XXIV. Constitutional Diseases.
There is at the present time must disagreement and misunderstanding concerning the presence of uric acid in the blood, and its excretion in the urine. At one time the influence of this substance was thought to be settled, while its origin was yet in doubt. At the present time more is known of its origin while its entire influence is conjectural. It is now attributed more to faults with the kidneys themselves than previously.
Etiology:—Uric acid is present where there has been faulty metabolism, although whether it is due to the conditions which prevent proper change and elimination in the various organs in the body is questioned. All physicians have observed as I have, that sedentary patients,—those subjected to a monotonous round of duties continuously, without break or interruption, those burdened with care and responsibility, with insufficient income to supply the necessaries of life, especially those who are of nervous or bilious temperament, with dark hair, dark eyes and skin, are especially liable to pass a small quantity of urine, which is heavily loaded with uric acid. This urine has a high specific gravity, is of dark amber color, is passed frequently and causes considerable irritation. It is strongly acid in reaction.
Uric acid is derived from the nucleoproteids which much of the nitrogenous food contains. The nucleins which contain xanthin, hypoxanthin, adenin and caflfein, are formative of uric acid. These substances are combined with albumen in the nucleins, but they are uncombined in the meat juices and in the extractives of animal tissue. The substances are not present to any great extent in milk, caffein, or in eggs, and not present to so great an extent in the muscular structure of beefsteak, as in its juices. Coffee, tea and cocoa are very active in producing uric acid. This substance has been increased more than 125 per cent by drinking coffee alone. A diet of bread and butter, potatoes, milk and eggs, will yield a normal quantity of uric acid, which will be increased one and one-half times by the addition of fresh meat. I have observed frequently that dried beef can be eaten with impunity by some uric acid patients with apparently no very great increase of uric acid, but with a marked increase of strength.
General Symptomatology:—These persons become despondent, morose, or irritable, and tend to melancholia. They suffer from constipation, have but little appetite, and that usually is perverted; they desire to eat freely of acid substances, which are often indigestible and injurious, their food must all be highly seasoned, and they drink to excess of tea or coffee. Sometimes whisky drinkers are also affected. Beer drinkers but seldom.
With a large quantity of uric acid in the urine there may also be an excessive quantity of the urates, and if there is nervous irritation or nervous exhaustion, the phosphates will be abundant. Whether the excess of uric acid present under these circumstances will act as the exciting cause, of rheumatism, gout, or chronic disease of the respiratory passages, as has been suggested, as well as of various other difficulties, which may exercise a reflex action, also, upon the functional operations of the various organs of the body, is still problematical. The presence of an excess of uric acid for an extended period of time will sometimes, from irritation or other cause, result in albuminuria.
Local Symptomatology:—There is usually a broad, thick tongue, which is heavily coated; ulceration of the mucous membranes of the mouth is not uncommon; the breath is more or less offensive, and there is occasional vomiting. There is a sensation of tenderness in the epigastric region with persistent flatulency, which is a frequent cause of palpitation. These patients suffer from nervous irritation, and I am inclined to think that the condition is one of the contributing causes to neurasthenia. It is certainly very often present with neurasthenic patients. Insomnia is persistent and mental depression and melancholia are frequently observed. Headache is a persistent complication, if present. It assumes various forms and is intractable to direct treatment. It is removed by removing.the cause, or by general treatment for the improvement of the constitutional conditions.
The skin is dry and irritable, and eventually pimples, boils, acne, eczema, herpes, with pruritus or other skin disorder, especially upon the face and neck, are apt to appear.
Treatment:—In the treatment of this condition there must be a change in the habits of the patient. I have often persuaded them to change their occupation entirely, to engage in that which would call into play all their physical functions, and would cause them to have something to think of except themselves and their daily burdens. I have then advised exactly the same course of diet that I suggested in the treatment of albuminuria, when the specific gravity of the urine was persistently high, and have suggested the same course in the taking of fluids. But little medicine is needed if such a course is carried out, as free elimination is the great desideratum. Any medicines advised will be suggested by the indications present in the individual case. With the drinking of large quantities of water, the patient should take small doses of macrotys, perhaps one minim four or five times a day with one grain of the acetate of potassium. To these may be added gelsemium, if there is much nervous irritability. For many years I have prescribed piperazin and have obtained a satisfactory influence. I have given from five to eight grain doses in a glass of water, four times daily, with excellent results. An infusion of polygonum, or epigea repens, or triticum, may be prepared, and to this may be added peroxid of hydrogen in the proportion of three or four drams to the pint. This quantity may be drunk each day for a considerable period. I am a firm believer in oxidation by the ingestion of oxygen carrying remedies, and imperfect oxidation is one of the causes of this condition.
When the liver and spleen are plainly at fault, such remedies as iris, leptandra, chionanthus, ceanothus, polymnia, or carduus marianus, may be selected according to the specific indications. Grindelia squarrosa is recommended where there is despondency, or melancholia, with chronic gastric or gastrointestinal disorder.
The salts of lithium are important remedies in lithemia. The benzoate, carbonate, acetate, or bromid of lithium should be selected, in accordance with the existing conditions.
Local treatment of skin disorders is only palliative if the constitutional conditions are not relieved. With the other remedies advised, I have found grain doses of the carbonate of iron, with or without hydrastis canadensis, as the condition of the stomach may demand, to be most serviceable in persistent facial eruptions.