Chapter 15

"There is almost constantly in these diseases, a frequent and urgent desire of passing water both by night and day. This desire is for the most part evidently excited by actual _diuresis_, or the increased quantity of urine; but frequently it cannot be ascribed to this cause, as the quantity voided at one time is often by no means considerable; though in almost every instance that has fallen under my observation, the total quantity voided during any given time has appeared to be greater than natural. The quantity appears also to be particularly liable to be increased by cold weather, and by all causes producing mental agitation. There is sometimes a sense of weight or dull pain in the back, but this is by no means a constant symptom. There is also occasional irritation about the neck of the bladder, which sometimes extends along the urethra. The functions of the skin appear to be natural; at least in every case which has come under my own observation, perspiration has been rather easily induced. The pulse is not affected. There is no remarkable thirst, nor craving for food, except in extreme cases; nor are the functions of the stomach and bowels much deranged. Hence for the most part the tongue is clean, and the dejections regular and apparently natural.

"In most of the cases of this disease, which have hitherto fallen under my own immediate observation, the subjects have been middle-aged men, of thin and spare habit, with a sort of hollow-eyed anxiety of expression in their countenance, free from gout and constitutional disease in general, and, as far as could be ascertained, from any organic defect in the urinary organs. In every instance they had been induced to apply for medical advice, not so much from the pain, as from the inconvenience of the disease, and the dread of its ending in something worse; and, what may be worth remarking, in several instances confessed, that they had been addicted to masturbation from very early youth," p. 41, et seq.

The remedy for this morbid derangement in the urinary secretion, most successful in the hands of Dr. PROUT, was opium, either administered alone, or in conjunction with alkaline medicines. It is rather a rare affection. When not arrested, it is liable, according to Dr. PROUT, to pass into diabetes.

In his chapter on diabetes, our author makes many interesting remarks; but the space we are enabled to devote to this analysis, will permit us only to make an extract, which seems to prove a close connexion between the disease characterized by an excess of urea, and diabetes.

"It has been mentioned in the preceding pages, that an excess of urea frequently precedes the appearance of saccharine matter in the urine. Now it is a remarkable fact, that in diabetes, in proportion as the saccharine matter diminishes, that of urea generally increases; and in such instances, the presence of the former principle can not only be no longer distinguished by the sensible properties of the urine, but scarcely be demonstrated by the utmost skill of the most experienced chemist, though the specific gravity of the urine may at the same time be nearly 1.040. I have recently been favoured by Dr. ELLIOTSON with the most complete and remarkable change of this description that has yet occurred to me. The patient, besides being diabetic, was in the last stage of phthisis, of which he died shortly afterwards. The quantity of urine passed daily, when I first examined it, was six or eight pints; its specific gravity was 1.038, and it contained a large proportion of very white sugar and very little urea. Dr. ELLIOTSON under these circumstances gave opium, beginning with gr. i, and increasing the dose to gr. iii, thrice a day. The opium produced stupor, and was obliged to be discontinued; but the effects produced upon the urine by its means were most remarkable. _In about 60 hours, the quantity of urine diminished to two pints, its specific gravity was reduced to 1.0174, the saccharine matter had apparently disappeared, and was superseded by urea, the quantity of which had become excessive._ This alternation of a principle containing nearly half its weight of azote, with another containing no azote at all, is perhaps, one of the most singular facts occurring in physiology." p. 74.

The second subdivision of functional urinary diseases comprises six chapters: _first_, on urinary gravel and calculi; _second_, on the data, showing the comparative prevalency of different forms of urinary deposite, and the order of their succession; _third_, on the lithic acid diathesis in general; _fourth_, on the mulberry or oxalate of lime diathesis; _fifth_, on the cystic oxide diathesis, and _sixth_, on the phosphatic, or earthy diathesis.

Under the first chapter, we have an account of I. Pulverulent or amorphous sediments; II. Crystallized sediments, or gravel; and III. Solid concretions, or urinary calculi. Of the latter, our author enumerates thirteen species.

1. The lithic acid calculus.

2. The lithate of ammonia calculus.

3. The oxalate of lime, or mulberry calculus.

4. The cystic oxide calculus.

5. The bone earth, or phosphate of lime calculus.

6. The triple phosphate of magnesia-and-ammonia calculus.

7. The calculus, composed of a mixture of the phosphate of lime, and triple phosphate of magnesia-and-ammonia, or fusible calculus.

8. The alternating calculus.

9. The mixed calculus.

10. The carbonate of lime calculus.

11. The xanthic oxide calculus.

12. The fibrinous calculus.

13. The prostate calculus.

Of these, the 2nd, 4th, 5th, 9th, 10th, 11th, 12th, and 13th species are more or less rare, and consequently of less interest. The remaining 5 are of much more frequent occurrence, and are thus described by our author:

"_The lithic acid calculus_ is generally of a brownish-red, or fawn colour; but occasionally of a colour approaching to that of mahogany. Its surface is commonly smooth, but sometimes finely tuberculated; and upon being cu t through, it is usually found to consist of concentric laminæ. Its fracture generally exhibits an imperfectly crystallized texture, sometimes an amorphous or earthy one, in which case, it usually contains a mixture of other substances. This is one of the most common species of calculi.--_Chemical characters._ Before the blow-pipe, this calculus blackens, emits a smoke having a peculiar odour, and is gradually consumed, leaving a minute quantity of white ash, which is generally alkaline. It is completely soluble in caustic potash, and precipitable again by any acid in the form of a white granular powder. Lastly, if to a small particle, a drop of nitric acid be added, and heat applied, the lithic acid is dissolved; and if the solution be evaporated to dryness, the residue assumes a beautiful pink or carmine colour."

"_The oxalate of lime, or mulberry calculus_, is generally of a very dark brown colour, approaching to black. Its surface is very rough and tuberculated (hence the epithet of _mulberry_.) It is usually hard, and when cut through exhibits an imperfectly laminated texture. This species of calculus seldom surpasses the medium size, and is rather common. There is a variety of it remarkably smooth, and pale coloured. These are always of small size; and from their colour and general appearance, have been termed the _hempseed_ calculus.--_Chemical characters._ Before the blow-pipe, this species of calculus expands into a kind of white efflorescence, which, when moistened and brought into contact with turmeric paper, stains it red. This white alkaline substance is the caustic lime deprived of its oxalic acid."

"_The triple phosphate of magnesia-and-ammonia calculus_ is always nearly white; its surface is commonly uneven, and covered with minute shining crystals. Its texture is not laminated, and it is easily broken and reduced to powder. In some rare instances, however, it is hard and compact, and when broken exhibits a crystallized texture, and is more or less transparent. Calculi composed entirely of the triple phosphate of magnesia-and-ammonia are rare; but specimens, in which this salt constitutes the predominant ingredient, are by no means uncommon.--_Chemical characters._ Before the heat of the blow-pipe, this calculus gives off the odour of ammonia, and at length melts with difficulty. It also gives off ammonia, when treated with caustic potash. It is much more soluble than the preceding species in dilute acids, from which it is again readily precipitated by ammonia in its original crystallized form.

"_The calculus composed of a mixture of the phosphate of lime and triple phosphate of magnesia-and-ammonia, or the fusible calculus_, is commonly whiter and more friable than any other species, resembling sometimes a mass of chalk, and leaving a white dust on the fingers. This species is generally not laminated. Occasionally, however, it separates readily into laminæ, the interstices of which are often studded with sparkling crystals of the triple phosphate. The variety of this species which is not laminated often acquires a very large size, and assumes the form of a spongy friable whitish mass, evidently moulded to the contracted cavity of the bladder in which it has been formed. This species of calculus occurs very frequently.--_Chemical characters._ It may be readily distinguished by the ease with which it melts before the blow-pipe. It also dissolves readily in acids, and particularly in dilute muriatic acid; and if to the solution, oxalate of ammonia be added, the lime is precipitated alone, and the magnesium may be afterwards separated by the addition of pure ammonia.

"_The alternating calculus_, as the name imports, may consist of different layers of any of the preceding species. Hence its general appearance, texture, &c. will depend entirely on the composition, and may be very varied. Most commonly it is composed of a lithic acid or mulberry nucleus, and an external crust of the fusible calculus. In some rare instances, it is composed of laminæ of all three of these substances, and sometimes of even more--the mixed phosphates still continuing to constitute the external crust. This species of calculus often acquires a very large size and is very common.--_Chemical characters._ The chemical characters must of course vary with the composition; and as the different substances of which it is composed must almost certainly be some of the preceding, the nature of the different laminæ can be readily ascertained by what has been already stated," p. 79, et seq.

In the chapter on the comparative prevalency of different forms of urinary deposite; and the order of their succession, we have a number of important facts and observations. Dr. PROUT calculates, from the data collected by him, that about one-third of the urinary calculi which occur, are of the lithic acid species, and that another third are formed on a nucleus of this acid. Hence, "we may assert," says he, "that at least _two-thirds_ of the whole number of calculi originate from lithic acid; that is to say, if a lithic acid nucleus had not been formed and detained in the bladder, two persons at least out of three, who suffer from calculus, would have never been troubled with that affection. This is a most important fact, and deserves to be constantly borne in mind."

The relative prevalency of the oxalate of lime calculus is very various. The average proportion, as determined by Dr. PROUT is about one in seven. Of the calculi, examined by Mr. BRANDE, 1 in 25 was of the mulberry species; while in the Norwich and Guy's Hospital collections, the proportion is about 1 in 4. In the Bristol collection, one-sixth of the whole, was composed of oxalate of lime, nearly pure; while, including all the concretions containing more or less of the oxalate, the proportion was nearly _one-half_! This great disparity in the proportional frequency of this calculus in different districts of England, clearly shows the great influence of local causes, in determining the character of urinary concretions.

From a careful observation of the order of deposition of different species of calculous matter, Dr. PROUT has been enabled to deduce the following general law; "_that, in urinary calculi, a decided deposition of the mixed phosphates is not followed by other depositions_." So that it would appear, that a redundancy in the earthy phosphates is the last link in the chain of diseased alterations, to which the urinary secretion is liable.

In the third chapter, under the second subdivision of functional urinary diseases, Dr. PROUT describes the lithic acid diathesis, and communicates several important original observations. After remarking that the dyspeptic are particularly predisposed to lithic acid deposites, he enumerates, as exciting causes of this species of gravel, 1st. _Errors in diet_; 2nd. _Unusual or unnatural exercise of the body or mind, particularly after eating, and the want of proper exercise at all other times_; and 3d. _Debilitating causes_. Under errors of diet, an unusually heavy meal, especially of animal food, and the use of heavy, unfermented bread, or compact, hard-boiled, fat dumplings or puddings, salted and dried meats, acescent fruits, malt liquors, and acescent wines, are enumerated as particularly hurtful in the lithic acid diathesis.

The above remarks refer to the amorphous lithic deposites, consisting of lithate of ammonia. In regard to crystallized sediments, or, more properly speaking, gravel, our author makes the following remarks:

"Crystallized sediments, or red gravel, consist of lithic acid, nearly pure. Lithic acid, as has been before stated, exists in a state of combination in healthy urine; and in such a proportion, as to be held in a state of solution at all ordinary temperatures. Sometimes, however, a free acid is generated by the kidneys, which precipitates the lithic acid in the pure crystallized state we see it--a phenomenon easily imitated artificially, as is well known, by the addition of a few drops of any acid to healthy urine. The precipitation of crystallized lithic acid does not, therefore, necessarily indicate an excess of lithic acid in the urine, but the presence only of some free acid in that fluid; though such an excess does, for the most part, exist in this form of disease, as will be shown hereafter. With respect to the nature of the precipitating acid, it is probably not always the same. Most generally it appears to be the _muriatic_, sometimes the _phosphoric_ or _sulphuric_, and occasionally other acids. In general, however, it is to be understood, as noticed elsewhere, that when the mineral acids are present in excess, these are the _immediate_ cause of the preternatural acidity in the urine, and consequently of the precipitation of the lithic acid. The stronger acids act by decomposing saline compounds, into which destructible acids, such as the lactic acid, &c. enter, and setting them free. Hence the _immediate_ cause of the deposition of lithic acid gravel is generally a destructible acid of very weak powers: even, perhaps, in some instances, the carbonic acid. When the urine contains a free acid, it is commonly more transparent than usual, and of a bright copper colour." p. 112.

The treatment recommended by Dr. PROUT in this species of gravel is as follows: First, a strict attention to diet, avoiding the hurtful articles already enumerated. Secondly, the use of _alkaline_ remedies; but those must not be depended upon, without the aid of other means, more especially of alteratives and purgatives. Accordingly we are informed that

"The pil. submur. hydrarg. comp., or a pill composed of the pil. hydrarg. and pulv. antimonialis, may be taken twice or thrice a week at bed time, and followed up the next morning by an active dose of the sub-sulphate of magnesia, or a mixture of Rochelle salts and magnesia, or carbonate of soda. A little of either of these compounds may be also taken twice or thrice in the day, so as to keep the urine constantly neutral or alkaline, and the bowels freely open; or gr. x to xx of magnesia may be taken for the same purpose in a glass of soda water, as often as it may be found necessary."

In the chapter on the mulberry, or oxalate of lime diathesis, Dr. PROUT gives a number of cases, from which he draws the following conclusions:

"1st. That this form of disease occurs in both sexes; that it may exist before puberty, and at all ages between that and 40 or 50, at which time it seems to occur most frequently; but that no case occurs beyond the age of sixty. Hence that it is probably not a disease of old age.

"2nd. That it is not incompatible with gout, but seems occasionally to be associated with it. I have also seen it connected, as lithic acid frequently is, with a tendency to cutaneous disease.

"3d. That this variety of calculous affection occurs in individuals of sound constitutions, and who ordinarily enjoy good health; and that it rarely occurs a second time, except at long intervals, during which the intermediate health is good; which latter facts, it may be proper to observe, are confirmed by other observers, and particularly by Mr. BRANDE and Dr. MARCET.

"4th. That the urine is acid, and apparently but slightly deranged in this form of calculus, and remarkably free from all sorts of sediment and gravel.

"5th. That as renal calculi of the oxalate of lime often subsequently acquire considerable magnitude in the bladder, it may be inferred, that the formation of this compound is connected with a distinct diathesis, excluding the existence of other diatheses, and that is not an accidental occurrence, happening in common with many others to the urine.

"6th. That from the dissection of calculi, formerly mentioned, it appears that the oxalate of lime diathesis is preceded and followed by the lithic acid diathesis; a circumstance which seems to be peculiar to these two forms of deposite, and which, when taken in conjunction with the other circumstances, already related, appears to show, that they are of the same general nature; or in other words, that the oxalic acid merely takes place as it were of the lithic acid, and by combining with the lime naturally existing in the urine, forms the concretion in question.

"7th. That the diathesis being of a similar nature, the principles of treatment adapted for counteracting the original tendency to it must be also similar, that is to say, of an antiphlogistic character; great attention being at the same time paid to the digestive and assimilative functions." p. 137, et seq.

The diagnostic signs of the oxalate of lime diathesis are very obscure, as will appear from the following extract:

"With respect to the means of determining when this diathesis is going on in the system, I am sorry that I can give but little positive information. The absence of urinary sediment, &c. are of a negative character, and lead to no inference, where other circumstances are wanting, as is most generally the case. But if there be pain in the region of the kidney, and other symptoms of gravel, without any appearance of sediment; and if the urine be acid, and of the yellow tint above alluded to, the stomach deranged, and an inflammatory diathesis, either general or local (i.e. about the urinary organs), be present; and if all these are associated with suppressed gout, or tendency to cutaneous disease,--the existence of this form of the disease may be suspected, and means immediately taken to counteract it." p. 138.

We omit any analysis of the next chapter on the cystic oxide diathesis, on account of the rare occurrence of this state of the system.

The next chapter of our author is on the phosphatic, or earthy diathesis.

The phosphatic deposites are of two kinds; the _crystallized_, consisting almost invariably of the triple phosphate of magnesia-and-ammonia, and exhibiting the appearance of white, shining crystals; and the _amorphous_, consisting always of a mixture of the phosphate of lime, and the triple phosphate of magnesia-and-ammonia.

The causes apt to produce a deposition of the triple phosphate of magnesia-and-ammonia, are thus enumerated by Dr. PROUT:

"Any thing acting generally, and producing _a nervous state of the system_, such as the distressing passions, and particularly _mental anxiety_ or _fear_, will frequently produce in many people an excess of this salt in the urine. The same is also true of many articles of food or medicine that produce a hurried secretion of the urine, and act as diuretics; as the neutral salts in some cases, and particularly the Rochelle salts and other saline compounds, in which the acid is of vegetable origin. So also, a long continued use of alkaline remedies, or of mercury, in irritable habits more especially, will likewise produce a tendency to an excess of this salt, as well as of the phosphates in general, and even lead to an actual deposition of them from the urine. The same sediment also frequently abounds, or is easily induced, in the urine of those who have long been in bad health, and in whom the constitution may be considered as giving way, or, to use a common expression, breaking up. In general, it is to be understood, that the slighter causes affect only the predisposed, and those in particular who are subject to other diseases of the urinary organs or urine. It may be also remarked, that children are more subject to this form of deposition than adults; a circumstance, perhaps, to be referred to the irritability of the system at this age, and the great derangement of the digestive organs, to which they are subject." p. 151.

The above mentioned causes are stated to be equally productive of amorphous phosphatic sediments.

Our author next enumerates the very distressing symptoms, by which the deposition of the earthy phosphates is attended. They consist in great irritability; derangement of the chylopoietic viscera, evinced by flatulency, nausea, obstinate costiveness, or peculiarly debilitating diarrhoea; extremely unnatural stools, nearly black, or clay-coloured, and sometimes resembling yest; pain, uneasiness, or weakness in the back or loins; sallow, haggard expression of countenance; and finally, if the disease be not arrested, great languor and depression of spirits, coldness of the legs, and complete anaphrodisia, as occur in diabetes.

A curious and important fact has been stated in regard to the remote causes, producing the phosphatic state of the urine. It has been observed by Dr. PROUT, that a large proportion of cases of this complaint may be traced _to some injury of the back_ from mechanical violence, such as a fall from a horse, &c.