150 deg. becomes opaque, and deposites this principle in a
coagulated state. The precipitate varies considerably in its
appearance in different instances. Sometimes it is of a firmer
character, and similar to that formed by the serum of the
blood, from which, in this case, it may be supposed to be
derived; at other times it is very delicate and fragile in its
texture, and somewhat resembles curd, when it may be supposed
to be of chylous origin. In some instances, the effects of heat
upon albuminous urine are increased by the addition of nitric
acid. But the most delicate test of albuminous matter in
general is dilute acetic acid, and the prussiate of potash." p.
6.
Dr. PROUT combats very successfully the opinion, generally entertained
by chemists, that the power of healthy urine to redden litmus depends
on the presence of free lithic acid.[23] That this power cannot depend
upon lithic acid uncombined, is made evident to Dr. P. by its sparing
solubility; it requiring, according to our author, 10,000 times its
weight of water to dissolve it, or six times as much as is stated by Dr.
HENRY. The reddening power of the urine is attributed by Dr. PROUT to
the presence of lithate of ammonia, and superphosphate of ammonia: the
former of which, contrary to what might be expected, is found capable of
reddening litmus, and of remaining in solution with the latter, without
decomposition.
The following interesting remarks are made by Dr. PROUT on the effects
of muriatic acid, in precipitating lithic acid gravel:
"The muriatic acid, in combination with soda and potash, occurs
both in the blood and in the urine; thus appearing to pass
through the kidneys unchanged. This acid and its compounds
formerly appeared to be of less importance in a pathological
point of view than any other similar principles existing in the
urine: but since the unexpected fact has been ascertained, that
muriatic acid in a free state exists abundantly in the stomachs
of animals during the process of digestion, I have attended a
little more closely to the appearance of this principle in the
urine, and am disposed to believe, in consequence, that it is
the cause of the precipitation of lithic acid gravel from the
urine more frequently than any other acid. I do not mean to
say, that it is the _immediate_ cause of the precipitation of
this acid; for in most instances, it acts like all powerful
acids do under similar circumstances, namely, by liberating the
weaker acids, which are thus enabled to act in their turn, and
separate those having still weaker affinities than themselves.
Thus, in the present instance, the muriatic acid may be
supposed to separate the lactic, while the latter precipitates
the lithic, &c. If this opinion be well founded, as I believe
is the case, the muriatic acid may be considered of very great
importance, not only in a pathological, but a physiological
point of view; for if the muriatic acid, found in the urine in
such instances, be supposed to have its origin in the digestive
organs, we see at once the reason why the deposition of gravel
is so liable to be influenced by the derangements in general,
and more especially by the acidity, of the stomach."
"The muriatic acid may be shown to exist in the urine by the
white curdy precipitate insoluble in nitric acid, which is
formed, when the nitrate of silver is added to it, after the
sulphuric and phosphoric acids have been removed by the nitrate
of barytes or lead." pp. 20 and 21.
After finishing these introductory subjects, Dr. PROUT proceeds to the
consideration of the diseases of the urinary organs themselves; which he
divides into functional, mechanical, and organic. Under functional
diseases, we have _first_, those, in which principles _soluble_ in the
urine are morbidly deranged in quantity or quality, embracing three
chapters; and _secondly_, those affections, in which principles
_insoluble_ in the urine are morbidly deranged in quantity or quality,
comprising six additional chapters. Under the first subdivision, the
first chapter is on the affections, characterized by albuminous urine;
the second, on diseases, in which an excess of urea is the
characteristic symptom; and the third, on diabetes.
The diseased derangement, consisting in an excess of urea in the urine,
has not been particularly noticed by any writer before Dr. PROUT, who
believes that it has probably been confounded with that form of
diabetes, called diabetes _insipidus_. The state of the urine and
symptoms in this species of urinary derangement are thus described by
our author:
"The average specific gravity of the urine seems to be a little
above 1.020, and occasionally to vary from 1.015 to 1.030. Most
generally it is pale, but occasionally it is high coloured, and
exhibits somewhat the appearance of porter, more or less
diluted with water; and this variety in appearance not
unfrequently takes place in the urine of the same person. When
first voided, it reddens litmus paper. For the most part, it is
entirely free from sediment, except the mucous cloud of healthy
urine; and the only remarkable property which it appears to
possess, is that of containing abundance of urea; so that on
the addition of nitric acid, crystallization speedily takes
place. From the quantity of urea present, it is very prone to
decomposition, and soon becomes alkaline, especially in warm
weather.
"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 laminae. 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
laminae, 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 laminae 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 laminae 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: