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be administered, or a minute quantity of morphia should be used hypodermically.

But the most powerful remedial agent in the treatment of gouty dyspepsia is the maintenance of a healthy state of the skin with a well regulated diet; there should be the spare use of nitrogenous food, and only of the more easily digestible forms, and a free allowance of vegetable diet, and of ripe fruit—of the former, greens and similar productions; of the latter, strawberries, grapes, oranges, &c.

Wine should only consist of the lighter kinds, and of these claret is perhaps the best; but ardent spirits as a rule should be entirely avoided.

Another essential part of right treatment in these cases is outdoor exercise, either as horse or carriage exercise, walking, yachting, &c.; the free inhalation of pure oxygen tends not only to invigorate and strengthen, but to remove effête material.

I have tried the salts of lithia in these cases, but without the benefit expected from the laudatory terms of its introducer. Dr. Garrod, from the fact of the greater solubility of the compounds of uric acid with lithia, considered that this alkali would effect more readily the separation of redundant uric acid. The dose of these salts, as the carbonate or citrate of lithia, is five to ten grains with aerated waters or with vegetable infusions. Equal, if not greater, benefit arises froin the use of the iodide of potassium with the

bicarbonate, or the potash tartrate with bitter infusions; and if the heart be enfeebled, the ammonia citrate or potash tartrate of iron may be advantageously conjoined.

CHAPTER XI.

RENAL DYSPEPSIA.

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THE connection of disorder of the stomach with diseased conditions of the kidney, is scarcely less intimate than that which exists between the liver and the stomach, but this connection is of two kinds : 1st, it has its origin in the intimate union of the nerves supplying the two organs; and, 2nd, the imperfect depuration of the blood in disease of the kidneys produces gastric disorder.

The first form of malady is seen in the acute vomiting and extreme irritability of stomach produced by calculus in the kidney or ureter; intense pain comes on in the region of the kidney, in the course of the ureter and of the genito-crural nerve, and at the same time vomiting of a most severe kind ensues. The sudden onset of the paroxysm of agonizing pain is caused by the impaction of a calculus in the ureter; and, as the pain radiates across the abdomen, it is frequently mistaken for colic, or from the sympathetic affection of the stomach, it is regarded as primary gastric disorder. If the structure of the kidney be unaffected, the gastric

symptoms disappear when the pain ceases ; and the patient rightly states, that as soon as the pain has subsided, a hearty meal can be taken, and well digested without any renewal of pain.

This condition then is due to the relation of nervous structures; the renal plexus of nerves is intimately connected with the semi-lunar ganglion, and branches of the pneumogastric nerve also pass directly to the kidney; the stomach also receives its nerve supply from both these sources, the pneumogastric nerve and the semi-lunar ganglion ; these instances are not really dyspepsia at all, nor even disease of the stomach in any sense, although not a few instances have been brought under my notice as such.

The second form of gastro-renal disease is from organic disease of the kidney; the blood is imperfectly purified, urea is retained in it, and as a symptom of this uræmia, gastric disturbance is produced. From this bloodcontamination all the secretions become changed, and the gastric juice itself is altered from the presence of urea in it.

The symptoms of this disorder are loss of appetite, nausea coming on without any assignable cause, and vomiting of clear watery mucus; anything placed in the stomach is at once expelled, even the blandest diet is with difficulty digested ; distension and pain are exsited, and when the viscus has become composed, any indiscretion is sufficient to bring on a recurrence of the

irritability. These symptoms are often less severe, and we may find the urine highly albuminous, without any disorder of the stomach.

This dyspepsia is accompanied by other characteristic symptoms of renal disease, such as anæmia and anasarca, but in numerous instances this is not the case ; the anæmia may not be remarkable, and the only evidence of anasarca may be an oedematous condition of the conjunctiva and of the eyelids. Pain in the head, and at the back of the neck, or an unusual disposition to sleep, may, however, be the indication of an uræmic state.

These instances of disease are of a most serious kind, and great care is required lest the already diseased kidney almost cease in its action, and the case terminate fatally. In sudden suppression of urine, vomiting is sometimes as marked a symptom as in intestinal obstruction, as shewn many years ago by Dr. Barlow.

When vomiting is persistent in albuminuria, and especially when it is accompanied with purging, we regard it as a very unfavourable symptom. The whole mucous membrane of the alimentary canal becomes cedematous, and the serous discharge produces irritation, disturbs the ordinary functions, and exhausts the patient. With renal dyspepsia other cerebral symptoms are often conjoined, as occasional momentary loss of consciousness or epileptiform attacks; the senses are also affected, and amaurotic symptoms come on from degenerative change

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