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1. To diminish the quantity of Uric Acid. As the existence of this acid in the urine is connected with the use of food containing azote, it is necessary to diminish the quantity of the latter in order to prevent the undue secretion of the former. Majendie has frequently seen those cases in which the urine is loaded with red sand, cured by the patient's leaving off meat breakfasts, that is, if they did not make up at dinner for the morning's privation. At the commencement of this restriction the patient often feels weakness and malaise, but after a few days he finds the benefit, both in the increase of his spirits, and of general comfort. Those persons who make but one solid meal should diminish that one quarter or a half; this simple and efficacious remedy is difficult to put in practice for many persons, and particularly for old men; the dinner is the most important act of the day, a period of true and positive enjoyment. This diminution may be supplied by less hurtful food, such as bread, pastry, farinaceous articles of diet, rice, potatoes, green vegetables, sugar, &c. but still the patient must not abuse the use of these, as some bread and pastry contain much azote. Strong liquors and pure wine must be avoided, and aqueous drinks plentifully taken. Too often, notwithstanding these precautions, the gravel persists, and is very painful, and the stones are large and numerous; the patient must then be wholly deprived of azotized food. To give a general idea of the diet he recommends, M. Majendie has given an extract from the letter of a gentleman who was addicted to the pleasures of the table, and suffered severely from gravel, for which Majendie recommended a nonazotized diet. "On rising I take a cup of weak tea, in the course of the morning some orgeat,' (a drink whose chief ingredient is almonds); I dine at noon off vegetables and fruits, drinking many glasses of water with old white Bordeaux wine, and at dessert, two or three small glasses of the same wine undiluted; at five o'clock I drink sugared water; in the evening I take rice, or 'boullie de blé noir,' and sometimes gruel made with water and butter; I drink with this meal some diluted white wine, and before going to bed a glass or two of sugared water." At the end of six weeks the gravel disappeared. After continuing the diet for 12 or 15 days the patient made an abundant quantity of urine, more than in proportion to the drink. A similar phenomenon was observed in the experiments on the dogs.

2. To Augment the Secretion of Urine. The most simple method is to drink abundantly of those fluids whose base is water, and particularly those known to be diuretic. Various vegetable decoctions, mineral waters, &c. have been recommended as specifics, but that must be chosen which proves diuretic, and agrees with the patient's digestion, and suits his taste. Five or six pints of such a liquid taken daily is not too much, especially if the gravel is severe. This sometimes produces a loss of appetite, laborious digestion, and general debility; the quantity should then be diminished, and aromatic or iced drinks substituted.

3. To Saturate the Uric Acid. When non-azotized diet, and abundant drinks have failed, recourse must be had to remedies which act by combining the uric acid with an alkaline or earthy base in order to form salts much more soluble than the lithic acid itself. It is well known that certain substances taken into the stomach impart very quickly to the urine their peculiar qualities, either of smell, as asparagus; of colour, as rhubarb; or are found in the urine without undergoing any alteration, as certain saline substances. Darwin found nitrate of potash in the urine half an hour after a few grains had been taken; and Majendie has confirmed these experiments both in man and animals. In order to saturate uric acid, alkaline carbonates are to be employed, whose bases are in excess, the uric acid combines with the excess of base, and urates are formed with the greatest facility, as a small quantity only of the base is necessary to saturate the acid. Even when the uric acid is saturated all fears for the deposition of sand are not removed, for the urates are only soluble in an excess of their bases, and are decomposed by the weakest acids; it is necessary then to have an excess of alkali in the urine in order to prevent the formation

of a new species of gravel by the deposition of the urates. This important result is promptly and easily produced in carnivorous animals, whose urine, like that of man, is acid. Majendie has many times found it alkaline in dogs two hours after they had swal lowed a certain quantity of carbonate of lime, soda or potash, and the same phenomenon is not more difficult to produce in man; pure alkalies have a similar action, but they cause greater irritation of the bladder. The carbonates of soda and of potash being soluble in water, in all proportions, may be given dissolved in a large quantity of fluid, in a saturated solution, or in the solid form; but as carbonate of lime and magnesia are not soluble, they must be taken in the form of a powder, or suspended in water by means of mucilage; their insolubility renders them less efficacious than the former, and sometimes they are not absorbed but form concretions in the alimentary canal. The dose of carbonate of lime and of magnesia may be carried to many drachms in the 24 hours, some have taken an ounce. If more than from 24 to 36 grains of carbonate of soda or potash are taken daily, the stomach is apt to become deranged, and vomiting to come on, which is seldom the case if the dose is less considerable. Soda or potash, from their causticity, should be prescribed with greater precautions; they must be diluted so that the solution may make but a slight impression on the tongue, and a pint of this liquid may be taken daily for the same purpose. Magnesia may be given in the dose of 10 grains to an ounce or more in the 24 hours, either suspended in water or in boluses. Mineral waters containing earthy or alkaline carbonates act usefully in gravel by exciting the secretion of urine, for the small quantity of alkali they contain renders it improbable that it can saturate the uric acid.

This observation does not apply to the waters of Vichy, which contain a large propor tion of bicarbonate of soda, which speedily renders the urine alkaline, as appears from the experiments of M. Darcet, in a paper published in les Annales de Chimie, Mars, 1826. M. Majendie has several times observed that an alkaline bath has rendered the urine alkaline. Experiment will alone determine which alkali will agree best with the patient, and will most effectually answer the desired end. The employment of alkalies in the cure of gravel is attended by the most marked and prompt success, but unless the diet is changed and the causes of the disease removed, it is a palliative merely, whose effects after a certain time will completely cease. In a physiological point of view the action of the alkalies, taken into the stomach, on the urine deserves attention. The surface of the stomach and intestinal canal being supplied with an acid which is constantly renewed, how is it that the alkalies do not combine with this acid, and that the carbonates are not decomposed? These combinations do take place, but the quantity of acid in the stomach and intestines is so great, and absorption so rapid, that the greater part of the alkali is absorbed and taken into the blood before it is acted upon by the acid of the digestive organs. Once mixed with the blood it can undergo no decomposition, as the blood itself is alkaline. But it is not so easy to explain the passage of an acid from the stomach to the bladder, for as soon as it arrives in the veins and mixes with the blood, it must necessarily combine with the excess of alkali in the serum. Is not the fact of the passage of acid from the intestinal canal into the urine still doubtful? M. Majendie does not regard this as impossible, but he thinks that experiments have not proved its truth. Although carbonic acid has been procured from the urine of a man who had previously drunk water saturated with this acid, it does not necessarily follow, that it had passed from the stomach to the kidney, as urine contains, when in a healthy state, carbonic acid. M. Majendie has frequently tried to neutralize alkaline urine by giving mineral or vegetable acids in strong doses, but he has never been able to obtain the result in a non-equivocal manner.

4. To favour the Expulsion of Sand Gravel, and to attempt their Solution. As soon as the pain and uneasiness in the lumbar region, or the expulsion of a small quantity of sand, announces the existence of urinary concretions in the kidneys, means must be used for their expulsion. The small size of the grains of red sand renders their expulsion less difficult than the other varieties; in most cases it is sufficient to drink freely of water, or some other aqueous drink to increase the quantity of urine; some take for this purpose a large glass of Seltz water, or of weak beer, or very diluted wine, either at night or in the morning; and with this simple precaution are able without inconvenience to enjoy the pleasures of the table, and to expose themselves with impunity to the causes which produce gravel; but the majority are not so fortunate, and are obliged to follow the necessary means for the diminution of uric acid, otherwise they are harassed by constant pains in the kidneys, producing want of sleep, and general disturbance; momentary relief may be obtained by leeches or venesection, but permanent benefit cannot be expected unless the diet is changed. Some patients consider that the formation of sand ensures them against renal and vesical calculí, and in consequence neglect these rules of diet, but this opinion is without foundation; it is not rare to find calculi in the bladder of those who have discharged sand for many years, and there are authentic cases of the ureters having been obstructed by the accumulation of very fine gravel. Calculi, often of a very considerable size, have been discharged periodically during many years with no more inconvenience than a slight impediment to the flow of urine at the moment of the exit of the calculus; probably the ureters of such patients are large, and the concretions smooth; even in these cases it is advisable to drink every day a certain quantity of aqueous drink to render the urine more abundant, and to prevent the possibility of the calculus being impeded. Such patients will derive advantage from exercise, either on foot or horseback, and in rough vehicles; of course such means would be injurious if the passage of the calculus is attended with pain. For the same purpose an emetic may be given in order to produce strong contractions of the abdominal muscles. Usually the passage of a gravel stone from the kidneys is attended with the acutely painful symptoms, and when this is the case, the expulsion of the calculus must not only be favoured by drinks, but the irritation should be subdued by complete abstinence, general bleeding, leeches, cupping, local and general baths, emollient fomentations, &c. according to the violence of the symptoms, and the age, temperament, and strength of the patient. Generally after 36 or 48 hours the symptoms abate, and one or several calculi are expelled; in some cases the attack is prolonged 10 or 15 days. If the remission of pain, &c. is not followed by the expulsion of a calculus, it is probable that the unfavourable symptoms will recur. Every remedy should then be employed for the evacuation of the retained calculus, as diuretic drinks, baths, dry frictions over the loins and in the direction of the ureters, exercise on foot, or on horseback, or in a carriage, if the patient can bear it. Emetics sometimes succeed when other remedies have failed. If the situation of the pain announces that the calculus has traversed the ureter and is arrested in its inferior extremity, a metallic sound may be introduced into the bladder, to endeavour to detach it, or the finger into the rectum to attempt to displace it by striking the back of the bladder. If the calculus is detained in the urethra, judicious pressure along the canal, oily or emollient injections into the passage, and abundant drinks, which often are alone sufficient to expel it; in some cases surgical aid is requisite. Notwithstanding these means the calculus may remain in the pelvis of the kidney, or in the bladder; its increase must then be prevented by putting the patient on a non-azotized diet, and the urine must be maintained alkaline, to endeavour to produce a solution of the concretion. Supposing the calculus to consist of uric acid, both physiology and chemistry lead us to suppose that these means will succeed. Experiments have shewn that a mass of uric acid plunged in urine, which is saturated with potash or soda, with an excess of alkali, and kept at a temperature of 77° to 95° Fahrn. which is frequently renewed, is in time completely dissolved. There is no positive proof of the solution of a renal calculus, but the many cases of calculous nephritis, which have been cured by the use of alkaline remedies, render it probable. This only applies to those formed of uric acid. M. Robiquet, an expert chemist, has published a case in which it was probable that a red calculus was dissolved by

alkalies.

J. B. M., æt. 74, a retired merchant, had all the symptoms of stone in the bladder Marjolin sounded him, and found a stone which was small and soft; he recommended

him to have it extracted by Civiale's method; but M. Robiquet and Dr. Farrot, whose patient he was, put him under the following plan of treatment:-to drink daily two pints of a solution of bicarbonate of soda, (5 grammes, 3j. grs. xvij. to the pint) and to take frequently hip-baths, and emollient glysters. He was recommended to abstain from excitants. After a few days he was better, and his urine was more abundant, its emission was rarely preceded by pain, and there was less irritation of the bladder. In 15 days the baths and lavements were discontinued; in a month the patient considered himself so well that he could be with difficulty persuaded to continue to take a pint of the solution per diem. Three months after the commencement of the treatment he felt acute pain in the urethra and expelled a small calculus, the form and size of a lentil; this was wholly composed of lithic acid, having all the appearance of the nucleus of a larger calculus, which had been gradually worn away. Marjolin, as the patient felt no pain or inconvenience, declined sounding him again.

Treatment of White Gravel. There are two varieties, one consisting of phosphate of lime, the other of carbonate of lime. 1. Gravel composed of phosphate of lime may be successfully treated by diet and drinks. The diet is the same which has been recommended in red gravel, for it has been shewn, that the urine of carnivorous animals who have been kept on non-azotized food, loses all traces of its phosphates. The drinks should consist of fluids charged with carbonic acid, which taken in great abundance augment the quantity of urine and tend to dissolve the phosphate. For this purpose, either artificial or natural Seltz water, or the waters of Contrexeville, Bains, or even Vichy, may be recommended. By such treatment Majendie has known this white gravel disappear in a few weeks, he has had no personal experience as to the efficacy of the diluted mineral acids, and he has known many affected with gravel who have derived no advantage from their use. M. Majendie has never seen white gravel composed of carbonate of lime: its treatment will consist in discovering the cause of the deposit, and in administering drinks strongly impregnated with carbonic acid, in order to dissolve the carbonates which are soluble in an excess of that acid.

Treatment of Hairy Gravel. M. Majendie has seen three cases; two of these yielded readily to a vegetable diet, and the carbonated alkalies; the third was more obstinate. This patient applied to M. Majendie in 1827. He had suffered from gravel for ten years, and after describing the acute pain which attended micturition, he writes, "but that which strikes me as a new feature in my case, is, that my urine, which is clear enough when I evacuate it, is no sooner cooled than it deposits a prodigious quantity of calcareous matter, which when dried appears like a thick layer of a friable grey sediment, the different particles of which, when attempted to be separated from each other, are held together by an infinite number of small hairs, something like hemp." On analyzing the sediment it was found to be composed of phosphate of lime united to a small quantity of phosphate of magnesia. M. Majendie recommended a slightly azotized diet, with carbonate of soda, and the patient's condition was much improved. The hairs first ceased to be observed in the deposit, and the quantity of the phosphate gradually diminished. Owing to a stricture

of the urethra the bladder was too irritable to bear the alkalies for a length of time sufficient to ensure his cure.

Treatment of Grey Gravel, composed of the Ammoniaco-Magnesian Phosphate. It is not very rare, but it is one of the most painful and dangerous forms, as the particles of gravel are often large and rough. It may be cured by regimen alone: by putting the patient, who is generally a lover of the table, on a moderate diet, he will be much relieved, and, if this does not succeed, the strictly vegetable diet, as recommended in red gravel, will certainly produce a complete cure, if the individual has sufficient resolution to submit to the

restriction.

Treatment of Yellow Gravel (Oxalate of Lime). M. Majendie has only met with the case which has been detailed, and which was traced to the eating of sorrel; interdicting the use of this vegetable produced a complete cure. Professor Langier communicated a somewhat analogous case to the "Academie Royale de Médecine" some years since. The father of a celebrated artist in Paris, who had been sounded, and a stone detected in the bladder, called upon him to know if he had no chemical agent which would supersede the necessity of an operation; he recommended him to have the operation performed, and it was successful. After some months the patient returned, and requested to know whether some remedy might not be recommended to prevent the return of the complaint; the patient shewed the stone, which consisted of oxalate of lime. M. L. questioned him as to his diet, and found that he was very fond of sorrel, and that he eat it daily; he was of course recommended to leave off this article of diet, as it contained an acid of which the calculus was partly composed.

Treatment of Transparent Gravel (Cystic Oxyde). M. Majendie has seen but one case; this was much benefited by a vegetable diet and alkalies; this treatment was founded on the consideration of the chemical nature of cystic oxide, which, according to Lassaigne's analysis, contains, in 100 parts, 34 of azote. M. Majendie considered that, by diminishing the quantity of azote in the food, he should prevent the excessive formation of a principle which forms one-third of the diseased deposition; and as cystic oxide is soluble both in alkalies and acids, he attempted, by rendering the urine alkaline, to dissolve the foreign body if it existed in a solid state.

Mixed Gravels and their Treatment. Proust mentions the case of a man who expelled gravel stones of phosphate, and others of carbonate of lime. M. Majendie attended a patient, who was affected with sand consisting of phosphate of lime and Magnesia, who stated that he had been previously subject to red gravel. Alternating calculi prove the same thing. This is probably a less rare affection than is supposed; but physicians often neglect the analysis of gravel. M. Majendie, towards the conclusion of this volume, pays a verbal compliment to the work of D. Prout, but he does not appear to have paid him the compliment of reading his book, otherwise he would hardly have stated his one case of mixed gravel, and his supposition that it is not so rare as is supposed. Dr. Prout most distinctly states, that the deposition of the phosphates is rarely original, but that it is a state induced by, or consequent to, the other forms of urinary deposition, especially the lithic acid and oxalate of lime; he also describes the symptoms which mark the transition from the lithic to the phosphatic diathesis! M. Majendie does not vary his treatment in these cases.

Prostatic Calculi. It is of importance to distinguish these from gravel. They are never larger than a small pea, having almost always distinct and regular facets, which are produced by the attrition of many in one cell; at other times they are fusiform, and then there is but one calculus in each cell.

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