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may persist with very little pain, sometimes pain is a prominent symptom, especially after food, and it may trouble the patient for months, as if there were organic disease; or, intense pain at the region of the stomach comes on, without vomiting, but soon followed by extreme prostration, compressible pulse, a haggard countenance, and in rare instances a fatal issue soon follows. Although some of these cases may really be explained by the presence of undigested substance in the stomach, and in others by gall stone, or renal calculus, or lead colic, still there are patients affected with gout who, without any such exciting cause, suffer from intense pain at the stomach of a most alarming character. We lately witnessed a case of most severe colic, which, after lasting about forty-eight hours, gave place suddenly to severe gout in the foot, as well as in the small joints of the hands; after a few days the gout subsided, without any return of abdominal pain.

It is when these anomalous dyspeptic symptoms exist without any gouty deposit in the neighbourhood of the joints, or in the fibrous tissues, and without previous paroxysms of gout, that the diagnosis is accompanied with difficulty; but when gout has become manifested by these outward signs the organs of primary assimilation are found to be very easily disturbed.

In chronic gout, degeneration and contraction of the kidney often occur; albuminuria is found to exist without dropsical effusion, and the gastric symptoms

are greatly aggravated. Some of these patients who have consulted me, merely complained of drowsiness; and on investigation the urine was found albuminous, and the kidney organically affected. With great care a fatal issue may be warded off; but too often cerebral disease and apoplexy ensue from degeneration of the minute capillaries of the brain.

In rheumatism, both of an acute and of a chronic kind, the gastric functions are disordered; in the acute form the tongue presents a white and creamy fur, and there is loss of appetite, with more or less constipation ; and in chronic rheumatism, we often find that there is troublesome gastric affection.

The most effectual relief for this gouty dyspepsia is to promote the separation of the excreta retained in the blood; saline purges with colchicum, and the cautious employment of neutral salines or carbonated alkalies with vegetable infusions should be used, and if there be much depression these remedies should be given with aromatic spirit of ammonia. The saline waters of Karlsbad, Vichy, Bath, Cheltenham, &c., are often very serviceable. A few doses of mercurial medicine serve to stimulate the abdominal glands to more vigorous action.

If the gastric pain be severe, bismuth and the carbonated alkalies of potash, soda, or magnesia, with hydrocyanic acid and chloric ether, may be used; and when the pain is intense, opium or chloroform should

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 from 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.

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

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