VESICAL CALCULUS IN INDIA: ITS DISTRIBUTION AND A THEORY OF ITS CAUSE* By Surgn..Capt. A. E. Roberts m.b., c m. m.r.c.s., i.m.s. Civil Surgeon, Aligarh, N.-W ? P.
It has long been a commonplace of a certain rough-and-ready order of pathologists to assert salts in the the origin of vesical calculus in itself commends The drinking-water." theory by its beautiful simplicity: the patient takes "
"
"
end and passes it (or fails to other, and makes as little demand so) the thoughtful intelligence of those who upon accept it as it received in the process of its conception. In the course of some observations on the chemistry of the excretions of natives of India, I was struck by the fact, which runs counter to the routine doctrine of the schools, that the excretion of uric acid was far more marked in well-fed natives who never touch meat (or rarely) than in the ordinary European official living in this country. It then occurred " to me that some one had attributed " stone in Norfolk to the excessive farinaceous diet of the people (? Dumplings), and it was thought to be a promising subject to trace the incidence of the disease in its relation to diet in different parts of India, and on arriving at a definite fact of connection to endeavour to explain cause and effect in physiological terms.
in do
stone
at
one
at the
Preliminary.?Very roughly,
divided into three great
I. the
India may be
agricultural regions Extra-tropical India, the wheat region? great plains of Northern India, where
rainfall is moderate
or
small, and the winter
temperature comparatively low. This region almost corresponds with that lying north of the January isotherm of 65. Principal grains, wheat and barley. II. The damper portions of tropical India, the rice country?all Bengal proper (including Rend at the Indian Medical Congress, December 1894.
July
1895.]
ROBERTS ON VESICAL CALCULUS IN INDIA.
Assam), all the region north of the Krishna from the Bay of Bengal to the edge of the Trap country in the Deccan, together with the coast and delta lands of Southern India.
III. The drier parts of tropical India, and all the black soil country, the millet region ; besides the whole Deccan Trap area, with the exception of the west coast; this comprises all the black soil tracts of Southern India, and a very large proportion of the undulating red soil
country. Principal grains, jawari (or cholam), and bajra (or kambu). 1. jRice.?The rice-eating people of India number 67 to 70 millions. If we except the deltas of the great rivers and the narrow coast slips, rice is a rare crop throughout the Peninsula ; but where it is grown, it is almost exclusively the local staple crop. For Bengal, no general statistics are available, but taking ? Rangpur as a t3'pical district, we find one and a half million acres under rice, out of a total acreage of one and three-quarter millions '88 per cent.) It is in similar proportions in Orissa, as also for the deltas of the Kaveri, Godaveri, and Kistna, the lowlands of Travancore, Malabar, Kanara, and the Konkan. Except in Assam, which is agriculturally an extension of the Bengal delta, rice occupies a very subordinate place throughout the interior of the country. In the N.-W.P. it is grown in damp localities, and supplies a favourite but partial article of diet for the upper classes, but here the local supply has to be supplemented by importation ; in Madras Presiden43 per cy generally, the area under rice is about In Bombay cent, of the total food-grain area. proper only 14 per cent., in Sind 17 per cent., in the Central Provinces 55 per cent., and in the Punjab but 3 per cent. o
...
?
261
Millets.?Millet is the staple food of India, it all over. Excluding rice tracts, millet is gc'ovvn more largely than any other grain from low down in Madras to Rajputana in the north. The common kinds are :? 3.
taking
"
(1) Great millet cholam."
(Sorghum vulgare)?"joar,"
Spiked millet (Pennisetum typhoideum) Bajra," kambu." This latter is the crop of South and Central India. In Mysore and neighbourhood, ragi" takes first place. All millets
"
(2)
"
"
crops, and are watered by rainfall, under either monsoon. In the table Mysore is shown to crop 96 per following cent, of rice, but this is in the lowlands; in the uplands, dry crop ragi rises to 77 per cent, of the total cultivation?or 84 per cent, of total food-grain area. The total area, under all millets in Bombay and Sind, may be taken at 83 per cent., in Central Provinces as 39 per cent., in Punjab 36 per cent., in N.-W. P. 40 per cent. rank and
as
dry
sown
are
Plan
of Food,?Staple
Rates
(per cent.)
of area
PRINCIPAL FOODGrains.
UNDER THE
Areas. Total population.
eating rice.
Millions.
Millions.
Population
Area. Wheat &
Barley. Punjab
N.-W. P. nndOudh
Bengal Proper
Madras
3(3% %
40
,.
Assam Central Provinces Behar
Bombay-
61% 57%
Millets.
45
%
97% 15%
71% 57%
Note.?"a" signifies
no
Rice.
3% 3% %(?)
88 60 55
%(?)
% 3% 14%
43%
figures
45
69J 4i 9f Si
10J 31
available.
The materials for the above sketch, and all statements as to figures, are taken from the Imperial Gazetteer, corrected up to 1883. Rice requires 36 to 40 inches of water, and We have only to add that the rice-bearing requires it at the right time. areas (Deltas and Coast) are approximately 2. Wheat.?The great wheat-growing tracts those also, where fish and fresh fruit also enter The N.-W. P. has 57 per cent, far more largely into the diet of the people, are in the north. under wheat alone, and 97 per cent, under than in the millet and wheat regions; in the wheat, barley and millets combined. In the latter especially are fish and fresh fruit wantPunjab, the wheat and barley area rises to its ing. With this table before us let us set down highest point, viz., to 61 per cent, of the whole at once the relative incidence of calculus of the in the various areas, as above. The crop area. Beyond this we have 36 per cent, bladder, we of a total 97 the cent, under give are the annual average prevalence, figures millets, making per three chief kinds of cereals. The Punjab there- of a varying number of years, as shown by all fore very closely approximates to N.-VV. P., but the various operations for calculus, and great care has been taken to search all available reits percentage of wheat per se is higher. cords, though these are, in many cases, very Wheat is also grown largely in Behar, and to a imperfect, and kept on a different plan in nearly less extent in the western area of Bengal proper. We are every Medical Administrative area. In the Central Provinces, wheat covers a large not aware that previously anything nearer than been made as to the proportion of the food-grain area, with millets a rough guess has ever 45 per cent. It is the chief cereal in Districts prevalence, relative and actual, of calculus in India. The following are the data extracted Hoshangabad, Narsingpur, and Saugar. from the reports of the various Administrative but the wheat returns vary year In Bombay only 15% wheat) I am also indebted to various J by year & show tendency upward. Medical Officers. In Sind only 12% wheat 35
262
INDIAN MEDICAL GAZETTE.
[July
of these officers for other help in this
private communications and result is question, where the. official chloride, they often do, to give required this salt,
1895.
that the sea accumulates all the sodic while the soil inland is robbed of reports failed, as and contains little else than potassium information : salts (see Bunge).* Now, the amount of Na CI in any organism corresponds and varies with the Different Areas of Hindustan in the order of amount in the environment. Na differs in this calculus 'prevalence. respect from K, which is an integral and indis1 s pensable part of every animal and vegetable cell. s 2 o -' .2 All sea and land plants contain K, but many Z 2 a ?? \ .2 2 Remarks. Area. contain but the faintest traces of Na, and plants "S.2 5, -^H O sea-weeds and coast vegetation are rich in a Sa only &2 oh it. Any exceptions to the rule have probably migrated inland, and were originally indigenous 1. Punjab 19 ?07S 1,4S2 iV 2. N.-W. P. andOudh 925 i 45 to the sea-coast. ?021 iV Passing upwards in the scale 3. Bombay 283 i ?017 i 16J of organised life, we find it precisely the same 4. Central Provinces 112 ?Oil 0} I 5. Bengal Proper 218 Numbers heightened ?0034 69b with invertebrates. Only sea forms and the ! by Behar. 6. Madras 21 j 31 ?00067 allied forms on the coast areas contain such salt, 7. Assam., Nil. | None known, Nil. while purely land invertebrates have very little salt in them. But land vertebrates are remarkTotal Annual Average Operations for all India 3,041 ably rich in salt in spite of the dearth around I. In British India, then, every year, 110 less them, but we can account for this by rememberthan 3,041 calculi are removed from the bladders ing that the first vertebrates lived in the sea, and of natives, or rather 3,041 operations for the we humans owe our salt constituent to our generemoval of as many (and more) " stones" are alogical connection. We have each one gone performed, and of this total nearly one-half through the "chorda dorsalis and ' branchial occur in the Punjab. arch stages of our marine ancestors. The II. The next point to note is that the order younger the vertebrates in their individual deveof calculus prevalence is in inverse ratio to the lopment the more salt (Na CI) they possess, and population eating rice as its staple food, upon the embryo of the mammal contains more than each area. If there seein to be even a slight the new-born offspring. Cartilage, our tissue flaw in this inverse relation, in the fact of Bengal of greatest antiquity, contains more Na CI than proper having a higher calculus ratio than any other tissue, and thus dry land vertebrates Madras, with twice the amount :of rice-eaters have left their more normal environment near the (relatively) to that of the latter, this is only sea, and far inland are now undergoing a proapparent, and is due to the inclusion of cases in cess of adaptation to their less normal saltless Behar (a wheat and millet region) in the Bengal surrounding. From these facts we deduce? proper statistics. If Behar were excluded and (I) That inland populations are, to a certain carried into the N.-W. P., Bengal would take its extent, battling with an unfavourable environproper place in the list below Madras, with a ment as regards the absence of the necessary ratio per mille of -0004. salt in which they originally developed; this III. Where practically the whole population also serves to explain the unconquerable desire lives on rice as its staple food, calculus dis- which the great majority (see later) of people exhibit for salt in their food. appears, as in Assam. IV. As we leave the coast areas, and mount (It) It explains the necessity for a liberal ever higher above sea level towards the interior, allowance of salt to children, our " embryological calculus increases in prevalence. Though Bom- ancestors," if we may so call them, and the conbay stands third on the list, its coast area is sequences of its deprivation will be the more very limited, the rice-eating population is small, apparent in pathological effects (see later). The and the calculus rate represents the high-lying offices which common salt performs include? millet region of the Deccan. The constructions of (1) organs. We place a double contrast in view in the (2) It is the chief factor in the formation of A contrast between the staple above sketch?(1) ; gastric juice. " foods of certain defined areas. (3) It dissolves globulins." (2) A contrast between the sea-coast and the (4) The nitrogenous products of metabolism interior. cannot be eliminated by the kidneys in the What we here set ourselves to show is, that absence of chlorides. Now, in all food we take, vesical calculus in India flows as a result of the there is always some amount of sodic chloride, factors involved in this double contrast. and animal food contains far more tlian vegetable A very interesting battle drama is constantly and cereal food, and we might at first think that going on in the upper layers of the soil?a fight on theoretical grounds there is no physiological between carbonic and silicic acids for possession of the bases, sodium and potassium, and the * Physiolog. and Patholog. Chemistry. "
?
CO o u i. rO O i'
?1
;
,,
..
..
"
"
July
1895.]
ROBERTS ON VESICAL CALCULUS IN INDIA.
263
for extra quantities of salt to be taken striking excess. No\v we can appreciate the our food. in that we But special necessity?the imperious demand of the incorporated beyond notice that it is only herbivora that require economy in members of a gramnivorous race like the natives of India for salt, and a large amount these extra quantities; carnivora and all purely of We remember how extra salt in their diet. not races but avoid it. only despise flesh-eating the Mosaic law enjoined the Jews to offer gifts Look at the Karaschatkales, the Eastern Finns, of vegetables, fruits accompanied by salt, to their the hunting tribes of Northern Siberia, the "Sudas" of the Neilghiris, the Kirghese, the Deity; in Greek and Roman sacrifices animals were bushman of South Africa, the shepherds and always sacrificed ivitliout salt to their gods. From the above facts we see, that at every American the All of South stockmen Pampas. period, in every part of the world, and in every these are purely carnivorous races, or sections climate, there are people who use, must have of races, eating flesh solely and abundantly, and they do not understand the uses of salt, and also certain people who do not use it. salt, inasmuch as they have never needed it. The people who take salt, though differing in every other respect, are all characterised by a Whereas we find that as a tribe emerges from vegetable diet. In the same way, those who do the nomadic hunting state to that of agriculture, not use any salt at all are all alike in taking in a more or less fixed environment, the taste for purely animal food. We have also seen that salt arises imperatively and demands supply. this urgent necessity for salt in vegetable diet The people eat less and less flesh, and more and 011 the soil, on depends upon the eliminating action of the exmore and vegetable grains depend cess potash salts, and if various food-stuffs are products. We see ruminants seeking out places in respect of this potash constituent, compared where rock salt is exposed, or salt pools. Why it will be found that the proportion of potassium is this ? First, there is far less salt in the food to sodium is highest in the very food staples on of herbivora and vegetarians than in flesh diet, which the vast bulk of the Indian population is but the great point is that the herbivora take in supported, that is to say, highest in all the comtheir food three or four times more of the salts of mon Indian food-stuffs, save rice. potassium than the carnivora. Now, a salt of with comLook now for a moment at the diet of the carbonate) meeting potassium (say natives of India. The cereals and leguminosEe mon salt (Na CI) in solution in the body, an exchange takes place?K CI and Na2Co3 are formed are very rich in K, and hence much salt (Na CI) (and here we may point out that Na2Co3 plus is required, if disturbance of normal metabolism is not to ensue. (It is found in France that the uric acid equals acid sodium urate). Na CI is well known to be the chief inorganic constituent agricultural population consumes, man for man, three times the amount of common salt eaten of the blood?plasma, and when K. salts reach the blood, the above exchange takes place; the by the urban population.) blood loses its invaluable Na CI, and a foreign But one important food-staple (vegetable) of constituent, viz., Na2Co3 (sodic carbonate) is India is very poor in K salts, viz., rice. This there in excess, replacing the necessary and norcontains six times less K than the cereals, wheat, mal Na CI. One result of this is that the blood barley and rye, and 10 to 20 times less than the is rendered alkaline, and uric acid is swept out leguminosse, 30 times less than the potato. of the economy (see later). The next result is People, therefore, who live solely, or almost solely, brought about by the power the kidneys possess on rice, scarcely require salt at all as an extra, of eliminating all foreign constituents, and so and in fact we find that the rice-races of India, maintaining the due standard ; hence this sodium and of some East Indian islands, and some Besalt (Na2Co3) is eliminated together with the douin tribes on the Arabian Peninsula have no K CI (see above), and the net result is that Na CI desire for salt. (Bunge,* op-cit.) Besides this, is withdrawn from the organism ; that is (let us rice is a low level coast food, where salt-fish and grasp the fact)?we start with less Na CI in our fruits are abundant. food, if we are gramnivora and vegetarians; this Salt is then, as we see, absolutely essential food contain excess of potash salt, and this, by in all other vegetable diets. Further, we draw the reactions described, withdraws even the to the fact that the milk of herbivora diminished amount of salt consumed in the food attention times a3 much potassium salts as contains three as from the economy, i.e., regards the salt (Na CI) that of the human subject; hence those with less intake and far greater expenditure on purely whom the of herbivora is a prominent milk vegetable diet. Let anyone try the simple ex- article of diet, along with cereal food?especially of cutting off his meat entirely and periment does this refer to children in this country?will replacing it by extra amount of vegetable grain suffer let 110 extra salt especially in their digestive reactions, if food ; also (Na CI) be taken, or, the supply of salt be insufficient. demonstration the salt make let less to plainer, than usual be taken with this purely vegetable diet, the urine will later be found alkaline, and Ethnologisclier Xachtrag Zur-Abhandlung uber die Bedttitxlng chlorine and sodium are discovered in quite des Kochsctkes.
necessity
*
1
264
INDIAN MEDICAL GAZETTE.
Now, here it will be convenient to compare, in view of the foregoing facts, the diets which are considered the standards for physiological requirements for Europeans ivnd natives in India, " respectively. We venture to attach the scales in the actual form in which they stand in the regulations," so that no question need arise as to the facts upon which we are basing important "
"
conclusions
:
European
Soldiers' Rations in India.
I
Article.
Oz Meat for
1 lb.
bone)
(deduct 20%
Bread
Vegetables
..
Oz.
Oz.
Oz.
12-8
9-6
1-92
1-075
16
6*4
1-28
0-24
16
11-S4
0-024
0-016
:
Oz.
I
j
?
Oz.
Oz.
???'
0-204
3-2
S7
0-208
!)-6
0-16
4-16
2-425
0-7
Tea
2-5
Sugar Rice
..
Salt
_
..
.
.4
0-075
2-41
0-012
0-4
3-328
0-02
3-6
1-25
1-25
1-25
Total
Daily
53-25
Food
3-424
of
Native
Sepoy.
Attar, ground Wheat
24-0
3-36
Dal
4-40
0-6
0-88
o-os
1-0
0-06
0-003
0-91
Ohee
3-504 0-288
0-16
Salt
Total
29-16
1-854 24-235
1-363
116-464]
0-3S4
2-12
0-096
|
4-387
1-278
3-4 0-913
0-16
4-02
20'64
0-16
25-113
We note:? The intrinsic dryness of the native diet. I. II. The large excess of albuminates and carbohydrates; albuminates are in excess to ail extent of one-fourth. III. The extraordinarily diminished amount of salts, just one-third, in the native diet; and further, this decrease is almost solely in the common salt (Na CI) ingredient?the very element that, on our facts, ought to be in excess. Bearing this well in mind, we may now set down the results arising in the human economy from a diet exhibiting? (?) Insufficient common salt (Na CI), (?) Excess of potassium salts, (c) Excess of albuminates.
{To
be
continued.)
[July
1895.
It has long been a commonplace of a certain rough-and-ready order of pathologists to assert salts in the the origin of vesical calculus in itself commends The drinking-water." theory by its beautiful simplicity: the patient takes "
"
"
end and passes it (or fails to other, and makes as little demand so) the thoughtful intelligence of those who upon accept it as it received in the process of its conception. In the course of some observations on the chemistry of the excretions of natives of India, I was struck by the fact, which runs counter to the routine doctrine of the schools, that the excretion of uric acid was far more marked in well-fed natives who never touch meat (or rarely) than in the ordinary European official living in this country. It then occurred " to me that some one had attributed " stone in Norfolk to the excessive farinaceous diet of the people (? Dumplings), and it was thought to be a promising subject to trace the incidence of the disease in its relation to diet in different parts of India, and on arriving at a definite fact of connection to endeavour to explain cause and effect in physiological terms.
in do
stone
at
one
at the
Preliminary.?Very roughly,
divided into three great
I. the
India may be
agricultural regions Extra-tropical India, the wheat region? great plains of Northern India, where
rainfall is moderate
or
small, and the winter
temperature comparatively low. This region almost corresponds with that lying north of the January isotherm of 65. Principal grains, wheat and barley. II. The damper portions of tropical India, the rice country?all Bengal proper (including Rend at the Indian Medical Congress, December 1894.
July
1895.]
ROBERTS ON VESICAL CALCULUS IN INDIA.
Assam), all the region north of the Krishna from the Bay of Bengal to the edge of the Trap country in the Deccan, together with the coast and delta lands of Southern India.
III. The drier parts of tropical India, and all the black soil country, the millet region ; besides the whole Deccan Trap area, with the exception of the west coast; this comprises all the black soil tracts of Southern India, and a very large proportion of the undulating red soil
country. Principal grains, jawari (or cholam), and bajra (or kambu). 1. jRice.?The rice-eating people of India number 67 to 70 millions. If we except the deltas of the great rivers and the narrow coast slips, rice is a rare crop throughout the Peninsula ; but where it is grown, it is almost exclusively the local staple crop. For Bengal, no general statistics are available, but taking ? Rangpur as a t3'pical district, we find one and a half million acres under rice, out of a total acreage of one and three-quarter millions '88 per cent.) It is in similar proportions in Orissa, as also for the deltas of the Kaveri, Godaveri, and Kistna, the lowlands of Travancore, Malabar, Kanara, and the Konkan. Except in Assam, which is agriculturally an extension of the Bengal delta, rice occupies a very subordinate place throughout the interior of the country. In the N.-W.P. it is grown in damp localities, and supplies a favourite but partial article of diet for the upper classes, but here the local supply has to be supplemented by importation ; in Madras Presiden43 per cy generally, the area under rice is about In Bombay cent, of the total food-grain area. proper only 14 per cent., in Sind 17 per cent., in the Central Provinces 55 per cent., and in the Punjab but 3 per cent. o
...
?
261
Millets.?Millet is the staple food of India, it all over. Excluding rice tracts, millet is gc'ovvn more largely than any other grain from low down in Madras to Rajputana in the north. The common kinds are :? 3.
taking
"
(1) Great millet cholam."
(Sorghum vulgare)?"joar,"
Spiked millet (Pennisetum typhoideum) Bajra," kambu." This latter is the crop of South and Central India. In Mysore and neighbourhood, ragi" takes first place. All millets
"
(2)
"
"
crops, and are watered by rainfall, under either monsoon. In the table Mysore is shown to crop 96 per following cent, of rice, but this is in the lowlands; in the uplands, dry crop ragi rises to 77 per cent, of the total cultivation?or 84 per cent, of total food-grain area. The total area, under all millets in Bombay and Sind, may be taken at 83 per cent., in Central Provinces as 39 per cent., in Punjab 36 per cent., in N.-W. P. 40 per cent. rank and
as
dry
sown
are
Plan
of Food,?Staple
Rates
(per cent.)
of area
PRINCIPAL FOODGrains.
UNDER THE
Areas. Total population.
eating rice.
Millions.
Millions.
Population
Area. Wheat &
Barley. Punjab
N.-W. P. nndOudh
Bengal Proper
Madras
3(3% %
40
,.
Assam Central Provinces Behar
Bombay-
61% 57%
Millets.
45
%
97% 15%
71% 57%
Note.?"a" signifies
no
Rice.
3% 3% %(?)
88 60 55
%(?)
% 3% 14%
43%
figures
45
69J 4i 9f Si
10J 31
available.
The materials for the above sketch, and all statements as to figures, are taken from the Imperial Gazetteer, corrected up to 1883. Rice requires 36 to 40 inches of water, and We have only to add that the rice-bearing requires it at the right time. areas (Deltas and Coast) are approximately 2. Wheat.?The great wheat-growing tracts those also, where fish and fresh fruit also enter The N.-W. P. has 57 per cent, far more largely into the diet of the people, are in the north. under wheat alone, and 97 per cent, under than in the millet and wheat regions; in the wheat, barley and millets combined. In the latter especially are fish and fresh fruit wantPunjab, the wheat and barley area rises to its ing. With this table before us let us set down highest point, viz., to 61 per cent, of the whole at once the relative incidence of calculus of the in the various areas, as above. The crop area. Beyond this we have 36 per cent, bladder, we of a total 97 the cent, under give are the annual average prevalence, figures millets, making per three chief kinds of cereals. The Punjab there- of a varying number of years, as shown by all fore very closely approximates to N.-VV. P., but the various operations for calculus, and great care has been taken to search all available reits percentage of wheat per se is higher. cords, though these are, in many cases, very Wheat is also grown largely in Behar, and to a imperfect, and kept on a different plan in nearly less extent in the western area of Bengal proper. We are every Medical Administrative area. In the Central Provinces, wheat covers a large not aware that previously anything nearer than been made as to the proportion of the food-grain area, with millets a rough guess has ever 45 per cent. It is the chief cereal in Districts prevalence, relative and actual, of calculus in India. The following are the data extracted Hoshangabad, Narsingpur, and Saugar. from the reports of the various Administrative but the wheat returns vary year In Bombay only 15% wheat) I am also indebted to various J by year & show tendency upward. Medical Officers. In Sind only 12% wheat 35
262
INDIAN MEDICAL GAZETTE.
[July
of these officers for other help in this
private communications and result is question, where the. official chloride, they often do, to give required this salt,
1895.
that the sea accumulates all the sodic while the soil inland is robbed of reports failed, as and contains little else than potassium information : salts (see Bunge).* Now, the amount of Na CI in any organism corresponds and varies with the Different Areas of Hindustan in the order of amount in the environment. Na differs in this calculus 'prevalence. respect from K, which is an integral and indis1 s pensable part of every animal and vegetable cell. s 2 o -' .2 All sea and land plants contain K, but many Z 2 a ?? \ .2 2 Remarks. Area. contain but the faintest traces of Na, and plants "S.2 5, -^H O sea-weeds and coast vegetation are rich in a Sa only &2 oh it. Any exceptions to the rule have probably migrated inland, and were originally indigenous 1. Punjab 19 ?07S 1,4S2 iV 2. N.-W. P. andOudh 925 i 45 to the sea-coast. ?021 iV Passing upwards in the scale 3. Bombay 283 i ?017 i 16J of organised life, we find it precisely the same 4. Central Provinces 112 ?Oil 0} I 5. Bengal Proper 218 Numbers heightened ?0034 69b with invertebrates. Only sea forms and the ! by Behar. 6. Madras 21 j 31 ?00067 allied forms on the coast areas contain such salt, 7. Assam., Nil. | None known, Nil. while purely land invertebrates have very little salt in them. But land vertebrates are remarkTotal Annual Average Operations for all India 3,041 ably rich in salt in spite of the dearth around I. In British India, then, every year, 110 less them, but we can account for this by rememberthan 3,041 calculi are removed from the bladders ing that the first vertebrates lived in the sea, and of natives, or rather 3,041 operations for the we humans owe our salt constituent to our generemoval of as many (and more) " stones" are alogical connection. We have each one gone performed, and of this total nearly one-half through the "chorda dorsalis and ' branchial occur in the Punjab. arch stages of our marine ancestors. The II. The next point to note is that the order younger the vertebrates in their individual deveof calculus prevalence is in inverse ratio to the lopment the more salt (Na CI) they possess, and population eating rice as its staple food, upon the embryo of the mammal contains more than each area. If there seein to be even a slight the new-born offspring. Cartilage, our tissue flaw in this inverse relation, in the fact of Bengal of greatest antiquity, contains more Na CI than proper having a higher calculus ratio than any other tissue, and thus dry land vertebrates Madras, with twice the amount :of rice-eaters have left their more normal environment near the (relatively) to that of the latter, this is only sea, and far inland are now undergoing a proapparent, and is due to the inclusion of cases in cess of adaptation to their less normal saltless Behar (a wheat and millet region) in the Bengal surrounding. From these facts we deduce? proper statistics. If Behar were excluded and (I) That inland populations are, to a certain carried into the N.-W. P., Bengal would take its extent, battling with an unfavourable environproper place in the list below Madras, with a ment as regards the absence of the necessary ratio per mille of -0004. salt in which they originally developed; this III. Where practically the whole population also serves to explain the unconquerable desire lives on rice as its staple food, calculus dis- which the great majority (see later) of people exhibit for salt in their food. appears, as in Assam. IV. As we leave the coast areas, and mount (It) It explains the necessity for a liberal ever higher above sea level towards the interior, allowance of salt to children, our " embryological calculus increases in prevalence. Though Bom- ancestors," if we may so call them, and the conbay stands third on the list, its coast area is sequences of its deprivation will be the more very limited, the rice-eating population is small, apparent in pathological effects (see later). The and the calculus rate represents the high-lying offices which common salt performs include? millet region of the Deccan. The constructions of (1) organs. We place a double contrast in view in the (2) It is the chief factor in the formation of A contrast between the staple above sketch?(1) ; gastric juice. " foods of certain defined areas. (3) It dissolves globulins." (2) A contrast between the sea-coast and the (4) The nitrogenous products of metabolism interior. cannot be eliminated by the kidneys in the What we here set ourselves to show is, that absence of chlorides. Now, in all food we take, vesical calculus in India flows as a result of the there is always some amount of sodic chloride, factors involved in this double contrast. and animal food contains far more tlian vegetable A very interesting battle drama is constantly and cereal food, and we might at first think that going on in the upper layers of the soil?a fight on theoretical grounds there is no physiological between carbonic and silicic acids for possession of the bases, sodium and potassium, and the * Physiolog. and Patholog. Chemistry. "
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CO o u i. rO O i'
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..
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July
1895.]
ROBERTS ON VESICAL CALCULUS IN INDIA.
263
for extra quantities of salt to be taken striking excess. No\v we can appreciate the our food. in that we But special necessity?the imperious demand of the incorporated beyond notice that it is only herbivora that require economy in members of a gramnivorous race like the natives of India for salt, and a large amount these extra quantities; carnivora and all purely of We remember how extra salt in their diet. not races but avoid it. only despise flesh-eating the Mosaic law enjoined the Jews to offer gifts Look at the Karaschatkales, the Eastern Finns, of vegetables, fruits accompanied by salt, to their the hunting tribes of Northern Siberia, the "Sudas" of the Neilghiris, the Kirghese, the Deity; in Greek and Roman sacrifices animals were bushman of South Africa, the shepherds and always sacrificed ivitliout salt to their gods. From the above facts we see, that at every American the All of South stockmen Pampas. period, in every part of the world, and in every these are purely carnivorous races, or sections climate, there are people who use, must have of races, eating flesh solely and abundantly, and they do not understand the uses of salt, and also certain people who do not use it. salt, inasmuch as they have never needed it. The people who take salt, though differing in every other respect, are all characterised by a Whereas we find that as a tribe emerges from vegetable diet. In the same way, those who do the nomadic hunting state to that of agriculture, not use any salt at all are all alike in taking in a more or less fixed environment, the taste for purely animal food. We have also seen that salt arises imperatively and demands supply. this urgent necessity for salt in vegetable diet The people eat less and less flesh, and more and 011 the soil, on depends upon the eliminating action of the exmore and vegetable grains depend cess potash salts, and if various food-stuffs are products. We see ruminants seeking out places in respect of this potash constituent, compared where rock salt is exposed, or salt pools. Why it will be found that the proportion of potassium is this ? First, there is far less salt in the food to sodium is highest in the very food staples on of herbivora and vegetarians than in flesh diet, which the vast bulk of the Indian population is but the great point is that the herbivora take in supported, that is to say, highest in all the comtheir food three or four times more of the salts of mon Indian food-stuffs, save rice. potassium than the carnivora. Now, a salt of with comLook now for a moment at the diet of the carbonate) meeting potassium (say natives of India. The cereals and leguminosEe mon salt (Na CI) in solution in the body, an exchange takes place?K CI and Na2Co3 are formed are very rich in K, and hence much salt (Na CI) (and here we may point out that Na2Co3 plus is required, if disturbance of normal metabolism is not to ensue. (It is found in France that the uric acid equals acid sodium urate). Na CI is well known to be the chief inorganic constituent agricultural population consumes, man for man, three times the amount of common salt eaten of the blood?plasma, and when K. salts reach the blood, the above exchange takes place; the by the urban population.) blood loses its invaluable Na CI, and a foreign But one important food-staple (vegetable) of constituent, viz., Na2Co3 (sodic carbonate) is India is very poor in K salts, viz., rice. This there in excess, replacing the necessary and norcontains six times less K than the cereals, wheat, mal Na CI. One result of this is that the blood barley and rye, and 10 to 20 times less than the is rendered alkaline, and uric acid is swept out leguminosse, 30 times less than the potato. of the economy (see later). The next result is People, therefore, who live solely, or almost solely, brought about by the power the kidneys possess on rice, scarcely require salt at all as an extra, of eliminating all foreign constituents, and so and in fact we find that the rice-races of India, maintaining the due standard ; hence this sodium and of some East Indian islands, and some Besalt (Na2Co3) is eliminated together with the douin tribes on the Arabian Peninsula have no K CI (see above), and the net result is that Na CI desire for salt. (Bunge,* op-cit.) Besides this, is withdrawn from the organism ; that is (let us rice is a low level coast food, where salt-fish and grasp the fact)?we start with less Na CI in our fruits are abundant. food, if we are gramnivora and vegetarians; this Salt is then, as we see, absolutely essential food contain excess of potash salt, and this, by in all other vegetable diets. Further, we draw the reactions described, withdraws even the to the fact that the milk of herbivora diminished amount of salt consumed in the food attention times a3 much potassium salts as contains three as from the economy, i.e., regards the salt (Na CI) that of the human subject; hence those with less intake and far greater expenditure on purely whom the of herbivora is a prominent milk vegetable diet. Let anyone try the simple ex- article of diet, along with cereal food?especially of cutting off his meat entirely and periment does this refer to children in this country?will replacing it by extra amount of vegetable grain suffer let 110 extra salt especially in their digestive reactions, if food ; also (Na CI) be taken, or, the supply of salt be insufficient. demonstration the salt make let less to plainer, than usual be taken with this purely vegetable diet, the urine will later be found alkaline, and Ethnologisclier Xachtrag Zur-Abhandlung uber die Bedttitxlng chlorine and sodium are discovered in quite des Kochsctkes.
necessity
*
1
264
INDIAN MEDICAL GAZETTE.
Now, here it will be convenient to compare, in view of the foregoing facts, the diets which are considered the standards for physiological requirements for Europeans ivnd natives in India, " respectively. We venture to attach the scales in the actual form in which they stand in the regulations," so that no question need arise as to the facts upon which we are basing important "
"
conclusions
:
European
Soldiers' Rations in India.
I
Article.
Oz Meat for
1 lb.
bone)
(deduct 20%
Bread
Vegetables
..
Oz.
Oz.
Oz.
12-8
9-6
1-92
1-075
16
6*4
1-28
0-24
16
11-S4
0-024
0-016
:
Oz.
I
j
?
Oz.
Oz.
???'
0-204
3-2
S7
0-208
!)-6
0-16
4-16
2-425
0-7
Tea
2-5
Sugar Rice
..
Salt
_
..
.
.4
0-075
2-41
0-012
0-4
3-328
0-02
3-6
1-25
1-25
1-25
Total
Daily
53-25
Food
3-424
of
Native
Sepoy.
Attar, ground Wheat
24-0
3-36
Dal
4-40
0-6
0-88
o-os
1-0
0-06
0-003
0-91
Ohee
3-504 0-288
0-16
Salt
Total
29-16
1-854 24-235
1-363
116-464]
0-3S4
2-12
0-096
|
4-387
1-278
3-4 0-913
0-16
4-02
20'64
0-16
25-113
We note:? The intrinsic dryness of the native diet. I. II. The large excess of albuminates and carbohydrates; albuminates are in excess to ail extent of one-fourth. III. The extraordinarily diminished amount of salts, just one-third, in the native diet; and further, this decrease is almost solely in the common salt (Na CI) ingredient?the very element that, on our facts, ought to be in excess. Bearing this well in mind, we may now set down the results arising in the human economy from a diet exhibiting? (?) Insufficient common salt (Na CI), (?) Excess of potassium salts, (c) Excess of albuminates.
{To
be
continued.)
[July
1895.
