can dispute) is ascribed to their action on the digestive organs; where, either by obviating the formation of acid, or by neu tralizing it when formed, they prevent its secretion in the kidney. Dr. Prout considers alkaline remedies as palliatives only, allaying irritation, and in the case of magnesia, promoting a laxative operation.* He further gives it as his opinion, that general remedies (especially purgatives, judiciously administered, and never carried to excess) are those upon which reliance is chiefly to be placed.

The remarkable exemption from calculous complaints enjoyed in hot climates, has been frequently mentioned as a hint in practice. It has been attributed to the uniform moist state of the skin, and it certainly points out the propriety of attention in all cases to exercise and warm clothing, and perhaps the occasional use of a warm bath.

2. The treatment of those calculous cases where a phosphatic diathesis prevails, must vary with the duration of the disease, and the consequent degree to which the general health has suffered. They will often be found to yield to the same remedies as have been already recommended; proving that the two great forms of urinary deposition are much more intimately connected than is commonly imagined. In children, and adults where the general health is little impaired, the occasional use of rhubarb and calomel in moderate doses will prove highly serviceable. In the majority of cases benefit will be derived from tonic medicines; and the peculiar advantages of acids are equally suggested by chemical and pathological considerations.

The mineral acids (sulphuric and muriatic) have been most usually employed; and where they agree with the stomach, often give a decided check to the symptoms in a few days. Uva ursi, bark, and other astringent vegetables, may be had recourse to with the best effects in protracted cases, where the tone of the stomach is weakened, and the constitution much reduced. Saline purgatives, active diuretics, and alkaline remedies, must now be carefully avoided, both with reference to the general and urinary system. Above all, during the presence of a phosphatic diathesis, the mind is to be set at rest. Absence from care, change of scene, the sports of the country, and regular hours, have a surprizing influence upon the disease, and often prove effectual where medicines have failed.

• Medico-Chirurgical Transactions, vol. viii. p. 549.

In every variety of calculous deposition, strict attention is of course to be paid to diet; but we can hardly concur with those modern pathologists who have attempted to regulate this also by chemical principles. The excrement of animals feeding solely upon animal matter, contains uric acid in considerable quantity. It has been argued, therefore, that vegetable food should be preferred where the lithic, and animal food where the phosphatic disposition exists. The fact is curious, but the practical inference incorrect. That diet is in every instance to be preferred which agrees best with the stomach.

In the treatment of calculous cases, it is necessary to look to the degree of irritation prevailing in the system generally, and in the kidney particularly. Opium, hyoscyamus, and other sedatives, are often indispensable, and in most cases will be found useful auxiliaries. Where there is much pain in the loins, a galbanum or opium plaister may be recommended. If manifest injury has happened to the back, an issue or seton should be had recourse to.

It is hardly necessary to remark, that these observations on the treatment of lithiasis are intended to apply to those cases which are strictly constitutional, where no actual calculus has formed, and where no disorganization of the urinary organs has taken place. The treatment of such only is in the hands of the physician; but it will be obvious that the same general principles must apply in every variety and stage of the disease. This may be illustrated by showing how the doctrines now delivered become subservient to the determination of questions connected even with the operation of lithotomy.

Lithotomy, or its milder substitute, lithotrity, is to be recommended, without delay, whenever a calculus, no matter of what species, is ascertained to exist in the bladder before puberty; and in after life, when the phosphatic diathesis is fully formed. It is worthy of remark, that children upon whom lithotomy has been performed are not more liable than others to calculous complaints, at an advanced period of life. On the other hand, the operation may be safely postponed, when the calculus is small, and the lithic disposition steadily present,-provided the patient be in the prime of life, his general health sound, and he himself willing to conform to regular living. Under all other circumstances, the retention of a calculus in the bladder is to be dreaded, not only on account of the intensity of present suffering, but the probability of its future increase.

CHAP. II.

DISEASES OF THE KIDNEY.

Nephralgia. Symptoms and Mode of Treatment. Nephritis. Abscess of the Kidney. Hæmaturia. Ischuria Renalis. Its causes. Prognosis. Method of Treatment.

NEPHRALGIA.

THE presence of a calculus in the kidney is not necessarily followed by distressing symptoms. Instances are recorded where a calculus of considerable size, nay even a large collection of calculi, have been found, after death, distending the kidney, without any one symptom having occurred which could lead to an idea of disease in the urinary organs. In most cases, however, when a calculus becomes impacted in the kidney, suppuration and gradual wasting of that organ take place. This is generally accompanied by an obtuse pain, or sense of weight in the lumbar region, aggravated by exercise, especially by riding on horseback. There is also retraction of the testicles, and a sense of numbness extending down the inside of the thigh on the affected side. The urine is commonly of a deep red colour, depositing either sand or sediment. It is voided frequently, and in small quantity at a time. A person may exist for a great number of years with this affection, without materially suffering in his general health; but in most instances it brings on bloody urine, and ultimately proves fatal.

The retention of a calculus in the kidney is, after all, a rare occurrence. Far more commonly, while yet of moderate size, it quits the pelvis of the kidney, and descends into the bladder. There can be no doubt but this has sometimes taken place without pain or uneasiness, even where the stone was of considerable size. In the majority of cases, however, the descent of the calculus along the ureter is accompanied by very well marked symptoms, constituting nephralgia, or in common language, a fit of the gravel. There is a sudden attack of very acute pain in the region of the kidney, with violent sickness and vomiting. The pain extends to the groin, and is generally attended by numbness of the thigh, and retraction or pain of

4. A disposition to throw down the phosphates is given, not only by these general causes, but by many which act locally on the urinary organs, more particularly injuries of the back, and irritations about the bladder, kidney, or urethra, when operating without intermission, and for a considerable length of time. That injuries of the back produce alkaline urine, is a very old observation, but it was not known until lately that this was merely a symptom of that phosphatic diathesis which such a cause induces. Hence too it is, that the presence of a small uric calculus in the bladder comes at length to produce a decided deposition of the phosphates.

5. It is very seldom observed that phosphatic calculi are encrusted by layers of lithic acid; and it is argued, therefore, that the phosphatic diathesis is rarely succeeded by any other. Upon this subject, however, the great authorities are not in strict accordance. Mr. Brande asserts, that such a sequence may sometimes be observed, more particularly after a free use of acid medicines given incautiously while the phosphates are in excess. Dr. Prout, on the other hand, maintains confidently, that a decided deposition of the mixed phosphates (particularly in advanced life) is never followed by other depositions, and that the few exceptions to this law which have been observed are more apparent than real.

6. The question has frequently been discussed, how far depositions from the urine are ever of a mixed character. Pathologists are not agreed on this point. Mr. Brande informs us (on the authority of chemical analysis), that cases of mixed sabulous deposite are by no means unfrequent; while Dr. Prout, from an attentive examination of what have been called compound calculi, believes that such mixtures are very rare. He states,* that he has never seen an instance of the pure lithic acid intimately mixed with the phosphates, nor does he believe that such a compound ever existed in nature.

Prognosis.—I have now to add a few words respecting the period of life at which calculous complaints occur, and the prognosis which may be formed under the different circumstances in which they prevail. Every one must have observed how liable the urine is at an early age to every species of deposite. This particularly happens in children of delicate constitution and weak stomach. In most cases the deposite is white Inquiry, p. 113.

and consists of the phosphates, but in the very beginning of the complaint it is often lithic. The irritability of habit, however, at this age is so great, that the character of the sand frequently changes with rapidity. From tables which have been drawn up, it appears that nearly one half of the whole number of stone cases occurring in this country commence prior to the age of puberty. Of the remainder, a large proportion have their origin in early life; but the constitution being then sound, the general health good, and the calculus small, no symptoms are produced. The next period of life most prone to calculus occurs about the age of forty, when gout begins to make its inroads on the constitution. A calculus previously existing in the bladder will rapidly increase at this period, or a nucleus will now be formed for that of advanced life.

The phosphatic diathesis occurs most frequently in childhood and old age. Where its exciting causes, however, are strong, it may occur as an original disease, even in the prime of life. When the deposition of the phosphates is merely occasional, it is hardly an object of attention; but if it invariably follows meals, still more if it occurs as white sand, subsiding immediately to the bottom of the vessel into which the urine is voided, it becomes a serious disorder. When thoroughly established in the system it is with difficulty got rid of; and to this circumstance we may trace the large size which white calculi have sometimes attained, rendering their removal from the body, in neglected cases, hazardous, or even impossible.*

The infinitely greater frequency of calculous diseases in the male than the female sex, as well before as after puberty, has been clearly established. It may be ascribed in part to the shortness of the female urethra; but some other circumstances probably concur, which have hitherto eluded the researches of pathologists.

Treatment. The generally received opinion, that an accurate acquaintance with the chemistry of urinary deposites would lead to clear and definite views of treatment, is founded upon very imperfect observations. The chemical treatment of lithiasis indeed, though much talked of, is, comparatively speaking, of

In the Philosophical Transactions for 1809 (p. 303), is an account, by Sir James Earle, of a phosphatic calculus, sixteen inches in length, and weighing fortyfour ounces. Lithotomy was performed, but the stone could not be brought away, and the patient died ten days afterwards.