of d i s coverin g whether the precipitate wa s ca u s ed
by a lbumen or by pho sphate of lime bri sk efle rvescen ce
occur s s ho win g that carbonate s are pres ent i n co n sider
able a mou nt
Whe n the urin e is a lk a li n e from the pre sen ce of
vola tile alkali we have i n ad d itio n to the depo s it of pho s
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P H OS P H O R I C
1 18
AC I D
phate of lime cry sta l s of ammo nium magn e sium
pho sphate The ammoniacal condi tion of the urin e is
due to a ferme nt which ca n be i solated by fi ltra tio n ; it
cons ist s of sp herical globules which s ettle at the botto m
of the vess el a n d appear to increa se by bud d in g This
a mmo niaca l ferme ntatio n of the urea t a ke s pl a ce in the
urine o nly after its secretio n by the kidn ey s a n d doe s
n ot o ccur in n ormal u rin e un le s s it be come s mixed with
the products of decompo sition from the mucus of genito
u ri n ary tract or the ferme n t i n troduced i nto the bl a dder
by dirty catheter or the uri ne already alkalin e from fixed
I have
a lk a li is received in to dirty chamber ve ss els
a lready (p 49 ) expla in ed how the irride s cent film co n
s isti n g of cry sta l s of a mmo n ium magn e s ium pho sp hate
o cca sion ally fou n d o n the s urface of urin e of pers o ns
s uff ering from fla tu len t dy spep sia is due to the l a tter
cau s e The pres e nce therefore of cry stals of triple
pho sphate when pers is te n t i n the urin e a re in dicative of
lo ca l diseas e of the urin a ry organ s an d n ot the d irect
re sult of con stitutio n al di sturb a nce Th e t reatment of
ammonia c al uri n e mu st therefore be directed to the
relief of the mo rbid con ditions existing i n the gen ito
It is
u rin a iy tract a n d the de structio n of the ferme nt
a
con dition tha t is often extremely difficult to deal
with but the plan of treatme nt I have fou nd the mo s t
sa ti sfa ctory is the per s i sten t admi ni s tratio n of b e n zoate
of s oda combin ed with turpentin e a n d op iu m fi’ a n d wa sh
in g out the bladder twice a week with a on e per cent
s olutio n of hydrochloric a cid
Wh e n however we ha ve to deal with the p ersistent
elimin a ti on of pho sphoric acid in exce s sive quantities
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ges ; O l e i Tereb in th in ae aj
Mu cila ginis A cacia
Syru pi Tolu tnn aa gsa
3
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ss s
3vj
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Sod ai B
en zoat
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Two tab
l espo
l th ree tim es a d ay
on fu s
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L iq O pii Sed
A qu a a d
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1 20
P H OSPH O R I C
AC I D
atten ded with a superabun dance of urea—a zotwria
P arke s “ al so supp orted the view that diabete s in s ipidu s
wa s to be foun d exi sti n g u n der three d ifi eren t co n
dition s — (l ) I n ca s e s where there is n o i nc rea s e or
d ecre as e of ti ss ue metamorpho s is ; (2 ) i n ca s e s wh ere
there is a decided decrea s e of tiss ue m etam orpho sis ;
c
a s e s where there is evide nce of i n crea s ed tissue
3
( )
metamorpho sis a s h own by the in crea e of some of the
T o thi s latte r cla ss of ca se s P rofe ssor
u rin a ry s olid s
P arke s think s the term p olyuria preferable to that of
azoturia which only express es the fact of the urea bein g
i ncrea s ed ; whereas in the ca s es quoted by him the fixed
salt s a s chloride s s ulphate s an d pho sphate s were al o
pre sen t i n abnorma l quantities
L a stly the term
baruria
which wa s first introduced by the late
D r F u ller in de s cribing certain form s of d y spep sia
a ssociated with exces s of urea in the urin e might be
advan ta geou sly employed whe n o nly the solid m atter
is i ncrea s ed but n ot the wate r
L ately, Dr Tessierf
of Lyon s h a s recorded a s erie s of ca s e s clo s ely re semblin g
s accharin e diabete s i n the i n creas ed di scharge of urin e
the thirst the n euralgic an d rheumatic pains the
wa stin g an d the seco n dary lung c omplications o nly
that no trace of suga r could be foun d i n the uri ne an d
that the con stant phenomeno n was a very con siderable
in crea s e in the quantity of phosphori c acid excreted
(fifte en to twenty gram mes of ea rthy pho sph a tes i n
twenty four hour s) I n s ome of D r Tessier s case s the
urea wa s also elimin ate d in exce s s, but not in all a fact
which D r Tes sier th ink s serves to di s ti n guish them from
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Ed
H ea
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P rk e
a
s,
MD
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th a n d D ise a s e
L J Tcssier,
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F ile, 1 8 77
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The Com position
of
the Ur in e in
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D
u
D iab ete Ph ospha tiqu e
’
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Paris
,
B a llié re
ct
P u osp n o m c
AC I D
1 21
the ca se s origina lly de scribed a s a zoturia
D r Tessier
ha s given the n a me pho sphatic dia bete s to thi s cla s s
of ca se s H e divide them into four group — 1 Tho se
i n which n ervo u s sympt om s are predomina n t 2 Tho s e
which a cco m pany pulm o na ry c on sumptio n 3 Th o se
which alternate with or coexi st with sa ccharin e diabete s
Th os e which run a di stin ct co urs e re semblin g sa c
A s a few ca e s
ch arin e diabete s but without s ug a r
re semblin g in m a ny respect s tho se described by D r
Tes sier h ave come un der my ob servatio n although i n
n on e of them were the symptom s s o ma rked or the
excretio n of ph o sphoric acid so con sidera ble a s in tho se
de scribed by him I give a brief account of them , s in ce
they m a y be of some servic e i n ill u stratin g this in
tere stin g an d ob scure p oin t i n u rin ary pathology
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C ASE 1
P otywria with in crea s ed"
excretion o
f p hosp horic
—J H
n ervoa s s m
t
a cid a n d u rea
o
m
s
a ged s ixteen
y p
wa s a dmitted into the Sea m en s Ho spital July 1 8 76 i n
a s tupid semi comato s e co nditio n , extremely feeble a n d
em a cia ted Weight u n der 9 st n o grea t thir st ; pas s
i n g large quantities of urin e of medi um speci fi c gravity
with trace of a lbum en ; n o suga r N o hi st ory of syph i
A na ly is of the twenty four
lis or inj ury to the he a d
hour s urin e gave the followin g re s ult
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Quantity
S peci fic gravity
E a rth s
(
Pm sph om
A lkalie s
Urea
l
:
1 01 0
M
d)
{ }
29
51
'
52
gram m es
gramme s
.
.
The lad rema in ed i n bed for several day s in a dull
The
s tupid co n ditio n a n d the n gr a du a lly brighte n ed
diures is co ntin ued excess ive durin g the whole period of
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P H O S P H OR IC A C I D
1 22
tay in ho spit a l the specifi c gravity ran ging from
1 0 1 0 to 1 0 15
H e wa s treated s ucce ss ively with large
do ses of v a leria n with s ma ll do se s of opium with cod
liver oil a n d quinin e H e im p roved greatly un der
trea tm e nt with regard to his genera l con dition but he
I n thi s c a se the
wa s stil l polyuric when di sch a rged
quantity of urin e pa ssed wa s a b out three times the
about d ouble (ca lcula ted from the specifi c
s olid s
gravity) the pho sp horic a cid m ore than treble an d the
urea ra ther more than double the n ormal for a la d of
I n thi s c a se there wa s a decided in creas e of
his age
tiss ue meta mo rp h o si s a s evide nced by excessive exore
tio n of urea and pho sphoric acid the latter e specially
I t come s un der D r P a rke s third de finitio n an d corre
s pon d s with the fi r st grou p of D r Te ssier
h is
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C A S E 2 P olywria
elim
ina tion
f p hosp horic
a cid ; d ea th ; sm a ll syphilitic ga m m a a t ba s e of bra in
T G
aged twenty fo ur a patient of the l a te D r M u r
c hi s o n c a m e und er my ob s ervatio n on A ugu st 24th
The
1 8 78 durin g D r M urchi s o n s ab sen ce from tow n
patien t a slight man weighin g a bout 9 st ha d been
a ilin g four or fi ve mo n th s ; s ight failin g for a mon th
but ha s got r a pidly wors e durin g the last week ; cannot
n o w read or cou nt fin ger s whe n he ld up
P a ssin g la rge
qu a ntitie s o f water syphili s five year s ago O ph thal
m oscopic examin a tio n o nly revea led s light ful n e ss of
veins H e wa s instructed to collect an d mea s ure urin e
an d brin g s om e for analysi s n ext vi sit A ugu st 28th
P atie nt m u ch wor se ; compla in s of viole nt p a i n i n head
Quantity of urin e pa ssed in the la st twenty fo ur hour s
9500
rea ctio n n eutra l ; sp gr
ph osphoric acid
A ugu s t 30th — V iole nt pai n in head ; n ow
6 gramme s
quite blin d a s he required m ore care an d attention
in crea sed
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P H O SP H O R I C A C I D
1 24
No
apparen t di seas e of a bdomin al or thoracic viscera
Urin e pale
D ige stio n fa irly go od ; bowel s con stipated
whey like of m edium specifi c gravity alka lin e reactio n ;
n o suga r ; no albume n Sta tes that he pa s s es more
u rin e th a n he should a n d is frequen tly di sturbed at
n ight to p a s s it
In st ruc ted h ow to collect a n d measure
it an d to brin g a sa mple of the mixed twenty four
hours urin e at the next vis it Th e patient however
did n ot comply with a ll the con dition s n ecess ary for
accura te m ea s u rement, a n d it wa s n ot till O ct 21 st that
I wa s sa tis fied th a t my in structio n s h a d b een carefully
carried out B y tha t time he had been five weeks u nder
tre a tmen t (minera l a cids a n d n ux vomica) a n d h a d im
proved to so m e ex te n t A n aly sis of twenty four hour s
urin e : O ct m et — Qu antity 2300
gr 1 01 5 ;
sp
reactio n a lkalin e
P ho s ph oric a cid 78 grm s
treble
wh a t it sh ould be fer a m a n of his weight O rdered
Codeia pill on e third of gra ih a n d a mixture with
bromide of pota s siu m a n d nux vom ica N ov 1 8 th
V ery much imp ro ved ; is g a in in g Weight feels str on ger
h a s n ea rly lo st the pa in s di scharge of urin e still more
abundan t tha n it s hould B e To collect an d mea sure it
a s before a n d b rin
To co ntinue
g a sa mple a t n ext vi sit
m ixture s but to di sco n ti n ue the codeia
N ov 2 5 th
A n a ly si s of urin e qua ntity 2 300 sp gr ; 1 01 5 re a ctio n
alkaline P ho sphoric a cid
urea
grma
grm s
C onti n ued to atten d OE an d o n a s a n out patie n t till
N o vember 1881
H is gen eral co n ditio n wa s the n much
improved and he re sumed regul ar work
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C A SE 4
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E x cessive
elim
in a tion
p hosp horic a cid ; n o
ou s qu a n tities of ca lciu m
p olyu ria hyp ochon d ri a sis en orm
’
—
ox a la te in u rin e
A ge n tlema n s
s
eve n
.
f
o
erva nt a ged t wenty
F irst came un der ob s ervatio n S ept 28th , 1880
s
,
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PH O SPH O R IC
H e is
AC I D
125
a thi n s pare man weighin g about eight an d a
half ston e ; of sallow haggard complexio n N o history
of syphilis ; ha bit s tempera te C omplain s of a chin g
pai n s s pecially in the loin s s ho otin g do wn the hips
a n d o cc a s io nally afi e ctin g the bladder an d te sticle s
A bdomin al a n d thora cic
A lleged lo ss of virile power
organ s apparently hea lthy D igestio n fa ir bowel s
co nstipa ted
F eel s very wret ched a n d depre ssed
Urin e passed a t the time of vi sit ( 11 a m ) a cid ; specifi c
gravity 1 028 co nt a in in g 8 grm s of pho sphoric acid
Th e s ecretio n of urin e he sa id wa s not
i n 1 000
exce ssive ; he wa s rarely troubled durin g th e day
but frequently at n ight with call s to micturate (H e
wa s reque sted to collect a n d mea su re the urin e for a
few day s a n d send a n ote with rega rd to the qua ntity
p a s sed in the twenty four hours ; this proved to be
j u st u nder two pint s or a bout 1 1 00 c c ) The urine
he pa s s ed i n my pre sen ce depo sited i n a few h o u rs a n
en ormo u s quan tity of oxalate of lime ; n o sugar ; n o
albu men O rdered codeia pill a qua rter of a grai n a t
n ight a n d a mixture of hydro chlo ric a cid in nux vomica
liver oil N ov 1 8th — I s much better L ess
a n d cod —
p ai n in loins N ot so de spo ndent though still fears he
is impoten t ; con fe s se s however to o cca s io n al manife st
his n ature
To discon tinue codeia an d ta ke
a tion s of
pho sphoru s pills on e sixtieth of a grain ins tead To
collect urin e for twe nty four hour s an d s en d it for
D ec l st — Quantity 15 20
ex a min a tion
gr
sp
phosphoric acid 5 2
1022 urea
grm s
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C A SE 5
a cid ,
.
P olyu ria
co- ex istin g
with
in crea sed elim in a tion
ild
f p hosp horic
o
— A
l
os
c
u
/
r
i
a
gy
f
f
Th is ca se correspon d s w ith th ose or ig in a lly d e scribe d b y
Z u r P h ys a n d
B e n ek e of ph o ph a turia com b in e d w ith ox a l u r ia
Path d es Phosp h ors u nd Ox a lsau re Kalk e s 1 850
a
m
orm
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PH OS P H O R I C
126
AC ID
gentleman aged thirty seve n who for the la st eighteen
mo nth s ha s suff ered in termittently from a mild form of
glyco suria which did n ot a pparently affect his genera l
health began i n the au tum n of the pre s ent ye a r (1 8 80)
to sn fi er fro m con stant a chi n g borin g pains in the
loins shootin g roun d the pelvic regio ns with occasion al
cramp like s ensatio n s in the bladder a n d a tired sore
feelin g i n the mu scles of the thigh s a n d calve s of the
legs H e al so bec a me dispirited a n d hypocho ndriacal
began to lo s e weight an d fle sh The amount of s ugar
pa se d h a d n ever bee n exce ssive a n d had a lway s bee n
At thi s time he wa s
co ntrolled by re stricte d diet
certain ly n ot pa ssin g more s ugar than he h a d d on e in
the earlier stage of his illn ess an d it aga i n di sa ppea red
when he pl a ced hims elf o n re stricted diet for a few day s
Still however the pain s a n d ma lai s e co n ti nued
O n O ct 12th the urin e w a s collected for twenty four
hour s a n d sub sequently o n O ct 14 th an d 1 5th a n d
N ov 3rd 2 l st an d 26th
On each o cca sio n the a moun t
o f p ho sph o ric a cid pre s e n t wa s e s timated with the fol
lowin g re u lts
tity
Sp g Ph ph ric id
S gr
Ur
Q
-
,
,
,
,
,
,
,
-
,
,
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,
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u an
,
r.
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os
o
ac
u a
.
O ct 1 2th 2 020
c. c.
1 01 8
l ath 2 300
c. c .
1 01 5
n il.
1 5 th 1 5 2 0
c. c
1 02 0
n il.
.
N ov
.
3rd 2 5 00
c.c
.
grm
2 1 st 2 35 0
c . c.
10 19
2 6 th 2300
c . c.
1 01 8
.
n il.
s.
d er a b l e
10 1 2
.
ea
.
con si
69 grm
s
.
The patient began taking codeia i n half grain do se s
at bedtim e o n the night of O ct 12th an d co ntin ued to
t a ke it till O ct 25th ; it wa s then d i sco nti nued a s he
wa s feelin g better
On N ov 3rd the pain s h owever
-
.
,
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,
.
.
P h osph oric a cid in com b ination w ith
w ith the al k al ies
grm s
1
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,
the
ea rths
,
,
grm s ;
.
1 28
AC I D
P n o srn on rc
the tem perature wa s normal ; the pulse weak an d feeble ;
chest s ou n d s natura l with the exceptio n of so me coa r s e
miles i n the large bro n chial tu b e s
Urin e cle ar acid ; n o
albumen ; n o suga r H e sa y s the pres en t illn e s s com
m en ce d three week s previou s to admi s s io n but he had
otherwi se alway s enj oyed good health D urin g this
H e ha s
a ttack he had lo s t eighteen pou n d s in weight
a spin al curva ture the s eve nth an d eighth dor sa l vertebrae
bein g the b on es affected a n d he h a s al s o a strumou s
a ppear a nce gen era lly
O n N ov 1 9th s even day s after
admi ssion the mucou s rales in the ches t h a d cleared up
an d he wa s n ot so pro s trate The puls e wa s stro nger
a n d the temperature had rema in ed n orma l duri ng the
time he had been i n the ho spital Still the pa tient in
the absen ce of any definite symptom s wa s extremely
feeble a n d weak Although no suga r had bee n found
in the uri ne it wa s thought a dvisable to c ollect the
u ri n e for twenty four hour s a n d the n t e st for th a t su b
N ov 2oth — The urin e
stan ce in the whole quan tity
collected durin g the last twenty fo ur hour s mea sured
4 600 c c a n d had a sp eci fic gra vity of 1 01 0 but ga ve
n o reactio n with F ehlin g s s olutio n
N ov 21 st — The
quantity of urin e collected in twen ty four hour s m ea
s ured 14 00 c c a n early n ormal qua ntity but the specifi c
gravity h a d ri sen to 1 029 so that the relations hip between
the solid s excreted o n each d a y wa s tolerably co nstant
a n d exceeded by a third the normal excretio n
The
uri ne wa s c ollected m ea s ured a n d the specifi c gravity
ta ke n s ub s equently each d a y duri n g the patie nt s stay
in the ho spit a l ; but it will be su fiicien t here to state
that the a verage quantity p a ssed by the patient each
day for a m onth wa s 32 63 c c with a speci fic gravity of
1 01 7
Ta kin g the healthy excretio n of a n adult so be
a t the out side 1 500 c c , wi th a s peci fi c gravity of 1 020
,
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P H OS P H O R I C
A C ID
1 29
the
patie nt wa s pas sing more t han t wice the n orma l
quantity of urin e an d excretin g o n e thi rd more tha n
the ordi nary quantity of urina ry solid s
The urea an d pho sphoric acid were determin ed qu a nti
ta tiv ely on several occ a sio n s by the hou s e phy s ician
D r M urphy with the followin g re s ult :
tity f
Ph p
Q
Uri
Sp g
Ur
A id
D t
cc
Gr
Gr
,
.
-
,
,
u an
.
e c.
oa
ne .
a e.
D
o
r.
.
ea
c
.
m a.
.
3rd
4 47 6
1011
67
4 th
4 8 00
1 0 16
1 16
5 th
4 10 0
1018
1 03
7 th
30 5 0
1 017
61
.
.
in s .
the 1 3th of D ecember I ma de a quantitative esti
matio n of the urea a n d the earthy and a lkaline pho s
ph a tes wi th s tan dard s olutio n s di stin ct from tho s e u s ed
by D r M urphy a n d my re sul ts clo sely corre spon ded
with h is — viz qua n tity 2 700 c c total urina ry s olid s
P hosphoric a cid in combi
1 08 grm s urea 8 9 grm s
n atio n wi th lime a n d magne sia
pho s phoric
grm s
acid in combin a tion with the alkaline oxides
grm s
D iet : 4 oz win e milk
total pho s phoric acid
grm s
The p a tient
2 pint s stron g beef tea 1 pi nt bre a d 1 2 oz
remai n ed i n ho spital till the 20th D ecember when he
H is co ndit io n wa s m a te
wa s removed by hi s frien d s
ria lly impro ved a n d he h a d regain ed 1 5 lb s of his lo s t
weight but the urin ary s ecretion wa s not dimini shed
D uri n g his stay i n ho spital the patie nt sn fi ere d gre a tly
from boil s The patie nt h a d n o dimn e ss of sight n or
A t n o time could eve n
a n y a ppearan ce of cataract
mi n ute traces of suga r be dis covered i n the urin e This
may be con sidered a s a typical case of dia betes ins ipidus
accompanied with increas ed metam orpho si s of ti ssue
I t res embles Willi s a n d Prout s ca se s of azot uria a nd
a l s o corre s pon ds to Tes sie r s fourth group
On
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1 30
AC I D
PH OS P H O R I C
The particular s of th e
briefly s umma ris ed :
te
Appr xi
w ight
Ag
Q
8 st
C a se
o
e
e.
six
foregoing ca se s may thu s
h p
Acid
P
ma
u a n tity.
.
Sp gr
.
Ur a
e
.
.
.
oa
.
.
grm
s.
gr m
a.
s
-
6
-
9 st
.
the in creas e of pho s phoric acid over the n ormal
excre tion wa s co n siderable If we except C a se 2 they
diff er from the ordinary hydruric form s of dia betes
i nsipidus i n th a t the di sch a rge of urin e thou gh co n
sid e ra b ly more tha n no rmal in n o way approached th e
e normou s su perflu x met with i n tha t form of the d isea se f
O n the other h a n d th e ca se s in many re spects re s emble
tho s e related by P rout a n d Willis an d to which tho se
author s ga ve the title azoturia A s however the se
ob server s did n ot e stimate the pho sphoric acid excreted
a s well a s the urea it is impo ss ible to s a y in their ca s es
whether it wa s in crea sed or not D r P a rk es :t however
quote s a ca se of V ogel s which seem s clo sely to corre
sp on d with the in sta nce s I have given a n d i n which the
followin g a mounts were passed in two period s of twenty
four hour s re spectively Quantity 2800 c c a n d 3600 c c
urea
grm s a n d 4 7 grm s ; pho sphoric acid
grm s
a n d 8 3 grm s
I n this ca s e the urea a s well a s the
A v era ge of five ob ser vation s
1 I t m ay be a s w e ll to m e n tion th at th ou g h refere n ce is on ly
m a d e to th e q u an tity (
i u rin e a n d the spe cific gra v ity on th ose
hen an e s tim a tion of p h osp h or ic acid wa s m a d e yet cheer
da
q
va tion s on th is p oint w ere fre qu entl y m a d e in ea ch in d ivid u al ca se
a n d the rel a tion ship w a fou n d to be pretty con stan t
In
a ll
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1 Op
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c it
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pp
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.
1 32
ACID
P R O sp n o m c
remarked a n i n creased elimi natio n of phosphoric acid
e spe cially in combin ation with the earths in certai n
cas e s of diabete s mellitus but this i n crea se is very fa r
from bein g un iversal as other an aly ses prove
A gai n in the cases of diabetes in sipidu s given by D ickin
son though a n in crea s e is n oted in some it is n ot in all ;
an d in two cas e s which I reported in the L an cet } ? the
phosphoric acid wa s if an ythin g decrea s ed F or exam
ple in on e cas e in a m a n weighin g 1 1 % st the dai l y
a verage secretion of urin e was over 3000 c c whilst the
phosphoric a cid es timated on three o cca sio n s n e v er
excee d ed
I n the secon d case the patien t
grm s
c c a n d the
w eighed 8 % s t the uri n e pass ed wa s
pho sph oric acid wa s on ly
grm But if the ex
aggera te d ex cretio n of pho s phoric aci d is n ot a con stan t
phen ome n on of diabetes in sipidu s to what are we to
attribute its appearan ce in the ex ceptio n al cases P A n d
here w e pass from the co n sideration of fact s to the regio n
o f con j ecture
There is n o que stion in s cien tific medi
cin e o n which we ha v e fewer facts to gen erali s e from
than that con cern in g the elimin atio n of pho sphate s i n
di s eas e a n d con s equen tly there are few s ubj ects which
have yielded a richer harve st to the quack Phys iology i
ca n o n l y tell u s that the eleme n t pho s phoru s is ab s olutely
e s sen tial for the growth a n d n utrition of the tissues but
can n ot explain its wile Whil st therefore ou r in forma
tio n with regard to the phy siological actio n o f ph os
ph oru s withi n the body is still s o s can ty it is obvious
we are n ot yet in a position to in dulge in s peculation s
co n cern in g the part played by it in the production of
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c it
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34 4
L a nc e t
T t B ook
p 3 66 L on d on
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ex
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F eb 2 6th , 1 8 7 6
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of
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Ph i l gy
1 8 78
ys o o
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Mi chael F te M D
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1 33
P H O SP H O R IC ACID
certain pathological phen ome n a with which it h a s bee n
a s s ociated I t is satisfactory howe v er to kn ow that the
atten tion of s cien tific w orkers * has been called to thi s
s ubj ect
an d we may hope that shortly a s uffi cie n t
n umber of trustworthy fa cts may be collected which
will en able u s to gain a clearer i n sight in to the part
played by this importan t elemen t with re spect to the
n utritive ch a n ge s w ith which it is con cern ed wi thin the
body N or is clin ical observation i n this in stan c e mu ch
in advan ce of ou r phy s iological a n d pathological kn ow
ledge E xcessive elimin ation of pho s phoric acid h a s
bee n n oticed in acute in flammation of the membran e s
of the brain (Ben ce J on e s) in the acute paroxysm s
of certain forms of ma n ia ( S utherlan d a n d Beale) a n d
after i n juries to the he a d ( George H arley ) A n d the
la te D r Goldin g Bird attributed s ome of the cas e s of
phosphaturia that c am e un der h is observation to spin a l
le s ion s probably fun ction al in character But whether in
the s e co n dition s it is due to in creased metamorpho sis of
the n ervous matter or to the irrita tion of a still hypo
thetical coordin atin g che m ical ce ntre or to the in
flu en ce of a disturbed co n ditio n of the n ervou s sy s tem
upon n utrition gen erally it is at pre en t impossible to
decide In creased elimi n ation of pho sphoric ac id again
B en ek ef has con id ere d in some cas e s to be due to
exce s sive formation of acid i n the tis sue s di s s olvin g
o u t the earthy pho s ph ates ; in the s e case s oxalates a n d
W Z u lzer Ueb er das Verhaltniss d er Phosphorsi u re zu m
S tick stoff in U in C en tralb la tt f u r die Me d Wissensch a ft 1 876
p 4 74 Von P of D r Edle en in Kiel Ueber d a s Verb altnis
C en tra lb la tt f (1 Me d
d er P ho sph orsaure zu m S tick s to fl in U i
Wi ssen s ch aft 20 Ju lii 1 8 7 8 E m i l i Lehm u s Ue be r der Rel
C bl f
tive n Wert d e r P hos phorsau re in Uri n b ei K i d e n
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1 Dr
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a
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N O 1 9 , 1 8 78
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Archiv des Verei n s, P 450
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1 854
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1 34
P H O SP H OR IC ACID
phosph ates of lime will both be foun d in excess in the
u rin e
Simil arly in certain cases of dyspepsia a ssociated
with excessive formation of lactic acid i n the stomach
an d intestines more phosphate of lime m ay be re ndered
soluble an d absorbed into the sy stem an d thus p a ss out
by th e urin e in stead of by the bowel
has
shown from analyses of pulmon ary tissue in con sumptio n
that a con siderable reduction of phosphoric acid an d
pota sh takes pla ce both in the in so luble tis su e an d
nutritive m aterial as compared with heal thy lun g
tissue An d E dles sen f h as s hown that the excretio n of
phosph oric acid is in creased in cases of a n m m ia espe
The observ ation s of the
cially pernicious an ae mia
au thors I ha ve quoted are h owever too limited to
draw de finite con clu sion s from as yet All th at we
are warr anted i n a s sumin g from them is that i n cre a sed
excretio n of pho sphoric acid is met with i n those states
of the system which we characte ri s e a s n e rvous an d
tha t it is ofte n met w ith accompan yin g or precedin g
di s ea ses in which disorder of nu triti o n is u sually well
m ark ed 1
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W Mam et M D
N utrition of An im al Tissues p
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1 0 p cit
1: I t wi ll b e
Ex perim e ta l
‘
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47
.
I n q u iry in to the
Lon don, 18 74
.
’
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.
b v d tha t I h ave n ot include d rick ets a m on g
the di sea ses in which a n in cre a se d e lim i nation of ph osphori c a ci d
is n oticed
The truth is th a t th e f act of th ere b e i ng a n in crease is
b y n o m ean s estab l i she d
Prof esso Gam gee in his recent work on
Physiolog ica l C h em istry s ta tes th at n o reliab l e a na l ysi s has yet
b ee n m a de to prove it Whi l st Dr S eem an who has ana lyse d
th e u rin e of six teen ra chiti c child ren h a s a ct u all
y fou n d a d i m i
n a ti on whic h wa s m ost m a rke d wh en the d i sea se was at its h i g ht
e
D r Seam an reg ard s the b on e ch a n g es in ri ck ets to b e d ue to
l i m e starvation the sal ts of th at b a se n ot bei n g introd u ced in
s u ffi cient qu an ti t i nto th e s ste m
owi n g to th e catarrh a l con d i ti n
y
y
o
o ser e
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1 36
P HO SP H O R IC ACID
be warm an d the patie nt caref u lly gu arded a g ain st
cold sin ce in these case s a reductio n of b odily tempe
rature is always n oted W he n in spite of the pursu an ce
of these therapeutic an d hygien ic con diti on s th e diuresis
a n d excreti o n of phosphoric acid co ntin ues th o u gh the
gen er al con ditio n of the patie n t may tem porarily im
p rove there is rea s o n t o fear that phthisis will sup er
ve n e or tha t the disea se may assume the fea tures of
sacch arin e dia betes
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AP P END
E FF EC T
IX
B ICA R B O NA T E O F P OT AS H
O F U R INE
OF
ON
TH E
ACIDI T Y
T HI R T Y TWO year s a go D r Ben ce Jon es in a paper
read before the Royal S ociety * s howed con clusively
from a series of observation s that large doses of se s qui
carbo n ate of ammon ia n ot o nly did n ot dimin i sh the
acidity of the u rine but actually in creased it ; as he
fo u n d that the day when most carbon ate of ammon ia
was take n the aci di ty was higher than it had bee n a n y
previous day an d that the acidity of the urin e was stil l
very high on the day followin g its discon tin uan ce Four
y ears later a similar observatio n was made by D r W F
B en ekef with regard to the eflect of bicarbon ate of
A n d lastly Professor P arke s 1 in his w ork on
s oda
the Urin e publi s hed in 1 860 in stan ces a case of rheu
m atic fever in w hich the acidi ty of the urin e on the day
following the admin istration of bicarbon ate of pota sh
was con siderably higher than on the day before it wa s
taken
I t is stran ge that observation s made by authoritie s so
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Phi losophi ca l Transa ction s 1 8 50 p art ii p 67 3
S tudie n
f Archi v d es Wi ssen scha ftl i ch en H eilku n de 1 8 54
p
zu r Urol og i e
1 Com p os iti on of th e U ri ne in H ea l th an d D isease p 29 7
C hurchi ll 1 860
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APPENDIX
1 38
emin e n t a n d trustworthy te ndin g to co ntrovert the
ge n erally received opin io n as to the a ction of these
alkalin e bicarbon ate s a s an tacid s a n d establis hin g the
that they i ncrea s e rather than
c on trary propo s itio n
dimin i sh the acidity of urin e s hould have attracted so
little the atten tion o f writer s on therapeutics or urin ary
pathology in thi s cou n try or abroad
A s the que s tio n is of con s iderab le importan ce with
regard to treatmen t espe ciall y of tho s e affection s which
are cau s ed by the exces s ive formation of acid within
the sy ste m I have thought a n a ccoun t of some ob ser
v a tion s made by myself on the actio n of on e of the s e
of potash— would be of
c arbo n ates — the bicarbo n ate
s ervic e n ot merely i n callin g atte ntion to a n importan t
therapeutic fact but also in determinin g the circum
stan ces that i n du ce this appare n tly a n omalous actio n
an d in en deavourin g to explain the paradox of the s e
alkal in e s alts in creasin g in stead of d imin ishin g the
acid reaction of the urin e
The fir st eries of observation s were m ade to test the
eff ect o f bicarbon ate of potash on the reactio n of the
urin e when taken before meals The quan tity of the s alt
taken wa s two drachms in the twen ty four hour s
n amel y on e drachm at 12
p m (on e hour before din n er)
a n d on e drachm a t 8 p m
(o ne hour before supper)
The phy siologica l con ditio n s of food rest a n d work
were kept a equal as possible
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O B SE R VA T I O N 1 —
.
S ept 7th
.
,
8 th , 9 th , 1 8 76
Qu antity
Cu b
D a y b efore
D a y, w ith 2 drs
D ay
t
a f er
.
.
of
bi carb on ate
t
cen
1 7 30
2 0 80
1 75 0
.
.
.
Acidity
Uric acid
Grm
Grm
.
.
.
.
140
A
PPENDIX
D ay of ex perime nt — Au g 1l th 1 8 77
tity
Acidity
Q
,
.
u an
Cu b
Water passe d
from 1 2
a m
1 p
2 p
to l p m
to 2 p m
.
m
.
.
m
.
3 pm
4 pm
.
.
to 3 p
to 4 p
.
to 5 p
.
m
.
m
.
i
Gu n
.
'
m
.
40
.
70
.
90
Total
'
05
'
09
'
09
'
04
'
08
'
08
'
07
31 7
O B SE R VA T ION
2
.
D ay precedin g experime nt— N ov 6th, 1 8 7 7
A idity
Uric
Grin
Cu b ce t
Water p asse d from 12 a m to 1 p m 34
.
.
c
n
.
.
I!
n
9,
g,
n
a,
.
05
.
.
.
.
72
.
.
.
Grm
i
Ur c ac d
.
.
cent.
.
.
1 pm
2pm
.
.
.
.
3 pm
4 pm
.
.
.
.
to 2 p m
to 3 p m
.
.
.
.
.
.
.
m
.
.
m
.
41
Total
'
094
'
06
'
09 6
'
03
'
065
'
04
'
07 5
'
03
0 37 6
22 8
D ay of experime nt— N ov 7th, 1 8 77
Acidity
Quantity
Gr
C b cent
Alk a l in e
Wa ter p assed from 12 p m to 1 p m 8 2
.
.
u
1 p
2 p
.
.
m
.
.
m
.
8 pm
4 pm
.
.
.
.
.
m
.
60
.
m
.
98
to 4 p
to 5 p
.
Grm
in
'
.
.
to 2 p
to 3 p
.
Uric acid
.
.
.
acid.
.
.
to 4! p
to 5 p
.
.
m
.
1 50
.
m
.
310
Tota l
'
m
'
.
07
06
04
7 00
I t will be gathered from these observation s that
though the acidity of the urin e was depre s s ed o n the
days the bicarbonate wa s taken yet on the d ay s fol l owin g
there wa s in e ach in stan ce a co n siderable in crease a s
,
A
1 41
PPENDIX
compared with the day precedin g the experi men t B e
s ides the actu al depression of the acidity on the day s
when the s alt was take n is much les s than might be
expected when we con s ider the n eutralisin g effect such
a quan tity o f a n alkalin e s alt would have an d it is evi
den t that a co n s iderable quan tity of free acid mu st
have bee n passed in to the urin e after the im mediate
in order to have
e fi e ct of the alkali had passed ofi
maintain ed this degree of acidity How quickly the
urin e recover s its acidity is shown by the subseque n t
observatio n s on the hourly variation s of the reaction of
the urin e whe n the s alt wa s taken before meals ; the
reaction in both in stan ces n ever remain in g alkalin e more
than two hours whilst the acid passed in the remai n in g
three hour s amoun ts to little le s s than the a cid excreted
in the five hour s on the day precedin g the experimen t
It will a l s o be obs erved that the excretion of uric acid
wa s in crea s ed on the days the bicarbon ate of potash
was taken
A secon d series of observation s were made to test the
effect of bicarbon ate of potash when taken after meal s
The qua ntity of the s alt taken wa s two drachms in
twe n ty four hours— Viz on e drachm at 2 p m (on e
hour afte r din ner) a n d on e drachm at 9 p m (on e hour
after supper) The phy siological con dition s of food
rest an d work were kept as equal a s po ssible
.
,
,
,
,
.
,
.
.
.
-
.
.
.
.
,
.
,
.
.
,
O B SE RVAT ION 1 — Feb 20th , 2 1 st, 22n d , 1 8 7 7
.
.
Qu antity
Cu b
D a y bef ore
D a y, w ith 2 d rs
D a y a f t er
.
A idity
G
c
.
cent
.
.
rin
.
1 4 80
.
of
bi carb ona te
1 72 0
2 5 40
Neu t ra l
.
r c acid
Ui
Grm
.
.
14 2
A
PP E N D I X
O B SE R VA T I O N 2 — Ma y 2n d , 3rd , 4th , 1 8 7 7
.
Quantity
Cu b
D ay b e fo re
D a y , w ith 2 drs
D ay
c t
en
.
c t
Grm
.
.
.
.
.
2 60 0
bicarbona te
of
.
N e u tr a l
1 9 00
tr
2 30 0
af e
OB
VA T I O N
SER
3 — Ma y 2 1 st, 22u d , 2 3rd
.
Qu antity
Cu b
D a y b ef o re
D a y, w it h 2 d rs
cen
.
c t
A idi y
.
t
Grm
.
.
c
Uri
.
acid
Grm
.
.
.
'
1 290
of
.
b ic ar bona te
A lk a l in e
26 00
,
D a y af ter
1 4 80
The cfi e ct a lso of bicarb on a te of p ot a sh
va ria tion of th e re a ct ion of th e u rin e wa s
two
r c acid
Grin
Ui
A id i y
.
.
occa sion s
;
for the pu rpose of com p a ris on the
a cidi ty of th e da y prece d in g , wh en n o
tion s of th e
bicarbon a te wa s ta ken
,
a re
given
.
VA T I O N 1
D a y prece din g exp erim en t — Ja n
tity
Q
C b c t
Wa ter p a ss e d fr om 1 p m t o 2 p m
53
2 p m to 3 p m
55
3 p m to 4 p m
41
4 p m to 5 p m
60
5 p m to 6 p m
61
OB
SE R
.
u an
u
.
.
.
.
.
.
.
.
.
.
.
.
of e
.
en
.
25 th , 1 8 78
t
A cidi y
Grin
’
3 p
4 p
5 p
11
'
04
.
.
.
.
02
.
m
.
.
m
.
.
m
.
m
.
m
.
.
.
'
.
to 2 p m
to 3 p m
to 4 p m
to 5 p m
to 6 p m
,
.
.
.
.
ce n t
.
Grm
.
47
.
.
83
N e u t ra l
.
.
1 03
Alk a l in e
.
.
1 05
.
.
110
4 48
r c acid
U i
G rm
.
.
'
.
38
t— Ja n 26th 1 8 78
Acidity
Q antity
Cu b
1 p
2 p
'
.
en
Gu n
.
15
.
xperim
r c acid
06
'
2 70
.
Ui
.
.
.
u
To ta l
.
.
.
T o ta l
Wa ter p a ss ed f r om
d e t erm in ed on
and
va ria
D ay
the h ou rly
on
11
0 6
‘
1,
.
.
144
th e
A
u rin e ,
PP E N D I X
for wh en th e
b ica rb on a te
wa s
ta ken b efore
pa ssed off a t th e en d of
of a cid p a s sed in th e su c
th e e fi e cts of th e a lka li
m ea ls
two h ou rs ,
cee d in g
and
three
the
a m ou n
h ou rs
wa s
t
y eq u a l to wh a t wa s
wa s t a k en ; whils t w h e n
n e a rl
p a s sed on th e d a y n o m e d icin e
th e sa lt wa s t a k en a ft er m ea ls th e
a lk a lin e u p
to th e
e n d of
'
u rin e
a f er
t
fou r h ou rs
rem a in e d
th e d ose wa s
ticea ble
Th e resu lt of th e s e ob s erva t ion s t e n d s to e st a blish the
fa ct th a t th e a d m in is t ra t ion of a n a lka lin e b icarb on a t e
o n a n e m p ty s t o m a ch in cre a s e s th e a cidity of th e sy s t e m
whilst its a d m in istra t ion a ft er a m eal dim in is hes it
T he e xpla n a t ion a s h ow it h a ppe n s th a t t h ese a lka lin e
bica rbon a te s h ave su ch opp osit e effect s will b e fou n d
given a t pa ge s 55 a n d 5 6 of the t ex t
taken
,
a n d n o recovery o f a cid i
ty
wa s
no
.
.
.
I ND EX
.
PA G E
A cid dy spe p sia
e x cess o f,
20
wh en c e it arise s
re m o va l of b y wh at cha nn el s
se c retion s ho w f o r m e d f r o m the a l k a l in e bloo d
A c idity co n seq u en c e o f e xc e ss
of ga stric j u ic e
of u rin e
A cid s m in er a l h o w sep ar a te d f r o m o rga n ic
A ction of a c id s w ith in th e bo dy
of a l k a l in e b ic a r bona te s w ithin the bo dy
A g u e a c au s e of a cid v o m itin g
A lcoh ol in g o u t
in o n e g a llo n of d iffere n t b e v er a ge s
A l k a l in e co n ditio n of u rin e in d y sp ep sia
A m m o n iu m m a gn e siu m p h o sp ha te in u rin e
An ae m ia in c rea s e of ph o sph o ric acid in
,
IO
,
17
,
,
12
,
58
25
,
82
83
1 34
,
e ck Ma r c u s v om itin g in ch r on ic bl a dd er a ff e ctio n s
B erna r d C l a u d e s e ction of v a gi d u r in g d ige stio n
B il io u s a tta ck s ao c a ll e d
B ism u th in c a ta rrh a l dys p ep sia
B loo d a l ka l in e re a ctio n of
e if e cts of dim in ish e d a l ka l inity
B u rn in g pa tch e s in p a l m s a n d sol e s
B
,
,
,
,
-
,
28
21
31
59
,
Can cer
t o m a ch vo m itin g of a cid in
u t erin e u r ic a cid d e po sits o ften pre c e d e
C a rl sba d salts in intestin a l c atarrh
,
of s
18
,
70
,
59 , 1 1 5
10
1 46
I Na
PA G E
Ch em ical circula tion in the b ody
C hom el,
la dy sp ep sia
ac ids
gra ve
19
22
”
p arta ge
g ou t
96
C old com press in datalent dyspepsia
59
C c e ifi cien t of
-
C olchic u m in
D ia b etes insipid u s
te m po rary m ay b e caus ed by dim inish e d alkalinity
of th e bl ood
u ric a cid d ep o sits in
D iet in fla tulen t dys pepsia
in goa t
in o xaluria
Diu resis
Dysentery u se of cha r coal in
Dysp epsia , associa ted with acid condition of urine
ass ocia ted with an alka lim conditio n of urine
119
,
71
70
63
91
1 15
1 19
61
,
E lim in a tio n, def e cti
ve
,
ex c ess of
e phosphate s in scu rvy
phosphoric a cid
of alkalin
of urea
36
4, 8 1
118
69 , 1 31
of uric acid
E w ald,
F aec e s,
Prof
.
,
L e ctu res
on
69
D igestion
lim y in inte stinal c ata rrh
59
F er m en ta tio n a cid of m u cus
Ferm e n ta tiv e c han ges in stom a ch an d in te s tin es
F o t h ergill D r on un re co gn ise d syph ilis
F o x Wils o n D r chief p oin ts of distin ction b etwee n acidity
fr o m hyper s e c re t io n a n d fr o m f er m e ntative ch an ges
F ree a cidity of cl a re t p orter p o rt win e a n d w hisk ey
of urin e
F u n c tional d eran ge m en t of liver
s
,
,
,
.
,
.
,
,
,
.
,
view s on g o u t
c
Go u t,
a
115
1 09
37
73
c idity
28
83
15
69
77
80
o n s urv
y
Gas tric j uice,
,
,
,
Ga rr o d, D r ,
37
of
t re of ac id in
rela tio n t o rh eu m atism
th e orie s co n c er n in g
82
na u
c vy
a nd s u r
80
77
14 8
IN D E X
PAG E
Ph ospho ric a cid a ctio n in cau sin g dia b ete s
P oore D r v ita l chan ges p r od u c e d b y e l e ctricity
Po tash b ica rbona te efi e ct on a cidity of u rin e
s al ts in s c u r v y
71
,
.
,
12
,
1 37
,
80
ena l c al cu l i a cid v o m itin g in
28
R he u m a tism re l a tio n t o g o u t a n d s c u r vy
80 8 5
R ic k e t s e l im in atio n of ph o sp h o r ic a cid in
1 34
R in ger D r u se of gl y c erin e in fer m e n ta tiv e dy s p e p s ia
59
R u th er f o rd Pr of e ss o r a s e ctio n of v a gi n er v e s du rin g dige s
21
tion
R
,
,
,
,
.
,
.
,
,
,
D r e l e ctrica l d is t u r b an c e in pl a n ts
S cr ofu l a a s a c a u s e of u r ic a cid d e po s it s
Sc u r vy a s a c a u s e of u ric a cid d e po s it s
p a th olo gy of
S u ga r in cl a ret po rter po rt win e a n d w his ky
e ffe ct o f in g o u t
Sy phil is as a c au se of u ric a cid d e po s its
Sa n d ers o n, B u r d o n,
.
12
,
73
'
,
,
-
,
3, 8 0 8 5
83
,
Ure a , in c re a se d
e l im in a tio n of
69
Ur ic a c id cir cu m sta n c e s a tten d in g its d e po s it
its e x c e ss iv e e l im in a tio n
views rega r din g its o rig in
Ur in e a l ter atio n s in its re ac tion af t er foo d
in a cid dy sp e p sia
in flatu len t dy sp e p sia
,
84
74
,
1 31
75
76
66
.
,
I
P R NTE
D
B Y J. E
.
A
D LA R D
.
B A B T H OL UM R
W
CL
O S E.
15
30
47
!CATAL OGUE 0 ]
D ON
L ON
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.
,
.
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.
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