Extracted from the American Journal of the Medical Sciences for October, 1881. 
THE NERVOUS SYMPTOMS OF LITH/EMIA. 
BY 
J. M. DA COSTA, M. D., 
PROFESSOR OF PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE AT THE 
JEFFERSON MEDICAL COLLEGE, PHILADELPHIA; PHYSICIAN 
TO THE PENNSYLVANIA HOSPITAL. [Extracted from the American Journal of the Medical Sciences for October, 1881.] 
THE 
NERVOUS SYMPTOMS OF LITH/EMLA. 
BY 
J. M. DA COSTA, M.D., 
PROFESSOR OP PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE AT THE 
JEFFERSON MEDICAL COLLEGE, PHILADELPHIA J PHYSICIAN 
TO THE PENNSYLVANIA HOSPITAL. 
Among the subjects which have been of late more clearly recognized is 
that of lithiasis or lithaemia. Able researches have done much, decidedly, 
to direct the attention of the medical mind to it, and the outcome is that 
it is now distinctly known that a state exists which is closely allied to 
gout, a half-gout that does not bring with it the inflammation, pain, and 
obvious swellings of the gouty paroxysm, but which works more silently, 
is characterized by the abundance of lithic acid or lithates in the urine, 
frequently coexists with signs of ill-assimilation of food, and with aches 
and pains unaccompanied by any perceptible changes of the aching part. 
Hepatic derangement is also often found; and from this end of the 
chain the links are stretched through many vague, almost nameless, symp- 
toms to outbreaks of true gout, or to structural change in heart, vessels, 
and kidneys. But it is not my object to discuss this relationship, and 
the mode of progress, nor the striking organic changes that are wrought. 
I shall confine myself to the less obvious, less known results which show 
themselves in the nervous system. This matter has long engaged my 
attention, and the more I examine it, the more I see these obscure phe- 
nomena becoming clear and demonstrating for themselves their true 
causation. 
The first nervous symptom, connected with lithiemia, that I shall describe 
is I'ertiyo. It is astonishing how many cases of vertigo turn out, on clos ; 
investigation, to be thus caused; bow pei’sistent are the symptoms, how 
grave the apprehensions, until their true source is made out and the treat- 
1 2 
ment based on it; and how gratifying then the results of the treatment. 
Cases go on for years, some of them weighted down with the suspicion of 
organic cerebral mischief, more especially of tumour of the brain ; lives are 
wrecked by the enforced abandonment of pursuits; the remedies employed 
are hurtful rather than helpful, until the hidden cause of the malady is 
discerned and by steady perseverance removed. 
I will, by way of illustration, record three such cases of grave aspect 
and long standing. 
Case I—A physician, 35 years of age, practising in a malarial dis- 
trict, himself a malarial subject, but not for some time affected with any 
distinct malarial outbreak, consulted me for violent attacks of vertigo; so 
violent and repeated that they interfered with the exercise of his profession ; 
often was he obliged to lie down in his carriage, and at times staggered so 
in going to a house that, leaning against the front door for support, he 
would fall into the entry when the door was opened. He Avas rarely a day 
Avithout an attack, although some were light; at times they Avere twice or 
thrice repeated in the twenty-four hours. His memory began to fail him; 
he Avas especially confused as to names, and was liable to use wrong words 
like an aphasic. At times a dull headache existed, but headache was on 
the whole neither a constant nor a prominent symptom; his vision Avas 
less acute than formerly. These symptoms had been going on markedly 
for a year, uninfluenced by quinia and other remedies, which he at first 
took under the belief that the disorder Avas malarial. Efforts to continue 
his professional duties increased his distress. He finally abandoned work, 
fully persuaded that he had an organic disease of brain or spinal cord, and 
alternating only in opinion between cerebral tumour, as he thought of the 
violent Arertigo and of the headache, and locomotor ataxia, as his mind 
dwelt on the uncertainty of gait and the attacks of shooting pains in the 
limbs which every now and then happened. 
When examined by me, I found no alteration of sensibility or of motion ; 
the tongue Avas slightly coated at the back, the bowels were regular; the 
conjunctiva rather muddy, and with the faintest yellowish tint; no marked 
dyspeptic symptoms existed, or enlargement of liver or spleen, though 
the liver dulness Avas, perhaps, a little more extended than normal. The 
pulse was compressible, and occasionally lost a beat; there Avas no cardiac 
murmur. The appearance of the patient was that of distress, but not of 
anmmia. The joints of the fingers Avere someAvhat tender on pressure. 
The urine Avas scanty, of high specific gravity, free from albumen, but 
loaded with lithates. 
It Avas difficult to persuade the patient that he was not affected with a 
hopeless disease; that his symptoms were those of lithmmia, produced by 
overwork and the disordered state of the liver due most likely to malarial 
poison. He yielded reluctantly to the view of trying a strict diet, rest- 
ing from work, exercising in the open air, and using alkaline purgative 
waters, followed by a course of small doses of arsenic. But he was glad 
he had yielded when health sloAvly, but steadily and fully, returning showed 
him the advantage derived from his submission. 
The case I am about to relate was of much longer duration, and the 
time that lias elapsed since the last attack shows hoAV complete was the 
recovery. 3 
Case II A gentleman, 48 years of age, fond of intellectual pursuits, 
and leading the life of a student in addition to bearing the cares and 
anxieties of the responsible direction of heavy interests, has been at least 
for twelve years subject to attacks of vertigo, which distress him and 
demoralize him. Some years since he never passed a month without 
them; they come, when feeling well, or with but little premonition, simply 
that of a slight dyspeptic state; they come when on a strain, and when 
taking relaxation, though much more generally under the former than 
under the latter circumstances. The attacks are of about a minute’s dura- 
tion; he has had them at night awakening him out of his sleep; they are 
objective, and followed by a dull headache, which does not last longer than 
a day and sometimes only for a few hours. He is very gloomy after them, 
and for years his life was haunted by the idea that he was becoming an 
epileptic. This view was seemingly confirmed by rapidly passing spells, 
during which his mind was a blank and he would stagger in his gait, and 
he eyed with keen suspicion any companion in his walk, fearing that the 
dreaded secret was at last disclosed. Irregularity of the heart I found to 
be very common with him, the pulse some days intermitting every fourth 
beat, and on others only every twentieth. When the irregularity was 
most marked, these passing attacks of oblivion happened most decidedly. 
The intellectual faculties were always acute, but long spells of iistlessness, 
requiring strong will power to force himself into exertion, were not in- 
frequent. Dyspepsia occurred occasionally, especially of the acid type, 
but was not a marked symptom; the urine often deposited lithates, was of 
specific gravity ranging from 1020 to 1024, was free from sugar and albu- 
men, contained lithates in abundance, and at times oxalates. The eye 
ground, examined by an ophthalmologist, was pronounced to be normal; 
it is right to add that the examination was made when there had not 
recently been vertigo. Slight sallowness of the skin and elevation of 
temperature, not exceeding one degree, were occasional symptoms, and 
joints of right hand at times tender on pressure, pain in the toes, and so- 
called rheumatism in the leg, some stiffness in walking, were also at long 
intervals observed. 
Lithsemia existed in the family; the father had clearly suffered from 
similar symptoms, including the vertigo; a brother had the uric acid dia- 
thesis very marked, and had passed renal calculi of uric acid. 
A system of active exercise, shower baths, regulated diet, produced 
very good results, so good that the attacks of vertigo happened only once 
in seven or eight months, while the dreaded slight suspensions of conscious- 
ness passed away altogether. But the cure was completed by a European 
trip, and the taking, while in Europe, of a course of Kissingen water. 
Two years and a half have elapsed since the last vertiginous seizure, and 
although there are still occasionally lithmmic symptoms, as regards the 
pain in the joints, and their soreness on pressure, the nervous symptoms 
have vanished; the action of the heart has become quite regular, the 
future seems as bright and promising, as before it was overcast and gloomy. 
In the cases just described, the symptoms of gastric derangement were 
so slight and inconstant that they scarcely can be said to have been feat- 
ures of the disorder. I will now cite one, remarkable also for its seem- 
ing gravity, in which, however, early in the case at least, gastric symptoms 
were marked. 4 
Case TIT A gentleman, SB years of age, tall, of fine physique, ot 
nervous temperament, born of a family in which gout lias been long heredi- 
tary, father, grandfather, and maternal uncles having been great sufferers 
by it, was in excellent health until October, 1878. He is temperate in his 
habits, fond of all outdoor exercises, an active walker and rider. In the 
autumn of that year, feeling the effects of the exhausting heat, he drank 
for a time Burgundy, but abandoned it when he began to perceive that it 
did not suit his digestion, and occcasioned some aching in the joints. 
While regaining his usual condition, he was exposed to the vapours of 
turpentine in a newly painted house; an attack of vertigo resulted. From 
this time on for three months his life was a very miserable one. Four or 
five attacks of vertigo were often of daily occurrence, and he woke up 
with them at night, the floor and the bed seeming to dance around 
vigorously; he himself, however, never appeared to move, in other words, 
the vertigo was always objective. An attack lasted, it was thought, about 
two to three minutes; it was often followed by clammy sweat and by 
dull headache. The worst ones only were attended with sick stomach, 
or with the subsequent vomiting of a glairy and intensely acid mucus. 
A symptom as annoying as the vertigo was the staggering gait frequently 
produced; while walking, he would sway so as to have to cling to a lamp- 
post, and he, one of the most temperate of men, had several times to 
undergo the mortification of being taken for an inebriate. 
He had no' persistent headache, was greatly troubled with impaired eye- 
sight; was obliged almost to desist from reading and from his ordinary 
pursuits; but bore his trials with unflinching courage. The heart acted 
normally, with an occasional intermission; he had at times shooting pains 
in his legs, and aches in the knuckles; the bowels were regular; the urine 
was habitually scanty, of specific gravity 1024, filled with urates, and occa- 
sionally with little cayenne pepper grains of uric acid. The gastric symp- 
toms were in the first month or two very pronounced ; they were of the 
form of a gastric catarrh with much acid dyspepsia. The impaired eye- 
sight has been alluded to. An expert who examined the eyes carefully, 
pronounced them astigmatic, but stated that in addition there was decided 
enlargement of the retinal veins, a sort of varicose condition, and a spot 
of intense congestion in the right eye explaining the absolute blindness 
to objects in the lower right-hand quarter of the field of vision. In the 
left eye there was some varicosity of the veins, but no marked congestion ; 
in neither eye-ground was choking of the disks found. 
Another most distressing symptom was numbness of the left side, chiefly 
of the leg, sometimes of the arm and the side of the face. It bore no re- 
lation to the vertigo, was apt to occur in paroxsyms of from three to five 
minutes’ duration, during which the sensibility of the skin was somewhat 
impaired, at other times the aesthesiometer detected no abnormal condition. 
Some improvement took place under treatment, especially under the 
strict diet, the use of small doses of Hunyadi water in the morning, and 
of corrosive sublimate between meals. The gastric symptoms were cer- 
tainly much benefited, the vertigo happened less frequently, yet scarcely 
a day passed without some attack, even if slight. A sea-trip was then 
decided on; and he sailed for Europe in January, 1879, The effect was 
admirable and immediate, at least, on the vertigo. He had but one 
seizure, which occurred while passing through Paris, at the end of Janu- 
ary. But his other symptoms did not at once subside. On the contrary, 
headache, which had been a very inconstant, almost absent symptom, while 5 
here, became a prominent one ; and more or less dull pain in the head 
with not infrequent attacks like those of nervous sick headache were com- 
mon ; the swaying, too, by no means ceased, and was, like the headache, 
for a time aggravated by visiting the picture galleries of Northern Italy. 
Pains in the limbs, cramps and aches, even slight swelling in the 
knuckles, with uric acid deposits in the urine, also happened from time 
to time. Sugar in any abundance, malt extract, and all wines, except the 
light red wine of the Riviera, made these symptoms worse, or at once 
developed them, if they had been absent. Eschewing all wines and 
great care in diet, especially with reference to saccharine substances, 
much exercise in the open air in some of the health resorts of the south 
of France, produced amelioration so decided that he returned home in 
the autumra well to all appearances, although still a little troubled with 
the headache and the swaying in walking. Since January, 1880, these 
have passed off entirely, and while careful about taking enough exercise 
and about his diet, he is as well as ever he has been. His eyes, too, have 
greatly improved ; when under active exercise and free from care, he can 
read without glasses, and has had at times glimmering of vision in the spot 
in the right eye which seems deprived of it. 
Reviewing the features which these cases have in common, and 
taking into account many other instances which I have seen, what I 
shall call lithcemic vertigo, may be, I think, thus described. It is a giddi- 
ness frequently repeated; often there are several attacks daily for a few 
days, and then there is a much longer interval; it may occur at night. It 
happens irrespective of exertion, although long continued fatigue, espe- 
cially in reading and writing, excites it; so does mental worry. But any- 
thing that aggravates or induces the lithsemic state develops it most promptly. 
Special articles of food do so; and I have had patients in whom a few 
glasses of hock, or a single glass of Burgundy or champagne, are sure to 
cause it the next day. The vertigo is objective, not subjective,—objects 
seem to whirl around the sufferer, not he himself to move. The giddiness 
is not associated with loss of consciousness, or this is so temporary that 
the patient is able to retain his position or speedily to regain it. Still he 
has to hold on for support to surrounding objects, and I have known him 
brought down on his knee before it is over. From the alarm and distress 
which attend it, it is very difficult to form an idea as to its duration. Not- 
Avithstanding the exaggerated statements made by the sufferer, to whom 
the seizure seems terribly long, it is safe to say that it rarely lasts more 
than a minute or two, and frequently less than a minute. It may come 
on without warning, or be preceded by a sense of emptiness of the head, 
by specks floating before the eyes, by dimness of sight. When it has set 
in, sudden change of position is apt for the next few days to develop it 
at once, although, perhaps, this is not more marked than in any form of 
vertigo. It may or may not be folloAved by headache ; generally it is only 
followed by a sense of discomfort in the head, or by a dull ache of short 
duration, and, as in Case 111., it may be noticed that Avhen the headache 
in litluemia becomes a marked symptom, the vertigo is infrequent. 6 
When often repeated, it produces effects on the special senses. Sight 
is less acute, the field of vision is limited in size ; letters look blurred, and 
there may be inability to see more than two or three letters in a word, or 
double vision may occur. One eye, or part of one eye, may be temporarily 
blind; and the ophthalmoscope detects marked congestion, especially ful- 
ness of the veins. When no attack has happened for some time, the eye- 
ground, as in Case 11., is found to be normal. Long continued and fre- 
quently repeated attacks may give rise to some persistent changes, though 
never to choking of the disk. It would be unfair to leave the impression 
that these changes are all the result of the vertiginous seizures. In part, 
at least, they belong to the lithcemic state itself, and may be caused by it. 
But the whole matter is new and not worked out; and I invite the atten- 
tion of ophthalmologists to this promising subject. 
The sense of hearing is sometimes impaired for a day or two, and buzz- 
ing in the ears is complained of. These phenomena, too, may follow 
attacks of vertigo, or occur when the patient is only markedly litheemic, 
and has not been dizzy. 
I have in the cases described alluded to the momentary suspensions of 
consciousness, the sensations of lightness in the head, with a dark shade 
passing over the eyes, which are, in my experience, very common, and are 
dreaded by physicians especially, when afflicted with the disorder, as the 
precursors of epilepsy. The sense of terror and of fear occasioned is quite 
inconceivable to one who has not bear’d these attacks spoken of by a victim. 
They happen in those who at other times have had distinct vertigo ; they 
are not at the time combined with giddiness, but produce a staggering or 
swaying, from which recovery is so quick that the disturbance mostly passes 
unperceived. Again, uncertainty of gait may take place for a long period 
without any of these signs of brain disturbance. In Case 111. it lasted for 
a year after the vertigo had ceased. 
As regards the cause of the vertigo, it is likely that the disorder is pro- 
duced by the impure lithremic blood. Whether this acts on the vaso-motor 
nerves and through them on the cerebral circulation, or primarily on some 
nerve-centre, must remain for the present a matter of pure speculation. 
It would not be difficult, following the ingenious reasoning of Woakes, 
concerning stomach vertigo, to connect the disturbance through the 
pneumogastric nerve and the lower cervical ganglion with the vertebral 
artery supplying the labyrinth and adjacent structures. But we must then 
assume as certain that a disturbance of this is always the cause of giddiness, 
and that the lithaunic process is invariably connected with a fault in the 
liver. 
Gastric vertigo has just been mentioned, and doubtless it will be thought 
that the symptoms described are those of gastric vertigo. So they are 
in many respects; except that, for the most part, there are no gastric 
symptoms, or but passing gastric symptoms in lithieraic vertigo, while the 7 
evidences of the lithseralc state are the marked features, or soon become so. 
Indeed, the error has been the other way; lithaemic vertigo has been 
confusedly included with gastric vertigo, from which we must learn to 
separate it. This is best done, as just indicated, by dwelling on the com- 
parative absence of the stomach symptoms, and on the evidence presented 
of lithaemia. But there are unquestionably mixed cases, which it is not 
easy to analyze. 
Headache is not, on the whole, a prominent symptom of lithsemia; that 
is, persistent headache is not. A dull feeling in the head, especially 
frontal, much more rarely occipital, happens at times for a day or two, if 
the digestion be specially disordered; or occurs as a morning headache, 
or, as already mentioned, for a few hours after an attack of giddiness. 
But severe acute periodical headaches of neuralgic type are common. 
They are very much like migraine, except that the bilious vomiting and 
signs of gastric disorder ax*e far less prominent. They are localized, are 
increased by noises and by motion, and are frequently accompanied or 
followed by a heavy deposit of red sand in the urine. This is the way 
the attack relieves itself, and it suggests a strong analogy with what has 
often been noticed, that gout in the joints and migraine are prone to 
happen in the same person, the violent headache ending when the gouty 
swelling begins. 
Neuralgia is a very common complaint in lithaemic subjects, and there 
is no nerve in the body that can ache which is exempt. Brachial neuralgias 
with pain shooting down the forearm to the tips of the fingers, intercostal 
neuralgias, sciatic neuralgias, are very common; neuralgia of the tongue 
happens ; and in women neuralgia of the breast is not rare. The only 
neuralgia which I have found infrequent, is the one which might be sup- 
posed to be the most frequent, that of the fifth nerve; still it, too, may be 
encountered. Women are, I think, more subject to lithmmic neuralgia 
than men ; we do not absolutely meet with more cases than in men, but 
tliis is because litluemia affects so many more men than it does women. 
The sciatic neuralgia may seize upon one or both nerves. There are often 
paroxysms of pain of three or four days’ duration, and lulls of at least as 
long. This may go on for several months unless checked by treatment 
for the constitutional state. Sometimes the attack relieves itself by gravel 
in large quantities being passed. When the disorder is protracted, it may 
well be, in these lithmmic neuralgias, that the uric acid, irritating and 
perhaps being deposited in the nerve sheaths, leads to a secondary neuritis. 
The comparative infrequency of trifacial neuralgia has been alluded to. 
What is generally called facial neuralgia are cases like this, which at the 
same time illustrates the form of neuralgic headache above mentioned. 
Case IV—A professional man, 48 years of age, portly in appearance, 
consulted me with reference to violent attacks of neuralgia and vertigo. 
The attacks of neuralgia frequently happened every day for some time. They 
are not, however, in the course of the fifth nerve, and it is more correct to 8 
describe them as severe lancinating, paroxsymal headache, the pain felt on 
both sides of the head, especially of the forehead, followed by a little general 
soreness of these parts, but without localized tenderness in the trifacial. 
At times there are violent attacks of gastralgia, as violent as the head pains, 
and apt to take their place. He often has sleepless nights, gets up fre- 
quently to pass water, and his restlessness makes him an early riser. He 
is not a dyspeptic, except that he is at times annoyed with acid eructa- 
tions; the tongue is clean. The urine is voided in full, rather large, quan- 
tities. It has an acid reaction, a specific gravity of 1014, no albumen or 
sugar. Examined under the microscope, there are urates, and also a large 
amount of free uric acid, with some epithelium. The pulse is compressible, 
about 75, easily influenced by emotion and fatigue; the first sound of the 
heart is short; the second very distinct. The vertigo and the headache 
are the only cerebral symptoms; the latter is not constant, but disappears 
for weeks and then returns in those violent outbreaks like neuralgia. 
These are sometimes terrible, and last, with their fierce exacerbations 
of several hours’ duration and their remissions, for one to two weeks at 
a time. A half pint of hock will at once provoke the frightful headache, 
and frequently at the same time pain in the big toe. Aconite and mor- 
phia, salicylic acid, but particularly iodide of potassium and colchicum, 
have relieved the head pains. There are depression and irritability of 
temper, and want of energy, but these are far from constant, and occur 
irrespectively of the pains. In bracing mountain air, and taking exercise, 
he is always well. The attacks of vertigo have been very severe, although 
they are not frequent; they are chiefly morning attacks, most apt to occur 
on first rising. A striking feature of the case is the inability to keep 
warm, and the coldness of the extremities; but this is largely subjective. 
Yet, the state of the skin is not quite normal; the sensibility is not acute. 
The two points of an aesthesiometer on the finger tips are not sharply felt, 
nor correctly appreciated when at all close together. There is the clearest 
history of hereditary gout. Father, grandfather, great-grandfather, and 
the mother’s father, all had been gouty. He himself has never had an 
attack. 
Under systematic skin friction, moderately active exercise, occasional 
saline purgatives, restricted diet, mild alkaline diuretic waters, this 
gentleman improved greatly, and headache and vertigo were strikingly 
influenced. Oxide of zinc, two grains three times daily, was also taken 
for a time, and it was thought with decided benefit. 
The next case illustrates a most violent form of intercostal neuralgia, 
finally cured by remedying the lithaemic state. 
Case V—A physician, 33 years of age, of good constitution and general 
health, except repeated attacks of left-sided, trifacial neuralgia, occurring 
every wreek or ten days since childhood, and expending their force on the 
supra-orbital branch. Never had malaria, syphilis, acute rheumatism, 
or gout. Is a moderate eater, and temperate in his habits, using oc- 
casionally a little whiskey after dinner and supper, at no time exceeding 
three ounces in all. There is no hereditary disease, his father is living 
affected with shaking palsy. Practising in a mining district, there was 
much hard work and exposure, but his health was fairly good until his 
return to the city after a three years’ absence. Soon, he began to be 
at tacked with what was at first looked upon as pleurodynia on the left side; 
it was finally relieved by blistering and by a course of iodide of potassium 9 
and cod-liver oil. For a year or two headaches happened, also generally 
relieved by the iodides. 
In the spring of 1878 he first felt a burning aching pain between the 
shoulders, extending to the occiput. The pain increased gradually, in- 
volved a considerable portion of the left side of the chest, which became 
sore, and very tender spots could be distinctly made out in the course of 
the intercostal nerves. There was loss of appetite, and of flesh, constipa- 
tion, and profound melancholy. 
The salicylates, quinia, colchicnm, the iodides were taken without re- 
lief; nothing did good but a trip to Florida of three months, and exercise 
in the open air ; the pain and all the other symptoms disappeared. But 
on returning home they soon came back, the melancholy was intense, 
the chest pains were most violent. These were relieved by the thermo- 
cautery applied along the spine over the site of exit of the aching nerves. 
Yet the relief did not last, and when I saw the patient about two months 
afterwards, lie had severe pains and aches in the dorsal and pelvic girdles. 
The pains were acute and in paroxysms, there were distinct tender spots 
to be made out in the course of the nerves; the intercostal trunks pre- 
viously affected were only slightly disturbed; the pain at times shot along 
the sciatic nerves of one or both legs, and was combined with very con- 
siderable diffused muscular soreness. IN’ot the least evidence of stiffness, 
swelling, or redness of the joints existed, and no fever. The body pains, 
which were aggravated in paroxysms, were worse in the evening and early 
morning and in damp weather. They often ceased when attacks of tri- 
facial neuralgia happened. There was very slight dyspepsia, a clear 
tongue, some constipation, only trifling loss of flesh, but foreboding of evil, 
with refined self-torture, and a melancholy as great as I have ever met 
with. The mental faculties remained good, except some impairment of 
memory; reasoning was keen on the false facts which the gloomy self- 
inspection furnished. The heart was slightly accelerated, at times irregu- 
lar, the first sound short, lacking weight, the second sharp. He passed 
but little over one pint of urine in twenty-four hours, of specific gravity 
1023, free from albumen and sugar; acid, containing a great excess of 
urates. The urinary examination repeated several times gave much the 
same results, specific gravity ranging from 1023 to 1028, abundant urates, 
uric acid forming readily and in abundance, but only after urine acidulated 
with nitric acid was allowed to stand, dumb-bell and octahedral oxalates 
in moderate amounts. 
I placed this patient on a diet of vegetables, fish, stale bread, and 
white meats, even these only in moderation; I forbade all stimulants; 
I insisted upon a certain amount of daily exercise and skin friction, and 
directed him to drink Poland water freely, to keep the bowels soluble, 
and to take oxide of zinc, two grains three times daily. After about a 
month of this treatment he reported himself very much better. In place 
of passing only a pint of urine daily, he passed three pints, of specific 
gravity 1017; he had hardly any dyspepsia, his tongue was clean. There 
had been some attacks of neuralgia, and a little pain in the great toe 
joint, worse before a rain storm, but they had not been very severe. 
For one attack of sharper and more protracted character, he took large 
doses of quinia with the same negative results as on former trials. 
Colchicum did much more good. He remained comparatively well, his 
spirits rallying with his improving health, until early in April, when he 
had a terrible seizure of left-sided intercostal neuralgia. Opium inter- 10 
nally, hypodermics of morphia, and of morphia and atropia, cannabis, 
and chloral gave but very temporary relief; the attack had been going on 
for nearly two weeks under this treatment, when T directed him to take 
Tlyth of a grain of aconitia. He took three doses in twenty-four hours, 
it produced its physiological effects. The pulse sank to 52, was slightly 
intermittent, a feeling of numbness spread all over the body, and the neu- 
ralgia vanished. For a month afterwards he was entirely free from pain, 
pursuing his treatment with zinc, subsequently with small doses of arse- 
nic, but always drinking freely of diuretic alkaline waters, using natural 
purgative waters from time to time, and keeping up the strict diet. The 
arsenic was not long continued, as it did not seem to suit his digestion. 
He has had but one bad attack of intercostal and dorso-abdominal neural- 
gia since. Aconitia influenced it, but not as decidedly as in the first 
trial; hypodermics of morphia and atropia relieved the pain, and the 
attack, much shorter than usual, lasting only three or four days, was 
broken up by free purgation with gamboge. At its height and at its de- 
cline, the urine, as usual in these seizures, was filled with heavy sandy 
deposits. The patient is now well, he has been to the seashore; he has 
gained flesh. He is careful in his diet, takes no medicine, and is cheer- 
ful and happy. 
One of the most common forms of lithmmic neuralgia is gastralgia. It 
does not differ in its manifestation from ordinary gastralgia, except that 
it is associated with evidences of lithremia, and that it is very apt to alter- 
nate with other neuralgias. It goes on unrelieved, until its source is de- 
tected and removed, and then yields entirely, to return perhaps only at 
long intervals, if at all, unless depressing care, work, or indiscretions in 
diet actively re-develop the constitutional fault which underlies it. It 
leads to emaciation, and is the source of much anxiety; and many is the 
case I have seen of supposed ulcer or cancer of the stomach which was 
lithmmic and recovered. 
Here is a typical instance, Selected from many. 
Case VI—A gentleman, 40 years of age, had been for two years a 
great sufferer with violent and oft repeated attacks of cramps in the 
stomach. While for six months in southern Europe, the disorder almost 
ceased. The pain now is very severe, lasting, with slight remissions, for 
about an hour; it is sometimes started by eating, but it is neither neces- 
sarily caused nor made worse by taking food. The tongue is clean ; the 
digestion, except for the pain, good. During, and more particularly after, 
an attack of pain, soreness at the epigastrium is noticed ; no tumour can be 
felt; the abdominal aorta throbs a great deal ; there are no murmurs. The 
patient has been thought to be labouring under gastric ulcer, while ab- 
dominal aneurism has also been diagnosticated. There is an old, but not 
marked history of malaria, none of syphilis. Considerable loss of flesh 
has happened. At times aching pains in the fingers are complained of. 
The urine is very acid, high coloured, free from albumen, but full of 
lithates, and frequently deposits heavy red sand, and shows in abundance 
crystals of uric acid. I made the patient watch these deposits, and found 
that their occurrence almost invariably coincided with, or followed the 
attacks of gastric pain, and when these were frequently repeated and de- 
cided, the appearance of the urine could be correctly predicated. A care- 11 
ful diet, with a good deal of milk food, rest from laborious pursuits, saline 
aperient waters, and the steady use for about one month of the citrate of 
lithium, broke up the painful disorder. A course of arsenic afterwards 
completed the cure. 
Cramps in the legs and muscular twitchings are often met with in 
those suffering from lithcemia. The former are apt to come on at night, 
and are very annoying and painful. 'They particularly atfect the gastro- 
cnemii muscles, and occur much more often in winter than in summer. In 
one of my patients cramp under the inner surface of the instep is as 
frequent as in the calf muscles ; in another, muscular twitchings of the 
face are also produced when the lithaxmic state is marked. Irregular 
choreic movements I have also seen in children, and they would be very 
much more common were the disease more common in childhood. Yet if 
we look for it we may find it oftener than we suspect. I have now under 
observation a bright young fellow of eleven, inheriting gout through seve- 
ral generations, with most marked lithic acid diathesis and nervous symp- 
toms ; the tendency to irregular muscular movements is only kept in check 
by rigid attention to diet. Pains and perverted sensations are also among 
the symptoms of lithcemia. Pain in the fingers, in the feet, without being 
necessarily associated with aching joints, pain in the tendo-Achillis, in 
the breasts, near the shoulder blades, and in women, at the coccyx, pains 
in the legs, thought to be rheumatic, and attended with some muscular 
soreness and stiffness of gait, are often encountered ; so are burning sen- 
sations of the tongue, and burning of the palms and of the soles. These 
localized flushings in hands and feet are attended with a very slight eleva- 
tion of temperatux-e. The general temperature is but little influenced by 
lithcemia; I think never raised more than a degree to a degree and a half, 
even during the genei’al hot spells, of which there may be complaint. 
One of the most singular abnormal sensations is that of great fulness and 
rather pleasant warmth in an entii’e leg from the knee down, not accom- 
panied by any sense of burning of the skin. All these perverted sensa- 
tions are not persistent, but they recur often. 
Ancesthesia is also a symptom of lithcemia, though not a common one. 
I have never found it very extended, but genei-ally localized to an arm or 
leg, or part of the thigh, or, what is not unusual, on corresponding parts 
of both arms and legs. It may affect the face and the lips, and those in 
whom it happens who have headache as a more than ordinarily promi- 
nent symptom, have told me that the disoi'dered sensation was on the side 
opposite to the headache. The sense of numbness is greater than the actual 
loss of sensibility is found to be. Still, there is some loss of sensibility, 
less keenness of appreciation of sharp points, inability to distinguish the 
two points of the cesthesiometer with X’eadlness. One of my patients 
tells me, that when suffering from the numbness in the lips he can bite 
the lips without feeling it. The numbness may be associated with forrni- 12 
cation or a sense of pricking. It is a persistent symptom in so far that 
while the lithsemic state lasts, it remains where it has been noticed, hut it 
dwindles down at times to very little, and increases markedly at others. 
Free purgation always benefits it greatly ; faradization with an electric 
brush improves it, and it will gradually disappear under strict diet, exer- 
cise, and remedying the lithsemic state; but recurrences are not un- 
common. 
In this case it was very marked :—• 
Case VII Miss S., age 38, inclined to corpulency, has been under 
my observation for eight years, originally for blood-spitting following an 
attack of acute bronchial catarrh and pulmonary congestion. She has 
suffered a great deal from torpor of the liver, at times from acid indiges- 
tion, and frequently passes urine loaded with lithates. Aching in the 
joints and shooting pains in the limbs are also common, and nervousness 
and sleepless nights. But the most singular feature of her case is a per- 
verted sensibility of the skin, a sense of pricking associated with great 
numbness. This is limited to the hands and forearm, it may be on one 
side, it may be on both. There are times when it is absent for months ; 
it is apt to come on in spells lasting in a very decided manner from four 
to six weeks, and during its continuance, the symptoms of acid indigestion, 
of sluggish action of the liver, of uric acid deposits in the scanty urine, 
of aching hands, are apt to be at their height; or it supersedes, as it often 
long outlasts, these. A blue pill, followed by salines, always strikingly 
moderates it. It is not a purely subjective sensation ; for when very marked 
an msthesiometer shows defective tactile sense ; when light, it is difficult 
to say that there is any lost cutaneous sensibility. There is no disorder 
of the heart or uterine functions ; the urine, except the lithates or crystals 
of uric acid, presents nothing abnormal. Care in diet has had a decided 
influence on the troublesome symptom, the greatest relief has followed the 
use of laxatives, and the administration of citrate of lithium, which has 
increased the flow of urine and altered its acid character. 
Other nervous symptoms are sleeplessness, sensitiveness to sounds, great 
susceptibility to odours. The sleeplessness is a very distressing symptom. 
Bromides and chloral have a good temporary influence on it, but it is best 
removed by purgatives and diet. Wine generally aggravates it; and so 
do such articles of food as readily induce the lithtemic state. The sensi- 
tiveness to sounds is especially annoying in those who have headaches, 
and loud sounds add not only to these, but provoke or increase the 
irritability of temper. Undue susceptibility to odours shows itself on 
many occasions. The odour of the magnolia causes headache ; that of 
turpentine is mostly very unpleasant, and I have known it to excite head- 
ache and vertigo. A certain nervousness which may pass into hysteria is 
also among the symptoms of litluemia. I have twice seen in man hys- 
teria from lithsemia; and lam very certain that the hysterical symptoms 
of women no longer in their youth, and which are attributed to nervous 
break downs, to menstrual disorders, to approaching change of life and the 
like, are often really of litluemic origin, and curable by the treatment which 
removes the constitutional cause. There are also among the rarer mani- 13 
festations of lithaemia reflex pains and aches, for which there is nothing to 
account, or which are only partially explained by the direct action of the 
acid urine. To the former belong the pains and sensitiveness in the 
region of the heart, while this organ shows nothing abnormal except per- 
haps an occasional intermittency; a distressing itching of portions of the 
skin, nothing being visible. The latter is illustrated by this case : 
Case YIII G., age 35, a man of extremely nervous temperament, 
son of a father with lithaemic symptoms; has had a great deal of care 
falling on him early in life. Has suffered much from mental depression 
and almost hysterical outbi’eaks of nervousness. Sleeplessness and irri- 
tability of the heart were also among the symptoms; all of which were 
aggravated by worry and relieved by long absence from home, especially 
in mountainous regions, and by horseback exercise. Yertigo has happened 
occasionally, early in the case, which has been going on for five or six 
years; but it has never been a marked feature. Early in the ease, too, 
gastric symptoms, coated tongue, some acid indigestion were observed, and 
this led to the long trial of an almost exclusive milk diet for several years 
with the result of influencing the digestive condition favourably, but having 
little effect on the nervous phenomena. Of late the digestion has been 
good ; attacks of flatulency and of enteralgia happen, however; the tongue 
is only at times coated, the bowels are regular. 
Studying the case I found no organic disease of any organ ; but ascer- 
tained that he passed habitually three pints of urine, of specific gravity of 
1022, very acid, free from albumen and sugar, but loaded with lithates, and 
also containing at times a great deal of mucus. It often shows a consider- 
able deposit of red sand, and when this happens to a marked degree his 
nervous symptoms previously very bad are strikingly relieved. So they 
usually are by repeated doses of calomel, which is apt to be followed for a 
few days by sand in the urine. When he has these abundant sediments 
of uric acid or the urates, a scalding in the urethra, a feeling as if water 
were passing from him, though none is passing, a constriction and burning 
back of the glans, a stinging at the orifice of the urethra; a feeling of 
pain above the pubes, are annoying symptoms of reflex character; and the 
uneasy feelings at the head of the penis are greatly aggravated by any 
irregularity in the time of his meals or in diet. This patient was placed 
on a diet of fish, green vegetables, a little oatmeal, milk, the white meats ; 
he was directed to drink Apollinaris water freely, to exercise, and to give 
himself as much relaxation as was compatible with his pursuits. The bowels 
were kept soluble by Hunyadi-Janos or Friedrichshall water; a little calo- 
mel and sodium bicarbonate were occasionally prescribed, and, while the 
uric acid deposits were so marked, a course of citrate of lithium. He is 
very much better; but he is not as yet quite well; fresh anxieties and 
worries bring about relapses. 
In concluding this examination of the nervous symptoms I must say 
something of the mental state. There are spells of languor and lassitude 
which befall the man whose blood is charged with lithic acid, in which all 
exertion is painful, and which strangely contrast with his usual energy. 
Then there is depression of spirits and gloom that may amount to melan- 
choly. But above all is irritability of temper; odours annoy, sounds 
infuriate, nothing pleases, and it requires more than ordinary self-control 14 
to prevent explosions of temper. The man is on edge, and the acid blood 
literally makes an acid temper. Indeed, many a man who has the reputa- 
tion of being a curmudgeon, is simply a lithaemic who finds it impossible 
to control his engendered irritability. 
Of the mental faculties the memory is the one which alone really suf- 
fers. It deteriorates markedly, especially after lithaemic vertigo. But in 
time as the lithaemia is kept away by a careful mode of life, it regains 
most of its original strength. 
The mental state described may last for several years with only tem- 
porary periods of relief; or the horizon may at once be cleared by the 
discharge of large quantities of lithic acid in the lithaemic, as it is by an 
explosion of gout in the typically gouty. Macaulay’s description of the 
Earl of Chatham’s condition is, from a medical point of view, strictly 
correct. A cloud settled on him; he, a most affectionate father, could not 
bear to hear the voices of his own children. He bought up houses contigu- 
ous to his own, that he might not have neighbours to disturb him with 
their noise. His appetite was fanciful and capricious; he was melancholy, 
irritable. The disputes of his colleagues, the responsibility of state, be- 
wildered this boldest of men, who behaved at times like an hysterical girl, 
bursting into a flood of tears. He had passed months without a twinge of 
the gout to which he had been subject since boyhood. At length the gout 
returned. His nerves were newly braced, his spirits became buoyant; he 
was once more the proud, resolute statesman. Nunquam poetor, nisi 
podager, says Ennius of himself. The hard-drinking old Roman, fresh 
from his cups, sang the deeds of his sturdy forefathers only when an 
attack of gout had purified his blood and cleared his mental vision. 
The symptoms of nervous derangement in lithaemia are interchangeable. 
Sometimes one or several exist for a time; the lithaemic condition gets bet- 
ter, they disappear; the lithaemic condition returns, but with it comes a 
fresh set of nervous symptoms; and so, until the state is permanently re- 
medied, they may appear for years. Indeed, recurrence of lithaemia is one 
of its characteristics, and the nervous symptoms may be so persistent that it 
is difficult to set aside the thought that they are not due to an organic cause. 
These nervous outbreaks frequently happen when the manifestations of 
hepatic and gastric disorder of lithaemia, except in so far as they,are recog- 
nizable in the urine, are not very marked; indeed, I believe they are more 
common in this class of cases. Still we find more or less of these pheno- 
mena at times present: such as flatulent distension of the stomach and 
bowels, acid eructations, fulness at the epigastrium, and drowsiness after 
meals; a bitter taste in the mouth; flabby tongue coated at the back ; 
capricious appetite; constipation, or, what is more significant, stools, from 
altered biliary secretions, either very dark or very light; short attacks of 
diarrhoea; passing slight jaundice; small ulcers in the roof of the mouth; 
hemorrhoids; palpitation of the heart with intermissions in its beat; throb- 15 
bing of the great vessels; lumbago; itching erythematous or slightly scaly 
eruptions, like pityriasis, on the chest and between the shoulder-blades. 
Again, we may observe that the patient has great liability, as Murchison 
so well points out, to ordinary febrile colds, and to more severe local inflam- 
mations. Perhaps he has passed gall-stones or urinary calculi; or shows 
that tendency to degeneration of the tissues, especially of the vessels, 
which is one of the worst results of the lithannic dyscrasia. Or his kid- 
neys and his heart may become structurally involved; the heart making 
its affection manifest by association with the signs of high blood pressure 
in the arteries, its perverted rhythm, the accentuated second aortic sound, 
the growing evidence of hypertrophy and mural degeneration, in a manner 
so brilliantly described by Fothergill. But I repeat, these phenomena 
have no necessary connection with the nervous manifestations; nay, I 
think the latter are far more apt to exist when these organic conditions 
are not developed. 
As so much in the recognition of lithfemia depends on the urine, I must say 
a few words about it. It may be, but it rarely is, copious. It is very 
generally scanty, deeply coloured, and of high specific gravity. It is very 
acid, readily deposits urates, of pink or brick-dust colour, and even crystals 
of uric acid. This state of urine exists more or less at all times, but a 
very large excretion of uric acid or its salts is apt to bring relief to the 
other symptoms. The pigment is increased in the urine; and under the 
microscope we commonly find the amorphous urates preponderating, more 
rarely well-formed crystals of uric acid, sometimes also oxalates. The 
urea is not increased, except in some instances, and in these loss of flesh 
is generally going on. Thus, in one case of the kind examined, the urine 
which was decidedly acid, had a specific gravity as high as 1035—in itself 
in the absence of sugar a suspicious circumstance,—was acid, deposited very 
abundant urates, amorphous under the microscope, had no free uric acid, but 
contained in 10 c. c. .4 grammes of urea, about double the ordinary amount. 
If the other symptoms of lithasmia exist, we must not, from the absence 
of characteristic sediment, conclude against the increase of uric acid. 
This excess may be, it is known, present in clear urine, and only be deter- 
minable by chemical analysis. Indeed, in any doubtful instance we should 
resort to quantitative analysis, repeated on specimens obtained at different 
times. It would be well to make quantitative examinations in any case. 
But the processes are tedious and difficult in general practice. Pavy’s es- 
timation of uric acid by its reducing action upon the ammoniated cupric 
test (Lancet, April, 1880) promises best. Examinations of the blood, 
such as Garrod has made in persons with articular gout, have not to my 
knowledge been instituted in those affected merely with lithaemia. They 
would check off admirably the observations on the urine. 
Lithaemia is much more common in men than in women. Its chief 
sufferers are men in the prime of life. It comes on in some who live. 16 
luxuriously, eat largely, drink freely, take little exercise in the open air, 
and are indolent in their habits. But it is quite as often, or oftener, seen 
in the active brain workers of good habits; in the marked men in the 
community in which they live; and it is in them too, that the nervous 
symptoms of lithmmia are most obvious. My list of lithamiic patients 
embraces many a name distinguished at the bar, in medicine, in the pulpit, 
in literature, and in the world of finance. And it is not only brain-work, 
and all the habits this implies, but strain and worry, which induce it. Our 
present civilization is very rife with its causes. It is a growing disease in 
this country, especially in our cities. Malaria also excites it, or at least 
aggravates it; so do sexual excesses. It happens most often, certainly its 
nervous manifestations do, in persons of nervous temperament, and it is a 
diathesis which is readily transmitted. Disordered liver action with imper- 
fect oxygenation of nitrogenous matter is supposed to be its cause, and 
to lead to the accumulation of uric acid and the urates in the blood. I 
am far from thinking that this theory covers the whole ground. The symp- 
toms of nervous affection are, I firmly believe, the result of the waste-laden 
blood; but whether the lithic acid, or the compounds generating it, get 
into the blood in consequence only of deficient glandular action, as of the 
liver, is not so clear. Again, the disorder may be first excited by some 
disturbance of a nerve centre? We now hold as an established fact of 
science that puncture of the floor of the fourth ventricle causes diabetes. 
The ingenious reasonings of Dyce Duckworth are paving the way for the 
belief that in the medulla is a trophic centre for the joints, thus explaining 
the phenomena of articular gout. Is there also such a centre for causing 
lithic acid formation and lithasmia? But these are speculations not further 
here to be indulged in. 
I must say one word as to the relations to gout. Gout itself is merely 
one of the results of lithremia, and the consequences of a functional derange- 
ment of the liver, teaches Murchison; lithaimia is simply undeveloped 
gout, say others. I believe neither view is strictly correct. There is close 
relationship, and one predisposes, perhaps readily passes into the other. 
But we have lithoemia where not a typical symptom of unequivocal gout 
is to be found, not happening even during the lapse of years, and where 
there is no inherited gouty diathesis. If we take the characteristic fea- 
tures of gout to be the peculiar periodic recurrence of the joint-affection, we. 
see at once the difference. A little aching in the knuckles or toes at times, 
in very few enlargement of a finger joint, are the only kindred features of 
lithsemia; and the diminution of uric acid in the urine for several days 
before the gouty paroxysm, the scanty excretion during it, the mere traces 
which, as Senator tells us, are found in chronic cases even between the par- 
oxysms, are not analogous to the abundance of lithic acid or the lithates 
to be observed in litluemia. There is a belief that gout is rare in this 
country; and typical gout certainly is comparatively rare. But lithajmia 17 
is most common, and if it be true gout it is pre-eminently the American 
gout. As seen with us, it is an affection more often acquired than inherited. 
The constitutional state, once established, lasts long, and is difficult to 
eradicate, although it is capable of being eradicated, or so nearly so, that 
it ceases to be troublesome. Still, under error in diet or fresh worries, 
relapse happens, and with it may return the nervous symptoms that are 
the subject of this paper. As to their treatment, the cases here reported 
have, I trust, made it apparent. But I may, in conclusion, summarize it: 
The main principle is, to treat the state, not the nervous symptoms them- 
selves. The indiscriminate use of tonics and nervines which most of these 
patients are subjected to, is absolutely of harm. Nothing is accomplished 
until the lithaemia is struck at. In doing this, our most potent means is 
diet; without attention to it, other remedies are nearly valueless. The 
diet must be a sparing one, and I think that with those of enfeebled di- 
gestion the American plan of a substantial breakfast is best, for in the 
morning the digestive powers are usually strongest; the other meals must 
be very light. • We diminish the work of the liver and kidneys by lessen- 
ing the amount of highly nitrogenized food and of the hydrocarbons; 
hence beef and mutton, butter, cream, fat of meat, sugar in all forms are 
forbidden, and the less the patient takes of alcohol in any shape the better 
for him. Champagne is poison to most, a light claret is least objectionable, 
but water is the best drink for the lithcemic. Fish, oysters, fruits that do 
not contain much sugar, the green vegetables, except asparagus, are per- 
missible; so are bread, wheaten meal, and oatmeal. Potatoes should be 
used in moderation, as they are mostly not well digested; eggs should be 
eaten sparingly. Poultry and the white meats are allowable; and with 
reference to other meats, although they are, strictly speaking, contraindi- 
cated, I find that, plainly cooked, they are well borne ; the brain-worker 
especially requires them, and does better taking them than remaining on 
an unvarying diet without them. Fats and sugars are certainly far worse, 
and I have met with more than one case aggravated by taking the sweetish 
extracts of malt to strengthen the nervous system and the digestion. 
Exercise is of importance next to diet, as active as possible without 
fatigue. Horseback exercise is admirable for persons who will take the 
time ; and I have known the greatest advantage derived from the Swedish 
movements, especially from those that exercise the muscles of the trunk. 
Of course, full action of the skin is to be stimulated, and I generally make 
daily systematic skin friction, either after a shower bath or without it, 
part of my directions, and when it suits, also order an occasional Turkish 
bath. To live very constantly in the open air ; to take a long mountain 
tramp or an ocean journey, are most useful prescriptions to persons who 
can comply with them. 
Of medicines, those that stimulate excretory action by the bowels are 
the most advantageous; mercurials, and the saline purgatives do well for 18 
the purpose in view, but the former at least are too wasteful of strength 
for frequent use; the nervous tone has to be kept up, not depressed. On 
the whole, the natural saline mineral waters answer best; and the Hun- 
yadi-Janos, the Friedrichshall water, the Saratoga Congress water are 
most to he depended on. Nor is it only the purgative waters which are 
so useful; the drinking of those that tend to neutralize the uric acid by 
their alkalinity, and to act freely as diuretics, such as Carlsbad, Con- 
trexeville, and Vichy water, or, in this country, the Capon spring water, 
the Saratoga Vichy, and the Poland water, are excellent; and the free 
drinking of a table water now much employed, the Apollonaris water, has 
been, I know, of marked use to many lithaemics. Citrate of lithium often 
does good,-iodide of potassium and colchicum less often. Medicines of 
direct action on the nervous system I rarely prescribe, until at least the 
lithsemia is being broken up, or as a very subordinate part of the treat- 
ment ; among these zinc and arsenic have seemed to me the most service- 
able. Bromides may be employed for the nervousness and the sleepless- 
ness, or to influence the headache after the vertiginous seizures. But the 
less often, they, or chloral, are used the better. Remedies of the kind 
should be reserved for very special occasions. The way to relieve the 
nervous symptoms of lithsemia, I repeat, is to remove the lithaemia. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
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