CARBONACIDAEMIA AND CARBONACIDOSIS
By Dr. A. Stiegele, Stuttgart
A short time ago Avery interesting and praiseworthy little work appeared by Dr. Heinrich Lahmann (Weisser Hirsch bei Dresden) entitled, “The Accumulation of Carbonic Acid in Our Body (Carbonacidamia and Carbonacidosis). A contribution to the Comprehension of the Nature of Internal Diseases.” Lahmann here presents very skillfully and in a convincing manner the idea thing new, something unheard of. But for us homoeopathic found in Grauvogl’s scientific activity. A comparison of the views of these two investigators will give us surprising and very satisfactory results. We only hope that Lahmann will find more recognition in the circle of the physicians of to-day than Grauvogl did in his day. In order to duly comprehend the work of Lahmann, and to understand the logic of events, we have to give lengthy extracts.
The last three decades, in which external causes of disease were almost exclusively regarded, have by no means been favorable to the development of the doctrine of the internal causes of diseases. But external causes alone were not sufficient to explain biological processes; therefore unknown quantities were still drawn into the solution of the account, such as Man’s Disposition. It is there fore to be expected that our investigations should now again turn more too internal causes and that we should return to Physiological Pathology. In order to understand better the development of the problem before us, we should first call to mind the following physiological facts: The reception of oxygen into the lungs and the excretion of carbonic acid gas are independent from each other. Oxygen is taken up by the haemoglobin of the blood and taken to the tissues, while the latter give up the carbonic acid to the soda which is at our disposal for the purposes of respiration. The carbonic acid combined with the soda is then through diffusion and chemical processes transmitted to the circumambient air.
We are apt to think of arterial blood as being nearly free from carbonic acid while the venous blood is loaded down with it, and we are surprised when we are reminded that the quantity of carbonic acid in arterial blood makes 34 – 38 per cent, of its volume, and in venous blood but little more, namely, 43 – 48 per cent. (Landois). This is due especially to two reasons:
The pressure of the carbonic acid in the alveoles is already considerably higher than in the open air, and the blood in the lungs cannot, therefore, be freed from more carbonic acid, than this pressure permits. The arterial blood streaming from the lungs cannot, therefore, contain a smaller amount of carbonic acid.
Furthermore, the arterial blood is soon again enriched with carbonic acid, since the oxidation of reducing substances may generate carbonic acid in the blood, as seems to follow from the experiments of C. Ludwig.
Now the less difference there is between the tension of the carbonic acid in the venous blood and in the alveolar air, the slower will be the transmission of the carbonic acid from the blood to the air in the lungs, and the greater must be the congestion of the carbonic acid in the blood and in the tissues (Bunge). These conditions take place proximately when the respiration becomes retarded or superficial, for thereby the ventilation of the air in the alveoles becomes diminished and the tension of the carbonic acid therein is increased. This takes place physiologically at night time, because then the respiration is retarded and generally more superficial. There must also be a diminution of the difference in the tension of the carbonic acid in the venous blood and in the alveolar air, when the blood does not contain sufficient soda and in consequence can take up less carbonic acid from the tissues. But the soda present not only has to saturate the carbonic acid, but also the muriatic acid of the plasma, thee phosphoric acid, albumen and perhaps quite a number of other substances; so that it is manifest that it is difficult to furnish sufficient soda even in physiological conditions. But what then are the consequences of the congestion of carbonic acid during the night?
The fluctuations of the elimination of carbonic acid pretty well agree with the daily fluctuations in the frequency of the pulse and of the bodily temperature, with the minimum between two and six o’ clock in the morning. This is connected with the retarded and superficial respiration and the retarded circulation of the blood at night. It is a fact that after awaking in the morning the respiration is quickened and becomes deeper, whereby the elimination of the carbonic acid is increased. But during the progression of the forenoon it again sinks, until dinner produces an additional rise up to its highest point. In the afternoon there is another decrease, and finally, through supper, there is only a slight increase (Landois). If, therefore, the elimination of carbonic acid is increased in the morning, and in spite of the muscular and cerebral activity, there is no increase in the course of the forenoon but rather a decrease. This is a conclusive proof of the position that during the night there must be a retention of the carbonic acid in the blood and consequently in the tissues. Lahmann denominates this physiological phenomenon which has been hitherto overlooked, the nocturnal Carbonacidaemia and Carbonacidosis. The soda which serves to transmit the carbonic acid may perform this duty repeatedly. But when there is a diminution of the tension of the carbonic acid, weaker acids, such as uric acid, lay claim on the soda, or even stronger acids not finding a sufficiency of alkali’s elsewhere, some of the soda is lost, as it is eliminated with the urine. The strong acid coming into the physiological breadth in the blood will be able to snatch up sufficient alkalis, so that they can leave the body without danger. The excretion of the weaker acids, especially of uric acid, depends entirely on the quantity of soda which the carbonic acid leaves over for them, for the most important form of the excretion of uric acid is combined with acid, i.e., Urate of soda. “The stronger the action of the mass, the higher the pressure of the carbonic acid, the greater is the share of soda which falls to the carbonic acid” (Bunge). We may, therefore, boldly say, that strong tension of the carbonic acid in the blood (or in pathological conditions, strong tension of the carbonic acid in the tissues on account of an absolute lack of soda in the blood) and an obstructed excretion of uric acid, and thus an accumulation of uric acid in the body, have a direct connection with each other.
This also explains the otherwise inexplicable fluctuations in the excretion of uric acid. We cannot doubt that at night, owing to the retention of carbonic acid and the increasing pressure of the carbonic acid and the consequent claim on soda, there must also ensue an accumulation of uric acid and other weak acids.
The physiological nocturnal retention of carbonic acid in the body has as a consequence the retention of uric acid and of other autotoxic substances acting as weak acids. What then ensues? The abnormal high tension of the carbonic acid in the tissue acts on the various nerve-centers. Proximately the blood, as it becomes more venous, has a narcotic influence, it acts as a wearying substance. But when the nocturnal blood, rich in carbonic acid, is on awaking urged into the peripheries under the influence of a greater pressure of blood, it here immediately exerts a vaso -constrictory in-citation, while owing to the high tension of the carbonic acid in the tissues these vessels have been led to contract so we now get the conjunction of the incitement of cold which contracts the vessels with the carbonacidosis or carbonacidaemia. This is seen most plainly and most lastingly in the extremities; for the vasomotor act most strongly on the vessels of those parts of the body which are in the periphery, e.g., those of the toes, the fingers, ears, etc. (Lewaschar cited by Landois). There are few healthy persons who do not feel the effects of this carbonacidaemaia to some degree even if it should be only in the brief stiffness of the fingers in the morning, due to the imperfect circulation. Every one notices this in winter.
The physiological arterial vascular cramp in the morning is aggravated with nervous, excitable persons, especially in winter, to such a degree that the arteries of the hands and feet are often constricted almost so as to make their open spaces disappear. The blood is thus really pressed over into the veins. But since there is always still some oxygen, diffused from the scanty arterial blood, while the congested venous blood is saturated with carbonic acid, there follows a severe engorgement of the tissues with carbonic acid, as shown in the bluish red finger tips. That in this carbonacidaemia and carbonacidosis this vascular cramp may also become permanent, we see in the Raynaud Disease. Then there is another group of people with bluish red hands, who in winter suffer from the cold and who may then also experience necrosis of the skin and disturbances in nutrition. The remainder of this host is formed by the great number of those who chronically complain of cold hands and feet. As a consequence, the internal and especially the large veins which usually are under a negative pressure and even “the heart itself is gorged and distended with blood” (Thiry). The venous capillaries, lying in soft tissues or near the surface exposed to the most severe pressure through congestion. That they are not always able to support this pressure, we see from nose-bleeding, and various kinds of haemorrhages, uterine bleeding’s, and haemorrhages from the bladder. It hardly needs to be stated that serous effusions of all kinds and not least of all the haemophilous serous and bloody-serous and catarrhal affections of all kinds may naturally be explained by the same increase of the pressure of the blood in the venous capillaries, and they are simply a substitute of the direct venous haemorrhages.
This self-help of the organism also shows the rationality of venesection in all cases where there is increased venous pressure; it also makes easy the comprehension of its unquestionable effects in the typical disturbance of chloro-sis which rests on carbonacidosis.
In consequence of the increased pressure of the blood in the veins the absorption of fluids by the veins is diminished, and we, therefore, have nocturnal and matutinal retention of water in the typical carbonic acid constitutions, which early in the morning have a bloated appearance, swollen eyelids, etc.
Males have from the eighth year up to an advanced age about one-third more of the elimination of carbonic acid than females; about the age of puberty females frequently have only half the elimination of carbonic acid we find in males.
In short, females are carbonic acid constitutions, and they therefore, also furnish a considerable part of those who suffer from pathological carbonacidaemia and carbonacidosis. In consequence of their carbonacidaemia women also have a less perfect circulation of blood in the periphery than men, and thence also a cooler skin; they retain more water in their tissues and are therefore more hydraemic, more juicy, more fat on account of a diminished power of oxidizing, as they have also, according to the investigations of Lahmann, less specific gravity than men. Owing to their carbonacidaemia they retain in spite of partaking of food which is poor in urea and moderate in quantity comparatively much uric acid and kindred autotoxins; this explains why there is among them such a high percentage of patients suffering from gout and from gall-stones. This tendency is yet increased by their impractical mode of dressing and living. The tendency of indulging and spoiling sick women and girls is therefore highly injurious; we should not allow ourselves to be deceived by their apparent weakness, weariness and somnolence, as these are of themselves symptoms of poisoning by carbonic acid. Their weakness will only be aggravated by a perverse treatment; the abdominal troubles which arise from the congestion of blood in the abdomen under the influence of carbonacidaemia will OT yield and the abnormal haemorrhages and catarrh will have no end. Motion of every kind is therefore the only true remedy.
Also the nature of gout may be seen from carbonacidaemia; the more soda is used for the excess of carbonic acid in the blood the worse the chances for the excrement of uric acid.
Rhachitis also, according to wachsmut, is due to an excess of carbonic acid in the blood.
The consideration of menstruation is also interesting from the view-point of Lahmann’s theory. In menstruation we have a physiological discharge of blood from the abdomen as compensation, a diminished peripherical circulation. This is also seen in the faded appearance, in the pallor and chilliness at that period.
In this diminished circulation of the whole of the skin and of the adjacent muscular regions, we have in consequence of the insufficient elimination of the carbonic acid a rapid development of all the symptoms of acute carbonacidaemia and, of course, all the local and general troubles caused by auto-infection, even to the cutaneous eruptions caused by this infection. As a matter of course, the pressure in the venous system, being considerably increased, there must be capillary venous haemorrhages. With many the venous haemorrhage of the uterus is not even sufficient; they must gain relief by contemporaneous bleeding from the haemorrhoids, by epistaxis or at least by an equivalent catarrh.
Together with or after his natural venesection the circulation improves owing to the diminution of the pressure of the blood in the veins, and there is then an increased excretion of carbonic acid and of the uric acid which had also been retained. After the menses, as after venesection, which free the circulation and makes possible the elimination of carbonic acid and other auto-infections, woman feels in the best of health, which then again gradually grows worse according to the increase of the physiological carbonacidaemia, until the next menstrual period comes around, which then again wipes out the surplus of carbonacidosis; so that the menses may well be conceived of as an organic function accruing under the influence of carbonacidaemia.
We find similar processes with vasomotory neurasthenic patients who have every three to six weeks their periods of ailment and are then overjoyed when haemorrhoidal bleeding or epistaxis cause compensation.
Also the so-called anaemic cephalgias and especially the vomiting caused by me-grim, many cases of “seediness,” a form of seasickness, the vomitus matutinus, and the vomiting of pregnant women, may all, according to Lahmann, be ascribed to carbon academia. So also the cause of epileptic convulsions (for the excretion of uric acid sinks considerably before an epileptic attack); the maximum of attacks occurs in the night and morning hours, i.e. it coincides with the physiological carbonacidous maximum. The center of the convulsions in the medulla oblongata is then irritated by the heightened acute carbonacidaemia.
Also the physiological local or general muscular convulsions, especially yawning, as also stretching, may be due to an irritation from carbonic acid in the center and seat of the convulsion.
As we have seen, the notion of carbonacidaemia or the accumulation of carbonic acid in the blood cannot be sharply distinguished from carbonacidosis, or the accumulation of carbonic acid in the tissues.
Persons, who suffer from chronic carbonacidosis, or the carbonic acid constitutions properly speaking, also retain other acids in the body, and they are the typical acid constitutions. An example which will serve to illustrate the subject we find in the embryo of dysaemic mothers, who besides may also be living in an impracticable manner. With such the fetal blood is so venous the since there exists a lack of soda in general, there is never any soda at its disposal for the elimination of the uric acid, so that the newly born may already have formation of uric acid in their kidneys.
We have already stated above that under physiological conditions the quantity of soda which may be used for the elimination do carbonic acid is so small that, even under favorable physiological conditions, there must be carbonic acid retained in thee body; in any case there will be a daily retention of uric acid as a consequence of a lack of soda; we may thence conclude a priori that in pathological conditions the relative or absolute lack of soda must in many ways become noticeable. The usual mixture of nutriments old civilized nations contains only one-fourth or one-sixth of the quantity of soda which would be found in a normal mixture; this results in an insufficient supply of soda, which shows itself in uric acid and kindred acids and in the unneutralized weak and strong acids. If there should be at the same time perverse nutrition, from an excess of meat and egg, then sulphuric acids, uric acid and other weak acids will arrive at their may lead to death from carbonic acid.
Between these extreme consequences and the normal ability of excreting carbonic acid, in which there is only periodical physiological carbonacidaemia or carbonacidosis, there are many intermediate steps. Among these we find the chlorotics, the anaemic and kindred natures, who are in a continual steady and slight narcosis. There is with them a continual slight irritation from carbonic acid off the vasomotory center, a defective circulation in the skin, a heightened pulse, and therefore, especially owing to the vasomotory resistance in the capillary circulation, a relative weakening of the heart.
The oedema of the lungs arises during fevers and exhaustion of the heart, since in fever the production of carbonic acid is considerably increased, so that the vasomotory center is more strongly irritated. The left ventricle exhausts itself in the attempt of overcoming the increase of pressure of carbonic acid in the aterial system and a congestion in the veins of the lungs takes place, while through the cramp in the arterial vessels the blood rushes abundantly to the veins and the right side of the heart, the impulsive force which increases the oedema of the lungs.
Then we have quite a group of people who are commonly reckoned among the healthy, since they never complain and are well nourished. They are protected by their deposits of fat against the attacks of the acids on their tissue. They accumulate, indeed, acid on top of acids (uric acid, and kindred acids, oxalic acid, oxybutyric acid), but “perhaps owing to this additional influx of acids there is a diminution of the consumption of oxygen” (Choostek). But when in such constitutions there is in feverish diseases a greater decomposition of cells so much acid is thereby live-rated that we quickly incur the danger of death from carbonic acid, with or without the concomitant death of the heart, thus showing the effect of retention of carbonic acid on account of the lack of soda. If they are preserved from the ocasional death from carbonic acid, by which they are threatened in every more severe fever, they furnish us typical acid constitutions, the material from which are recruited the people with bad teeth, with rheumatism, with tong, with nephritis and of those suffering from disturbances of the nervous system. It depends, of course, altogether on the individual mode of living and especially on the value of their protoplasm, in what manner these cnstitutions abounding in carbonic and other acids may come to grief. In the one case more frequent periodical injury from sulphuric acid, while uric acid and tissue-acids accumulate, with those nourished in a one-sided manner on albumen is the cause; with others weak acids with a sedentary occupation cause the injury.
The acme of the difficulty always arises when the strong acids lacking the alkalis “seize on the bases which form the integral constituents of living organisms, tear out some of the individual building-stones out of the cells, and thus destroy them” (Bunge). When thus the destruction of cell-material sets in, then the general decay of cells is already proclaimed; for its products, oxybutyric acid and acetic acid, take care to cause a rapid impoverishment of the organism as to alkalis, whereby continually new decomposition of albumen and of cells is caused. The same injury through acids, or rather the same in principle (for the individual variations of the acids acting according to their quantity and quality explain the various pathological sequences) produces in the one case scurvy and rhachitis and their com-mixture, Barlow’s Disease, and in another case a child’s spinal paralysis. In the one case we have an inflammation of the heart, and in the other a juvenile deforming articular rheumatism. In the one case we have the sugar-disease or Bright’s Disease, in the other, softening of the brain or some other central disease. Who does not know the ill-humor and the bodily and mental weariness which arise especially in the morning hours, thus at the time when the carbonacidaemia is being removed, lasting even to dinner-time; in this matter the age from forty upward is typical, as up to that age a certain accumulation of acids and perhaps a maximum of uric acid takes place.
Who has not found out that on going to sleep again in the morning we often wake up with headache and great discomfort? The trouble is, that the purification from the nocturnal products the carbonacidaemia which had begun on awaking has been checked through going to sleep again, through the slower respiration, the pressure of the blood which then is again diminished, and when we wake up, then, a few hours later, there is an increased quantity of retained carbonic acid, uric acid, etc., with increased self-infections that have to be removed.
The maximum of physiological crbonacidaemia and carbonacidosis in the early morning hours also explains the maximum of mortality at that time, which fact has not hitherto been properly understood.
Who that know the danger of poisoning with acids will here after fall into the mistake of putting the diabetic patient on a purely animal diet? The coma will appear all the quicker, the more sulphuric acid, etc., take away the soda from the carbonic acid
Thus also is explained the use of venesection in carbonacidosis.