CORNELL UNIVERSITY LIBRARY arVl9124*^°'""' ""'""""y Library oirn.anx ^^^ 0^1 256 682 The original of tliis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924031256682 URINARY AND RENAL DISEASES BEALE. THE WORKS DR. LIONEL S. BEALE, Professor of the Principles and Practice of Medicine in Kin^s College^ London. ON SLIGHT AILMENTS; their Nature and Treat- ment. Second Edition. Enlarged and Illustrated. Paper covers, .75; Cloth, $1.25 Finer Edition, Heavy Paper. Extra Cloth, ^1.75 ** We venture to say, that among the numerons medical publications issued during 1880, there has been none which will prove more useful to the young general practitioner, for whom it is really intended, than this volume, while the time of the older physician might be much more unproiitably spent," — American journal of Medical Science. THE USE OF THE MICROSCOPE IN PRAC- TICAL MEDICINE. For Students and Practitioners, with full directions for examining the various secretions, etc., in the Microscope. Fourth Edition. 500 Illustra- tions, Much enlarged. 8vo. Cloth, 3(7.50 HOW TO WORK WITH THE MICROSCOPE. A Complete Manual of Microscopical Manipulation, con- taining a full description of many new processes of inves- tigation, with directions for examining objects under the highest powers, and for taking photographs of microscopic objects. Fifth Edition. Containing over 400 Illustrations, many of them colored. 8vo. Cloth, §7.50 BIOPLASM. A Contribution to the Physiology of Life, or an Introduction to the Study of Physiology and Medi- cine, for Students. With numerous Illustrations. Cloth, g2.25 LIFE THEORIES ; Their Influence upon Religious Thought. Six Colored Plates. Cloth, $2.00 ON LIFE AND VITAL ACTION IN HEALTH AND DISEASE. l2mo. Cloth, ^2.00 ONE HUNDRED URINARY DEPOSITS, on eight sheets, for the Hospital, Laborator)', or Surgery. New Edition. 4to. Paper, $2.00 P. BLAKISTON, SON & CO., Publishers, Philadelphia. URINARY RENAL DERANGEMENTS CALCULOUS DISORDERS. HINTS ON DIAGNOSIS AND TREATMENT. LIONEL S. BEALE, M. D., Fellow of the Royal Society, and of the Royal College of Physicians ; an Examiner in Medi- cine of the Examining Board, in England, appointed by the Royal Colleges of Physi- cians and Surgeons ; Professor of the Principles and Practice of Medicine, and formerly Professor of Pathological Anatomy and of Physiology, and of General and Morbid Anatomy, in King's College, London; Physician to King's College Hospital. PHILADELPHIA : P. BLAKISTON, SON & CO., No. IOI2 Walnut Street. 1885. [Aii Rights Reserved-I u / Publishers' Notice. — This book is published simultaneously with the London Edition, by special arrangement between Prof. Lionel S. Beale and P. Blakiston, Son & Co. TABLE OF CONTENTS. PAGE Variation in the Quantity of Water 1 1 Importance of Diluting the Fluids of the Body, and of Washing out the Tissues '.12 Gouty Tendency . . . , 14 Of Diluents . • 17 Reaction of Urine , ... 20 Acid Urine 22 Action of Bicarbonate of Potash 25 Advantage of Liquor Potassas , 28 Alkaline Urine . . • 28 Alkaline Treatment carried too far 30 Variation in the Quantity of Solids 31 Urea, and Excess of Urea 32-33 Deficiency of Urea 38 Uraemia' 39 Ammonia ......... -42 Uric Acid and Urates 42 Urate of Soda 43 Gout 44 Importance of Water Drinking 48 Lithia, Ammonia, and other Remedies in Gout ... 49 Extractive Matters in Urine 52 Excess or Deficiency of the Inorganic Constituents ... 54 Deficiency of Chlorides in Pneumonia 54 Effects of Diuretics and Sudorifics in Acute Inflammati6ns . 57 Acetate of Ammonia and Citrate of Potash in Pneumonia . . 60 Excess of Sulphates : Action of Liquor Potassas ... 62 Alkaline Phosphates : Excess and Deficiency . . . .64 URINARY DEPOSITS. Opalescent Urine 68 Chylous Urine • . . 69 Chemical Composition of Chylous Urine ..... 72 Nature of Cases of Chylous Urine 75 Treatment of Cases of Chylous Urine 77 A* i TABLE OF CONTENTS. Deposits of Urates Treatment of Cases Deposits of Uric Acid Uric Acid Gravel Benzoic Acid and Benzoate of Ammonia Treatment of Cases in which Excess of Uric Acid is Xanthine. Uric or Xanthic Oxide Deposits of Oxalate of Lime Condition in which Oxalate of Lime is present . Treatment of Cases of Deposits of Oxalate of Lime Dumb-bell Crystals of Oxalate of Lime Cystine Deposit in the Urine Remarkable Case of Cystine Treatment by Large Doses of Ammonia Deposits of Earthy Phosphates Significance of Phosphate Deposits . Clinical Observations .... Blood Corpuscles in the Urine — Haematuria Haemophilia Hemorrhage from the Kidney . Hemorrhage from Calculus in the Bladder Blood Clots Hemorrhage Caused by Entozoa . Treatment of Haematuria .... Gallic Acid in Large Doses . Ergot of Rye. Hamamelis Injections Intermittent Haematinuria Black Pigment in the Urine Symptoms of Haematinuria . Important Case of Haematinuria Sporules of Fungi like Blood Corpuscles in Urine Deposits of Epithelium Chronic Changes of Epithelial Surfaces Treatment. Value of Iodides . Epithelium of the Kidney Epithelium of the Ureter and Bladder Epithelium of the Urethra . Vaginal Epithelium Casts of Uterus and Vagina — Leucorrhoea Cancer of the Bladder .... Cancer of the Kidney — Uterus Formed TABLE OF CONTENTS. Hemorrhage from Cancerous Growths Deposits of Pus Chronic Inflammation of the Bladder Formation of Large Quantities of Pus . Gall Stones in the Urine .... Ulceration of Ureters and Pelvis of Kidney- Pelvic Cellulitis Mode of Growth and Multiplication of Pus Of Changes in the Living Pus Corpuscle . Catarrh of the Bladder .... Influence of Bacteria Diet and Medical Treatment in Cases of Catarrh of the Bladder Pareira Brava, Buchu and Triticum Repens in Catarrh of the Bladder 164 147 148 149 150 152 153 153 15s 156 157 158 161 Importance of Attending to the General Health Iodide of Iron in Catarrh of the Bladder . Irritable Bladder and Frequent Micturition . Treatment of Irritability of the Bladder . Incontinence of Urine in Children Accumulation of Urine in Bladder .... Of Casts of the Uriniferous Tubes Importance of Casts in Diagnosis of Renal Disease Exfoliation of Epithelium of Uterus and Vagina . Spermatozoa. Derangement of the Sexual Function Detection of Spermatozoa in Cases of Rape Mucous Casts from Seminal Tubes .... Discharge of Seminal Secretion .... Public Morality " The Besetting Trial of Our Boys " Hints on Medical Treatment Consequences of Spermatorrhoea , 206 2og SUBSTANCES IN SOLUTION NOT FOUND IN HEALTHY URINE. Albumen in the Urine 212 Slight Albuminuria 216 Albumen in the Urine from Pressure on the Large Veins . . 219- Albumen in the Urine from Passive Congestion of the Capillary Vessels of the Kidney 220 IV TABLE OF CONTENTS. PAGE Albumen in the Urine Depending upon Changes in the Blood 223 Albumen in the Urine from Afifections of the Mucous Membrane of the Urethra, Bladder, or Pelvis of the Kidney . • .225 Albumen in the Urine from the Menstrual Discharge . • 227 Albumen in the Urine, Due to the Escape of Blood into the Urinary Passages or from the Presence of Morbid Growths . 227 Albumen in the Urine from Stone in the Kidney, Ureter, or Bladder 228 Albumen in the Urine from Acute or Chronic Functional or Structural Changes in the Kidney Itself . . . ■ 232 On the Nature of Structural Renal Changes .... 236 Acute Inflammation of the Kidney 240 Changes in the Cells and Vessels in Acute Inflammation . . 242 Chronic Inflammation of the Kidney with Enlargement . . 243 Chronic Wasting of the Kidney with Contraction . . . 245 Cirrhosis of the Liver and Kidney 246 Syphilitic Renal Disease 248 Albumen in the Urine Depending upon Fatty Degeneration of the Kidney 250 Albumen in the Urine Depending upon Amyloid or Lardaceous Kidney 252 On the Treatment of Diseases of the Kidney .... 254 Catheter Fever 256 Treatment of Acute Renal Disease 257 Hot-air Baths in Acute Renal Disease 258 Diet in Acute Renal Disease 259 CEdema. Anasarca 260 Uraemia 261 Ascites 262 Chronic Renal Disease 262 Warm Clothing 263 Air and Exercise 263 Sea Air in Chronic Renal Disease 264 Diet in Chronic Renal Disease 264 Pepsin " " '■ 266 Stimulants in Chronic Renal Disease 267 Medicine " " " 268 Iron " " " ..... 269 Digitalis " " " 269 Of the Treatment of Vomiting 270 " " Pleurisy 271 Counter-irritation and Bleeding 271 TABLE OF CONTENTS. V PAGE Treatment of Albuminuria of Advancing Age .... 272 Further Hints on tiie Treatment of Chronic Albuminuria . 274 Milk Treatment 275 Treatment of Albuminuria Dependent upon Syphilis . . 276 Bile 278 Jaundice from Obstruction and from Suppression . . . 280 Treatment of Cases of Jaundice 281 Sugar in the Urine — Diabetes 283 Specific Gravity of the Urine in Cases of Diabetes . . • 285 Temperature of the Body in Diabetes 286 Diabetes : — i. In the Young. 2. In the Middle Aged. 3. In the Old 287 Nervous Lesions in Diabetes 289 Coma in Diabetes 289 Sugar in the Urine in Pneumonia, Bronchitis, and Phthisis . 290 Boils and Carbuncles in Diabetes 291 Impaired Sight and Cataract in Diabetes 294 Large Quantity of Urea in the Urine in Diabetes .... 295 Analyses of Urine in Diabetes 29° The Treatment of Diabetes 296 Thirst in Diabetes . . ^ 298 Glycerine in Diabetes 298 Vegetables that may be Eaten 298 Substitutes for Bread in Diabetes 3°° Bran Cakes, Formula for Making 3°° Almond Cake. Glycerine Sponge Cake 3°! Manufacture of Gluten Bread 302 Wines in Diabetes 302 Skim-milk Treatment 302 Medicines in Diabetes _ • • • ■ 303 Rennet and Pepsin in Diabetes 3°4 Alkaline Remedies in Diabetes 3o5 Purgative Medicines in Diabetes 3°5 Opium and Codeia 3°° Cinchonine, Quinine, and Strychnine in Diabetes . . . 3°6 Alkapton in the Urine ^P^ Method of Obtaining Alkapton 308 VI TABLE OF CONTENTS. ON URINARY CALCULI AND CALCULOUS DISORDERS. Substances of which Calculi are Formed Crystallization in Viscid Matter . . . • Concentric Layers of Calculi . . . • Different Classes of Urinary Calculi . . . ■ Uric Acid Calculi Calculi Composed' of Urates Uric Oxide, Xanthic Oxide, Xanthine . Cystic Oxide — Cystine Fibrinous Calculus Blood Calculi Case in which Blood Calculi were Formed . Fatty Concretions . Oxalate of Lime Calculi Microscopic Calculi Large Calculi without any Symptoms . Calculus with Long Spines Projecting from It . Calculi in Patients who have had Cholera . Passage of Oxalate of Lime Calculi from the Kidney Calculi Composed of Earthy Phosphate Phosphate Calculi Passed in Large Number Prostatic Calculi Arrangement of the Layers of Prostatic Calculi Sir Henry Thompson's Observations .... On the Origin and Formation of Urinary Calculi Formation of the Nucleus of a Calculus The Formation of Microscopic Calculi . ? . Dumb-bell Crystals form the Nuclei of many Calculi . Collections of Dumb-bells in the Uriniferous Tubes Frequency of the Occurrence of Different Kinds of Calculi Distribution of Different Kinds of Calculi Dr. Carter's Observations Formation of a Calculus Composed of Phosphate, Uric Acid, and Oxalate of Lime 331 Of the Influence of Considerable Quantities of Fluid in Prevent- ing and Relieving Calculous Disorders 332 Quantity of Fluid Required 332 Importance of Continuing Remedial Measures for Some Time . 336 On Dissolving Urinary Calculi 337 Of Injecting Solvent Fluids into the Bladder .... 338 309 310 3" 312 313 314 314 314 314 315 315 316 317 317 318 319 319 320 320 321 322 323 324 325 326 327 328 328 330 330 330 TABLE OF CONTENTS. VU PAGE Dr. Roberts' Experiments with Alkaline Carbonate . . . 339 On Dissolving Calculi by Electrolysis 341 Treatment of Renal Calculus 342 Relief of Pain by Sedatives 342 Treatment by Complete Rest 344 Catheterism 344 On Washing Out the Bladder 347 Instrument for Washing Out the Bladder as Suggested by Mr. Job Collins, and Improved by Mr. Buckstone Browne . . 348 Lithotomy 348 Lithotrity. Litholapaxy 350 Dr. Freyer's Operations 352 The Spontaneous Fracture of Calculi in the Bladder . . . 352 Nephrotomy and Nephrectomy 353 URINARY AND RENAL DERANGEMENTS, AND CALCULOUS DISORDERS. HINTS ON DIAGNOSIS AND TREATMENT. Of all the products of secretion formed in the human body, the urine varies in character in the greatest degree within the range of health ; indeed, the quantity and relative proportion of some of its most important constituents change from hour to hour. Moreover, these variations must occur, and are a neces- sity, if physiological equilibrium is to be preserved. Great and adverse changes as regards the temperature of the body gener- ally, and alterations in chemical action detrimental and possibly dangerous to health are thus prevented. Considerations in this direction may be further generalized and more widely applied, inasmuch as the formation of the urinary constituents takes place in far distant parts of the organism and in tissues of the most diverse characters. Some of the urine substances are no doubt being perpetually produced in the blood, and are removed from the. circulating fluid almost as fast as they are produced. So important is the removal of many of them from the precincts of the most important organs, that if they accumulate in the blood for but a few hours, the activity of certain nerve centres is impeded or suspended, and unless relief be quickly afforded, life may be endangered, if not cut short, and the patient will have to pass through a long and severe illness before the normal B 9 10 URINARY DERANGEMENTS. State of things can be restored. No wonder, then, that from the earliest days of medicine, the urinary secretion should have , been studied with especial care, and that its consideration should constitute one of the most important departments of practical medicine. In these days, so extended is the range of our knowledge of urinary diseases, that the subject could not be treated of in a volume consisting of many more hundred pages than the present contains. I shall only attempt to direct the attention of practitioners to the management of those derange- ments and diseases of the urinary system which frequently fall to the province of the physician to treat. In many cases I can only give hints as to the general line of treatment to be pur- sued, but as regards some conditions, I hope to offer suggestions based on facts I have observed, or learned from others, in the course of more than thirty years' practice, which may be useful to the practitioner. I shall not attempt even to enumerate all the remedial measures whichhave been proposed or carried into effect, "but endeavor rather to concentrate attention upon the principles which should guide us in the treatment of the various departures from the healthy state, of which indications are afforded by examining the urine, or by other methods of clinical observation. Nor is it only in great alterations in the amount of its usual constituents that the urine of health may differ from that se- creted in physiological derangements or in structural disease. There are several substances which may be present, of which not a trace can be detected in the secretion in health — biliary, albu- minous and other matters from the blood, sugar — besides many things forming definite and perhaps bulky deposits, of which mere traces, or no indications whatever, exist in the urine in the healthy condition, may be present, and in varying quan- tity. Of these, some indicate a condition of things which may be expected to end fatally within a short period of time, while others are due only to a transitory disturbance, a tempo- rary and unusual chemical change, or are accidentally present. The practitioner has to bear in mind the distinguishing general features and chemical microscopical characters by which sub- DIAGNOSIS AND TREATMENT. 11 Stances which are of great significance may be identified and distinguished from those which are of no clinical consequence. VARIATION IN THE QUANTITY OF WATER — IMPORTANCE OF DILUT- ING THE FLUIDS OF THE BODY, AND OF WASHING OUT THE TISSUES. All the liquid secretions of the body vary from time to time as regards the proportion of water by which the special constitu- ents are held in solution, but in this respect the urine varies more than any other secretion. At one time the proportion of solid matter to water may be as i to lo, at another as i to looo. Although the quantity of water in the urine is determined mainly by the amount taken, it does not wholly depend upon this circumstance, neither does it vary in direct ratio with the water imbibed, for in hot weather, though an excessive amount of water be taken, the urine will be found highly concentrated, the water removed from the cutaneous surface preponderating over the quantity passing through the renal emunctories. The action of the kidneys as regards the removal of water from the blood varies from day to day and even from hour to hour. This constant variation is physiological, and is one of the many factors by which a uniform composition of the blood is maintained in spite of the tendency to change consequent upon various actions which determine chemical decomposition. An ever-varying body temperature would necessarily result, but for the compensating changes induced by the action of the skin and kidneys, whereby solid excrementitious matters and water are continually removed in ever-varying proportion, and some alteration in the composition of some of the solid constituents lalso occasioned. One is often surprised at the very different amount of liquid persons in good health habitually consume. Some find that a quart, or even less, suffices for their daily requirements and for the satisfying their thirst, while others drink twice or three times as much. One healthy man will walk from morning to night; and though sweating freely the whole time, will not feel any great desire for drink, while another, under precisely the same 12 URINARY DERANGEMENTS. conditions, will not be able to get on without consuming many pints of fluid. Some consider that water containing various nu- tritious matters and alcohol (beer ! ) is absolutely necessary if any unusual exercise be taken. In cases where the quantity of water removed by the kidneys is habitually considerable, we shall generally find on inquiry thafthe patient has gradually acquired the habit of drinking largely of water or other liquids, until at last he cannot get on without continually yielding to the desire to drink. The amount of food as well as liquid taken by an individual in good health is very much a question of habit. From time to time the most extraordinarily rapid flOw of water from the blood takes place. Through emotional influence more than a pint of water may be separated from the blood in ten minutes. In these cases the total amount of urine secreted in the twenty-four hours is not necessarily increased, but in re- sponse to rapid changes in the nerve centres, sudden relaxation of the vessels of the Malpighian body takes place, and the water transudes through the thin capillary walls with great rapidity. As is well known, the secretion of watery urine follows in the course of a few minutes the imbibition of considerable quantities of liquid. In a man in whom the anterior walls of the bladder were absent, and the orifices of the ureters fully exposed to view, I have seen limpid urine distilling drop by drop within five minutes after the man had swallowed a glass of champagne. Those who fancy that albumen of serum ordinarily escapes with the watery part of the blood from the vessels of the glomerulus, have not, I think, given sufficient weight to these facts, which, as it appears to me, tell against their hypothesis ; for is it not difficult to accept the conclusion that in this very rapid opera- tion time is allowed for the reabsorption of the effused albumen by the cells of the convoluted portion of the uriniferous tube ? At the same time one cannot go so far as to hold that this would be impossible under the circumstances referred to. The Importance of. Water and of Dilution and Dilu- ents. — Some persons no doubt get into the habit of taking more water than is necessary for their system, or for many reasons de- sirable. I feel sure that more take too little in proportion to DIAGNOSIS AND TREATMENT. 13 the solid food they consume — in fact, eat too well and do not take fluid enough to ensure the proper assimilation of much of the solid matter, and effect the free solution and removal of the excrementitious substances formed during the physiological action of the tissues and organs. The consequence is, that as time goes on the deposition of various substances takes place, and contraction and condensation of the tissues proceed faster than they should do, old age being reached years before the natural period of its advent. Not only is free dilution advan- tageous in many ways, but in this way food is wonderfully economized. Some of those who while really eating sparingly nevertheless gain rapidly in weight, take considerable quantities of fluid with or after taking food. In endeavoring to reduce weight, this important point must not be lost sight of, and the imbibition of large quantities of water must not be permitted. One reason why milk is so fattening is that its constituents are dissolved and suspended in a large proportion of water, for, as is well known, the insoluble fatty matter is very minutely divided, and by a special arrangement evenly spread through the whole bulk of the milk. Many morbid conditions are relieved by the introduction of plenty of fluid at proper intervals. The public have discovered the benefit of considerable, if not excessive, water drinking for a period of one or two months out of the twelve, and the annual expedition to springs in every part Df the Continent has become more than fashionable. The value of many of the mineral "waters" seems to be inainly due to the chief and universal constituent of all. In many forms of illness, which, if they persist for any time, are certain to damage the whole body, and may be painful to endure during the entire period of their existence, all that is really required' to restore the healthy condition is to wash out the tissues and organs, so that various noxious substances which have been accumulating, it may be for many years, may be dis- solved by the water made to traverse the. minute interstices of the textures, and thus removed in solution. To eff'ect this pur- pose considerable time is often required. A course of one or two months, during which from two to six or more pints of water 14 tJRINARY DERANGEMENl-S. are taken daily, is often requisite to produce much effec*. Although there can be no doubt that alkalies and other saline constituents in natural waters exert a beneficial influence, in many cases an excellent result is obtained by the use of water alone, and especially distilled water, which may now be ob- tained pure, or impregnated with carbonic acid gas, of the " Salutaris Water Company," 286 Fulham Road; Many, there- fore, who are unable to spend weeks in a German or even an English watering place, who cannot without losing their position, and perhaps their prospects of earning a livelihood, leave their work in town for a week or even a day, may subject themselves to remedial measures, from which they may derive great benefit, and in a comparatively short time. A fair allowance of fluid per diem not only economizes food, but by keeping the fluids in the interstices of the tissues in a dilute state, promotes free interchange, favors oxidation, and prevents the occurrence of many of the so-called degenerations. For these are mainly due to the state of things resulting from the accumulation of sub- stances in an insoluble form in the tissues which should be rendered soluble by oxidation, and removed in solution and excreted as fast as they are produced in the course of chemical change. Although not unfrequently we are constrained, from inexact- ness and insufficiency of our knowledge, to attribute certain symptoms to a "gouty tendency," "diathesis," "habit of body," "disposition," "peculiarity," or "susceptibility," acquired, inherited, or evolved, which belong to a different category, being due to causes different in their nature from those upon which gout depends, it is certain that a state of system, a state of the blood and the tissues, which often eventuates in gout, is really very common. That this state may be produced in certain constitutions by persisting in a particular mode of life is true, but it is also true that some are so prone to the change re- ferred to, so " susceptible" or "vulnerable" in this respect, that by no plan of diet can they, at least in this climate, wholly avoid it or protect themselves from it. In the great majority, how- ever, the state in which one or more of the many symptoms DIAGNOSIS AND TREATMENT. 15 indicative of the condition of system in question exist, may certainly be prevented by care in the mode of living from the moment the first evidence of disturbed action becomes manifest ; and, if already established, the condition may be mitigated or cured by judicious treatment persisted in for a sufficient time. To affect advantageous change in inveterate cases, appropriate treatment should be persisted in for a considerable period of time. Benefit, unquestionably, results from the annual visit to baths, and the altered diet and washing out to which the body is sub- jected for six weeks or two months, but in too many instances the good obtained is soon neutralized by the patient's return to the injudicious habits which originally occasioned the departure from health, and which if continued will certainly lead to the establishment of pathological changes beyond the possibility of cure. Rules cannot be laid down which will apply to all cases, and it will be sufficient to indicate the general principles upon which the treatment of such a case should be conducted. It is advan- tageous, if not necessary, that the patient himself should be acquainted with these, in order that he may know how to manage himself from day to day, and, if possible, prevent any changes that would interfere with steady improvement. I have often been surprised at the length of the period over which decided, and perhaps, uninterrupted advance towards the healthy state extends. An unmistakable indication of the general dis- turbance of nutrition, and departure from the normal state of the blood, is often afforded by the presence of patches of ecze- matous eruption, or of psoriasis in various parts of the body. These morbid conditions of the skin are very obstinate, though they may be slight. It is no uncommon thing to see patches of rough cuticle, as large as a shilling, to the number of ten or twenty in different parts of the body, not unfrequently attended with irritation and itching, especially in the evening and at night, when the cutaneous surface gets warm. They may persist for years — now better now worse. Everything that can be thought of may be tried in vain, and advisers of every kind have, per- haps, been consulted, one after the other, without avail. The 16 URINARY DERANGLMENTS. fact is, for the cure of such cases much time is required. The patient may have been put on the right course many times, but treatment for a month or two only is useless, or nearly so. It is only by degrees that health can be restored. Obstinate derangement of the liver and large bowel probably has an im- portant influence in keeping up the state of blood and of the nerve centres which favor the deranged state of nutrition of the cuticle. We may, undoubtedly, help the patient by prescribing small doses of gray powder, or other mercurial now and then, and by the judicious use of alkaline and purgative remedies. With a course of iodide of iron, or by sending him to Carlsbad for a month or six weeks, but he will not be cured, and on his return to his usual habits the trouble will return and get worse from year to year. He will come to the conclusion that he must make the best of it, and bear it as best he may, and possibly he will be assured that it is incurable, while, in fact, if he put him- self on proper diet, with plenty of air and an occasional warm bath, for. twelve months or more, he would not only cur? the cutaneous eruption, but would regain general health and vigor to a degree that would surprise him and his friends. It is astonishing how difficult it is to persuade people to act sensibly as regards the management of their bodies continuously for a con- siderable time. They will try, one after another, all the remedies you recommend ; they will live for a time on the simplest fare, take air and exercise by the clock, and subject themselves to hard hygienic discipline for a few weeks, but to get them to act with good sense for six months seems impossible, and I fear, with all our Health Exhibitions, books, lectures, schools, and instruc- tion far and wide among all classes, we are almost as far as ever from getting people to eat and drink and sleep and dress and take exercise without frequent and open defiance alike of health laws, common sense, and of the ordinary principles of physiology now taught in children's primers. It cannot be too often mentioned that most of the acute dis- eases which come on unexpectedly, and the invasion of which seems so sudden, the patient being as it were struck down in the most appalling manner without having been aware up to the very DIAGNOSIS AND TREATMENT. 17 moment of attack that he was not in ordinary and perfect health, have been threatening for weeks or months. For a long period preceding the attack the blood has been getting out of order, excrementitious matters have been accumulating, the in- terstices of organs whose free action is necessary to health have become occupied by imperfectly soluble matters, theintertextural channels have become clogged, and for a long while there has been frequent interference with proper action and in an aug- menting degree, until at last derangement eventuates in tempo- rary stoppage of action and a sudden and desperate shock to every organ in the body, consequent upon a serious change in the blood which cannot be compensated or controlled, results, and weeks or inonths must pass before the derangement and per- haps actual damage effected can be repaired. It_ seems possible that almost up to the moment of the "acute attack" active medical interference, according to well recognized principles, might have warded it off, or enabled the patient to escape with perhaps a violent rigor, followed by very free action of the bowels, the skin, and the kidneys. It is quite certain that in many derangements of the stomach and intestinal canal the free passage of fluid through them during a period of twenty- four or forty-eight hours is often of great service. The liquid in these cases does not go directly through the canal, but it, or at least the greater part, is absorbed by the stomach, taken into the blood, and again poured out by the secreting glands, and with it some of the excrementitious matters which have been accumulating in the system, perhaps for weeks or months, are got rid of at the same time. In many cases of headache, due to deranged digestion and assimilation, this free dilution of the fluids and washing out of the system is carried out with the greatest benefit, and in many cases a cure is effected in the course of from twelve to twenty-four hours. As regards the particular diluent, there is often great difficulty in selection. Weak lemonade answers well in many cases; milk or whey and water, or soda water in others ; potash water, Ger- man Seltzer water, Vals, or other effervescing water may be given, or an effervescing draught of tartrate, or citrate of potash, or 18 URINARY DERANGEMENTS. soda. The so-called effervescing citrate of magnesia is also very good, and makes a very cheap and convenient form of effervescing beverage. These may be iced, but not more than about.a wme- glassful should be swallowed at once. By suddenly swallowing a tumblerful of ice-cold fluid, people often disturb the stomach for hours, but if the tumblerful had been spread over a period of five or ten minutes, so as to allow just time for one mouthful of the cold fluid to be slightly warmed in the stomach before the addition to it of a second, no harm or inconvenience would have resulted. What we effect by this plan is the removal of substances which require much water for their solution and the prevention of the formation of a further quantity. The accu- mulation of various noxious matters in the blood and fluids of the tissues and, among the tissues themselves upsets the balance of physiological change, and leads to the initiation of the dis- turbance which may eventuate in an attack of acute disease. By free dilution, followed by purgation, diuresis, and sweating, there is reason to think that in many cases the acute disease might have been altogether prevented. It is often said that water acts as a " diuretic," but perhaps it would be more correct to say as a diluent. Water dilutes the fluids of the body, and serves to dissolve matters which are not very soluble, or dilutes solutions which are in a too concentrated state to undergo the further chemical change requisite for their discharge from the body. It must be obvious that when there is structural disease of the organs through the -ageticy of which many of the most important excrementitious matters are elimi- nated from the system in solution, it is a point of great conse- quence.that the solids should be constantly presented for excretion in a high degree of dilution, and also that the quantity of solids introduced as food should be reduced to the lowest amount con- sistent with the needs of the system. In chronic renal disease a considerable amount of liquid should be taken, large in proportion to the amount of the excreted solids. A weak solution of the organic and inorganic matters will filter through the vascular walls almost without the help of any special secerning action at all. This fact is impressed upon DIAGNOSIS AND TREATMENT. 19 the mind by many cases of chronic renal degeneration of various kinds. I have known many a patient who has gone on for some months, or even years, with scarcely any of the renal secerning apparatus in an active state. Taking little solid food, but much water, living; in fact, on milk, beef tea, and things containing much water, leading an invalid life, getting plenty of air, but taking little or no exercise— the system of the patient has slowly got into a state in which chemical change is reduced to a mini- mum ; and if tolerably free filtration goes oa through the vessels of the urinary apparatus, life may last till some accidental, sudden and exceptional change occurs, or until, by undue accumulation of excrementitious matters, the balance is destroyed, the living matter of the body is poisoned, and death may occur in the course of a few hours, to the dismay of friends, and often to the astonishment of the practitioner. As a rule, then, urine containing an unusual proportion of water is not a. matter of much consequence, for it generally depends upon the rapid separation of a large quantity of water from the blood, and may be preceded and succeeded by the secretion of urine of the usual density. This free and rapid discharge from the blood of considerable quantities of water may be due solely to altered blood pressure in the vessels of the Malpighian body, determined by changes in the nerve centres which govern the contraction of the muscular fibre cells (Jf the extensions of the renal artery. As is well known, this part of the nervous system is much influenced by the emotions. Fright, anxiety, or intense interest may, through this mechanism, determine the secretion of a considerable quantity of pale, watery urine within a few minutes. In cases, however, where the secretion of a large amount of urine of low specific gravity continues for a considerable period of time, it may be a fact of grave import, and probably depends upon serious structural alteration in the kidneys, which may soon result in death. And it is surprising how suddenly the fatal symptoms appear in some of these cases. The patient may seem to be in the state of somewhat weak or impaired health, which has existed for many months, when, without warning, and, as far as can be ascer- 20 URINARY DERANGEMENTS. tained, without any special change in the state of things, terrible exhaustion comes on, and is soon succeeded by complete failure of strength, collapse, and death. In such cases the kidneys are sometimes found to be reduced to little more than mere capsules of fibrous tissue, with scarcely a vestige of secreting structure left, and the wonder is not that death has resulted, but rather that the fatal result should have been so long postponed. In one case that came under my care some years ago, that of a lady about fifty, who had for years passed a large quantity of highly diluted urine, and died after two or three days' suppres- sion, the cause of the renal degeneration was found to be a stone in the pelvis of each kidney, so situated as to interfere with the free passage of the urine from the pelvis of the kidney into the ureter, but never to completely obstruct it. The renal structure was hard, and there was probably no portion of the cortical part as large as a pea where the normal secretion of urine could be carried on. What is very remarkable is, that this patient had had no renal symptoms whatever at any time of her life. She had often been treated for uterine disturbance, but to within a week of her death had enjoyed fair health. She could walk well, and though never very strong, was active, and able to get through more work than most ladies. REACTION OF URINE, AND OF THE USE OF ACIDS AND ALKALIES. I fear it must be admitted that with regard to the action of these simple and highly efficient remedies, acids and alkalies, there are many cases in which we still have to prescribe some- what empirically, or even in a haphazard manner. We meet with cases in which an acid or an alkali respectively seems to be indicated. We prescribe — but their symptoms, instead of being relieved are heightened. The remedy is therefore changed, and that given which it was thought was contra-indicated. Benefit immediately results, and the patient soon gets well. After a time, perhaps, he tries the same plan again, and it signally fails, while this time the remedy succeeds which before was useless. Many of the derangements in which acids and alkalies are DIAGNOSIS AND TREATMENT. 21 prescribed depend upon highly complex changes whicli are little understood aS regards their origin and causation. The contents of the stomach may be acid, and the "acidity," as well as the patient's discomfort, increased by giving alkalies, while relief may quickly follow the exhibition of a mineral acid. On the other hand, a case of what would be regarded by some as alkaline dyspepsia, accompanied by the discharge of an alka- line fluid from the stomach, may be cured by an alkali, but caused to return, and in a more severe form, if an acid treatment be persisted in for too long a time. One can only learn how long to prescribe, and when to withhold such remedies, by the careful study of individual cases, and by experiments on one's own organism. The practitioner will often find, in cases which do not improve upon any plan of treatment he has adopted, that benefit will be obtained by judiciously reducing, or by completely withholding food for a time, or by giving one par- ticular kind of food only — in some cases nothing but milk, in teaspoonfuls at a time, and iced ; in some, beef tea only ; in some, a diet limited to farinaceous food. Indian corn or lentil flour, made into the consistence of gruel with water or milk, and well boiled for a quarter of an hour or longer, often answers. In advising such a course, caution must be exercised, for some patients quarrel with us at the mere suggestion of a diet which they regard as starvation, although to us it might seem fairly liberal. But many who would rebel on the first mention of a plan of treatment considered by us to be necessary, will gradu- ally fall into our views and adopt our recommendations if we only allow them a little time to think about it, and lead them, by degrees, to adopt a restricted diet, instead of insisting that they should pass abruptly from the enjoyment of all the luxuries that money and skill can obtain, to the bare necessaries of existence, without sauce or flavor to tickle the palate. In teach- ing self-denial to people who have foolislily indulged their appe- tites to the detriment of their tissues and organs, the medical adviser must be<;ontent to work gradually towards the desired end. Sudden conversions to common sense are as rare, if not as impossible, as sudden restoration to health after years of 22 URINARY DERANGEMENTS. injudicious eating and drinking and silly management of the body. The characters of the urine are much influenced by the diges- tive process; and by the administration of acids or alkalies great changes in its composition as well as in the sensation resulting from the contact of the secretion with the highly sen- sitive mucous membrane of the urinary organs may be quickly effected. Acid Urine.— The mucous membrane of both the stomach and bladder is kept in a healthy state by contact with secretion which, although varying in the intensity of its reaction, is in its normal or healthy state acid. The epithelium on the mucous surface remains healthy, and is replaced by new cells at the proper rate, only as lopg as it is bathed with the acid secretion, and it suffers much, while a long time is required to restore it to its usual condition, if, as not unfrequently happens, particularly in the case of the bladder, the secretion becomes decidedly alka- line. If the latter condition lasts for some time, and especially if the urine becomes highly alkaline, the epithelial surface is practically destroyed, in which case, although the surface may improA;e up to a certain point, it cannot be restored to its origi- nal condition. A highly alkaline state of urine is engendered by the setting free of carbonate of ammonia, by the decompo- sition of the urea, in cases in which the bladder does not thor- oughly empty itself; and if the state of things causing this re- tention is not remedied, the erosion and destruction of epi- thelium, of the mucous membrane in its entire thickness, and not unfrequently of structures beneath it, are terrible. Now such a state of things may be prevented, or if it has not been al- lowed to persist for too long a period, greatly improved or even cured, as far as the working of the organ is concerned, in a very simple way. If the water be drawn off twice or three times a ' day, and the bladder be carefully washed out once daily with water of the same temperature as the urine — that is a little under ioo° Fahrenheit, = 37.7 Cent. — great improvement will result in a few days, and in many cases the patient's distress will be quite relieved in the course of a week. Perhaps in another week DIAGNOSIS AND TREATMENT. 23 the bladder will act for itself, and the urine need only be drawn off once a day, or the operation given up for a time altogether, especially if the patient is instructed to micturate on his knees, the body being bent forward. The process of pus formation upon the surface of the genito- urinary mucous membrane often begins in the urethra in an attack of gonorrhoea in early life, which soon gets well, but leaves a slightly altered epithelial surface. Here and there a few pus corpuscles continue to be formed, and are from time to time found in the urine. In any slight derangement of the health the process is apt to spread, and it not unfrequently extends into the bladder, and sometimes to the ureters and_so on to the pelves of the kidneys. If a patient with these tender patches of epi- thelium takes cold, the process of pus formation becomes very active and a catarrh of the mucous membrane is the conse- quence. The morbid action may be established and reach a high pitch of intensity in the course of a few hours, but weeks may pass, especially if the patient be advancing in years, before things return to their general state, for the perfectly normal or healthy condition is seldom quite regained after the age of forty or five-and-forty is passed. The treatment of this- con- dition, and further remarks upon its nature, will be found under the head of " Pus in the Urine." Bence Jones showed that in health, when the gastric juice was most acid the urine was least so, and vice versa. Before meals the acid reaction of the urine is most intense. After meals the urine is feebly acid, and it not unfrequently becomes alkaline about three hours after food. This change is associated with disturbance in the system, and feelings are often experienced which are very unpleasant to the patient. Headache, fullness, chilliness and languor are often experienced, and it is by no means uncommon to find persons made quite wretched by the disturbances consequent upon deranged chemical changes. Sleep and fasting, during which the exhalation of carbonic acid is diminished, " are attended by a rise in the acidity of the urinary secretion " (Ralfe). Highly acid urine very commonly accompanies certain forms of dyspepsia, especially the kind 24 URINARY DERANGEMENTS. to which those of a gouty tendency are subject, and it is not unusual to find thafthe means adopted to reduce the acidity of the urine are effective in improving or restoring the action of the stomach. There is still some difference of opinion concerning the way in which the acid of the gastric juice is produced. The question is well considered in Dr. Ralfe's little book "On the Morbid Conditions of the Uriae, Dependent upon Derange- ments of Digestion," to which I must refer the reader who desires to go more fully into the question. Most probably the hydrochloric acid of the gastric juice is set free during the mutual decomposition of neutral sodium phosphate and calcium chloride. Acid sodium phosphate appears to be the cause of the acid reaction of the urine in many cases, but uric and hippuric acids contribute. In speaking of varying degrees of the acidity of the urine we estimate the acid as oxalic acid. The acid of the urine secreted in twenty-four hours in health is equivalent to about two grammes of oxalic acid. Although the blood is invariably alkaline, from the presence probably of alkaline carbonates, many of the secretions of the body which are formed from matters taken from the blood are of a decidedly acid reaction. Probably from 300 to 500 grains of acid (irrespective of carbonic acid), calculated as oxalic acid, are formed in the body in twenty-four hours. As I have already remarked, the urine and the gastric juice are usually, in health, very decidedly acid, but the degree of acidity varies much, and in the intensity of their acid reaction these two secretions alter- nate with one another, and sometimes when one is intensely acid, the other may be even alkaline. Some of the acids upon which the acid reaction depends are formed within the body. During muscular action, carbonic as well as other acids are formed. Volatile fatty acids, -formic acid, acetic acid, lactic acid, and some others, result from changes in the contents of the alimentary canal, and are probably ultimately removed as carbonic acid, but some of them or their compounds may reach the blood and undergo further intermediate chemical changes prior to their elimination. When the action of the liver is de- ranged there is an accumulation of acid in the system, either DIAGNOSIS AND TREATMENT. 25 from the formation of excess, or from interference with the neu- tralization of as large a proportion of that which is produced as ought to be thus taken from the whole amount of acid formed. In rheumatism an unusual formation of acid takes place. Acetic, butyric, formic and valerianic are among the acids produced. The same acids are often set free by chemical decompositions occurring in the contents of the stomach. If bicarbonate of potash be taken before meals, the intensity of the acid reaction of the urine is diminished for some hours, but on the following day "the acidity was considerably higher than it was the day before the salt was taken. But when it was administered during the process of digestion, the acidity of the urine entirely disappeared " (Dr. Ralfe, "Morbid Conditions of the Urine, pp. 54 and 143). If, then, we desire to increase the acid reaction of the urine, we must give the bicarbonate of potash when the stomach is empty, while, if we wish to diminish its acidity, the bicarbonate should be given after food. When- ever alkalies are prescribed, the patient should be instructed to continue them for a definite time only, otherwise harm, instead of good, may result. Advantage is often obtained by a course of acids before meals, and a course of alkalies after meals alter- nately, and I have often found hydrochloric, nitric or phos- phoric acid before two meals in the day; and bicarbonate of potash or soda an hour or two hours after the same two meals, of great use. Such treatment may be continued for a fortnight, or longer, at a time. From nutnerous experiments, varied in many ways, Dr. Bence Jones came to the conclusion that ammonia in the organism was partly converted into nitric acid. Urea and caifein, and other substances containing nitrogen, give rise to the formation of a small quantity of nitric acid. Although Lehmann has failed to confirm these results, he has not, I think, succeeded in shaking the evidence adduced in favor of the conclusions. Lehmann attributed the action upon the iodide of potassium to the pre- sence of sulphurous acid. Jaffe performed some experiments in Lehmann's laboratory, and obtained sulphurous acid, but no nitrous acid from healthy urine and from urine passed after 26 URINARY DERANGEMENTS. taking ammoniacal salts. Dr. Bence Jones subsequently repeated his experiments, and found that Jaffa's experiments did not invalidate Price's test for nitrous acid, as Lehmann supposed {Proceedings of the Royal Society, Vol. VII, p. 94)- Dr. Bence Jones brings forward several cases of healthy persons vi^hose urine did not yield a trace of nitric acid ; but, three or four hours after they had taken carbonate of ammonia, evidence of the presence of the acid was afforded by the starch and also by the indigo test. After twelve hours, only a trace could be de- tected ; and in twenty-four, even this ceased to be perceptible. The urine was examined in precisely the same manner in every case. We must, therefore, conclude that a small, amount of ammonia in the organism is converted into nitric acid ; and it is not improbable that, under certain circumstances, the quantity of nitric acid formed in this manner maybe very much increased. Irritable Bladder. — In some cases, the deposition of uric acid and the secretion of a highly acid and perhaps concen- trated urine, persist for many years, and the derangements arising from this state, both as regards the urinary organs and the system, are often difficult to cure. Among the most common ailments which are due to a highly acid state of urine, is " irrit- able bladder." Without there being any actual disease of the coats of the bladder, the surface of the mucous membrane often becomes unduly sensitive, so that the mere contact of highly acid or concentrated urine excites an unpleasant feeling, and sometimes actual distress, which soon assumes the form of an uncontrollable desire to immediately empty the bladder, and although the organ may be nearly empty, this occurs again and again, causing much suffering and inconvenience. In some cases the patient cannot retain his urine for more than an hour ; and the pain is so great that the case is sometimes mistaken for inflammation of the bladder. The acid urine sometimes occa- sions the deposit of urates and uric acid in the bladder, and may thus give rise to stone. In some of these cases there is severe intermittent pain at the neck of the bladder and along the urethra, with frequent micturition and an almost constant feeling of a desire to make water. So severe are these symp- DIAGNOSIS AND TREATMENT. 27 toms, that the patient is prevented from discharging his ordinary duties, and is almost afraid to leave his own private room. He is ready to do anything or suffer anything in the hope of getting relief. Remedy after remedy is tried in vain, and he may fall into injudicious hands. Nitrate of silver or some other strong caustic may be applied to his urethra, not only without perma- nent relief, but his present suffering may be increased by this and other expedients most confidently recommended as being certain to effect his cure. Instead of this, changes, perhaps, take place in his urethra which may, at a future time, result in stricture, and necessitate constant surgical attention. The pathology of many cases of irritable bladder is obscure. In some there is undoubtedly catarrhal inflammation of the mucous membrane, but not unfrequently the condition seems to be due to, or is complicated with, an irritable state of the sensi- tive nerves of the mucous membrane and disturbances of the nerve centres most difficult to relieve. The practitioner will, however, often find that in many a case of what to the patient seems to be most terrible irritability, accompanied by even severe pain, a mercurial purge, repeated at intervals of a few days, will be of great service, although all the ordinary reme- dies which have been tried for his relief have failed. Sometimes the symptoms are actually caused, or greatly increased, by a con- centrated state of the urine, with excess pf urea, and an unduly acid condition of the urine invariably causes increased suffering. Very free dilution of the urinary secretion is indicated. Two pints or more of linseed tea flavored with lemon juice, dis- tributed over the twenty-four hours, should be ordered, and be kept up for a week or ten days. If the patient gets tired of linseed tea, barley water may be taken, or mucilage of gum, or infusion of triticum repens, or even pure water, or water flavored with orange or lemon juice. In many cases, the salts of the vegetable acids (citrates, ace- tates, tartrates) will be found more efficient in counteracting this acid state of the urine than alkalies or their carbonates, and are less likely to interfere with the digestive process. There are, however, low conditions of the system in which the acid state of 28 URINARY DERANGEMENTS. the urine, and a tendency to the deposition of uric acid in large quantity, are not relieved by this method; on the contrary, such cases are often much benefited by an opposite plan of treatment —tonics and the mineral acids before meals, a nourishing diet, with a moderate supply of simple stimulants with a little alkali, or with alkaline waters. Many of these cases seem to be inti- mately connected with impaired digestive power, and I have frequently found pepsine a valuable remedy (" Slight Ailments," 2d edition, p. 89). Some of the most obstinate forms of the malady under con- sideration occur in women. I have seen cases under the age of thirty, in which all sorts of devices had been employed without avail, yield at once to moderate purgatiori, alkalies, and plenty of linseed tea or barley water. In the treatment of such mala- dies, and in the management of the sufferers, we must be careful not to be influenced by the increasing tendency to prescribe remedy after remedy, to introduce various instruments, and to prosecute different methods of examination with the idea of im- mediately curing what is really a chronic malady. Sometimes, however, a careful consideration of the facts leads the practi- tioner to suggest a simple and efficient plan of treatment which may prove successful within a few days of its adoption, although all 'sorts of extraordinary and out-of-the-way expedients have been resorted to without relief having been obtained. Of all the remedies employed for relieving a highly irritable bladder depending upon very acid urine, with or without pres- ence of excess of urea, or of a deposit of uric acid, liquor potassce is the most efficacious, but it must be given with due care, and not continued for too long a time without intermission. Alkaline Urine. — An alkaline condition of the urine may be due to several circumstances, and requires, therefore, to be treated on different plans. The connection between an alkaline state of the urine depending upon fixed alkali, and the secretion of a highly acid gastric juice, has already been referred to. In such cases, attention must be paid to the state of the digestive process; and when this is set right, the urine will usually regain its normal characters. Dr. Bence Jones alludes to three cases DIAGNOSIS AND TREATMENT. 29 of dyspepsia with vomiting of a very acid fluid (two of them rejecting sarcinae), in which the urine became alkaline from the presence of fixed alkali when the quantity of acid set free at the stomach was very great ; but when this was small the reaction of ■ urine was acid. It must, however, be borne in mind that the very acid nature of the materials rejected in many cases of vom- iting, and especially in cases of sarcina ventriculi, arises, not from the secretion of an acid fluid b/ the glands of the stomach, but from the decomposition or fermentation of the food, when acids are developed, among which may be mentioned acetic, lactic, and butyric acids. At the same time, there can be no doubt that, in some cases of dyspepsia, the feebly acid or alka- line condition of the urine arises from the secretion of an abnor- mal amount of acid by the stomach. The degree of the acidity of the urine, says Dr. G. O. Rees, may, to a certain extent, be regarded as a measure of the acidity of the stomach. Dr. Rees long ago drew attention to a large class of cases in which he thought the alkaline condition of the urine was to be explained as follows : Urine which is highly acid at the time of its secretion, irritates the mucous membrane of the bladder, and causes it to secrete a large quantity of alkaline fluid. This mucous membrane in health secretes an alkaline fluid, to protect its surface, just as occurs in the case of some other mucous membranes. Under irritation, more aljcaline fluid than is suffi- cient to neutralize the acid of the urine is poured out ; and hence the urine, when examined, is found in some cases to have a very alkaline reaction. In such cases, this .highly alkaline condition is removed by giving liquor potassas or some other alkali, or a salt of a vegetable acid, which becomes converted into an alkali in the system. The urine is not secreted so acid, and, therefore, according to Dr. Rees, does not stimulate the mucous mem- brane to pour out as much alkaline fluid- I know no observations to disprove this explanation of the fact, that in some cases alkalies cause the urine to become less alkaline, or even restore its acid reaction ; yet one would hardly expect, if this be the true explanation in cases generally, that the natural reaction of urine would be acid. If there was danger of the healthy mucous 30 URINARY DERANGEMENTS. membrane suffering from the contact of a fluid only a little more acid than that destined to be continually touching it, should we not expect it to have been of such a character as to resist this action, like the mucous membrane of the stomach, instead of being excited to secrete a fluid which in excess might seriously damage it? It must be remembered that the mucous membrane of the bladder bears very well the contact of acid fluids which sometimes hs^e to be injected ; and it cannot be denied that patients may for years pass intensely acid urine, without there being any evidence of the secretion of the excess of alkaline fluid from the mucous membrane which is postulated. When there is fermentation in the contents of the stomach, with a setting free in large quantity of many organic acids, the urine is often only feebly acid or it may be decidedly alkaline in its reaction. Under these circumstances oxalate of lime will often be found in the deposit ; but that the oxalate is not due in any way to the stomach changes, is proved by the fact that it is often found in large quantity in cases where the stomach performs its work perfectly well, while in many cases in which the action of the stomach is very seriously deranged no deposit of oxalate of lime takes place. ' Alkalies taken just before a meal sometimes act advantageously, partly because they stimulate the increased secretion of gastric juice more decidedly than an acid, and partly because by neutralizing organic acids set free by the decompo- sition of some of the ingredients of the food, the secretion of normal gastric juice is promoted. The practitioner must not fail to bear in mind that great derangement of vesical action, and even actual and severe inflam- mation of the bladder, may result from carrying alkaline treat- ment too far, and it is very necessary to caution patients who have experienced benefit from alkalies and alkaline waters, on this head. I have seen many cases of most troublesome bladder disturbance caused by foolishly persisting in the use of alkalies. Patients generally know nothing of physiology, and having found what they call " a good thing" in the way of a remedy, are too apt to persist in its use even after its action is obviously detri- mental. This effect being attributed to some other circumstance, DIAGNOSIS AND TREATMENT. 31 the pet remedy is continued until real illness is induced, and It becomes absolutely necsssary to call in the medical adviser, who would have given the patient such directions as would have saved him much suffering and trouble, and perhaps prevented a long and tedious illness, had he been consulted before the patient took upon himself the responsibility of his own medical management. The persistently alkaKne condition of the urine occasionally met with is very difficult to successfully treat, and may continue in spite of large doses of acid persisted in for many weeks at a time. Indeed, no amount of acid that can be taken without risk will alter the reaction of the urine in some instances. The alkaline condition is usually associated with the deposition of earthy phosphates, and sometimes in very considerable quantity. In such cases, without very careful management, a distressing state of things may resulti The earthy salts are often deposited upon the surface of the mucous membrane, not only of the blad'der but upon that of the- ureters and pelvis of the kidney. This process not unfrequently results in complete disorganization of the mucous tract, and generally leads to a serious state of things; not uncommonly portions of the deposit become de- tached, and receiving earthy phosphates upon their surface, layer after layer, concretions of a soft and very brittle character, but not unfrequently of considerable size, may be formed. The injection into the bladder, from time to time, of very dilute acid (one part of strong acid to one hundred of water), with frequent washings out of the viscus with tepid water, generally affords relief. VARIATION IN QUANTITY AND IN THE RELATIVE PROPORTION OF THE SOLIDS OF THE URINE. Among the commonest derangements of the urinary secretion within the healthy range is an increase of the solid matter in proportion to the liquid present. In a given quantity of urine the solids may be found to be double that of the ordinary amount, and other specimens within twenty-four hours may contain much less than the ordinary percentage of solid matter. In the case of a secretion like the urine, which is always changing. 32 URINARY DERANGEMENTS. at least as regards the quantity of its constituents, it is not pos- sible to adduce a standard analysis which shall represent its normal composition. We may arrive at an average by making analyses of a portion of the mixed urines of the twenty-four hours, and instituting comparisons between the urines of a number of healthy individuals. In this way we are able to point to what we may call a healthy standard, but in nature variation is constant with reference to this, and in both directions. It is to the con- siderable and constant variation in the composition and quantity of the urinary constituents that what may be spoken of as the capacity of maintaining a steady, even state of health is to be attributed. Urea is the most important of the solids of the urine. It is always present and in-greater proportion than any other of the constituents of urine. The amount .varies greatly within the physiological limit, and in slight departures from the healthy state it is not uncommon to find the urea amounting to double as much, or to not more than one-twentieth of what is stated to be its normal amount. The quantity of urea excreted by a healthy man during each period of twenty-four hours may be roughly stated to be 500 grains, and corresponds to about 3^ grains per pound of the body weight. In many cases, however, it does not amount to nearly so much. Some organisms are exceptionally economical "machines," and do not consume even half as much food in the performance of the same amount of work as seems to be necessary in the case of the majority. Even in engines the greatest difference exists in this respect, and engineers are continually discovering new means of econo- mizing fuel. As compared with an engine, however, the most extravagantly feeding man is a very economical machine. A good deal of urea found in the urine is produced in the liver. In some diseases of this organ the quantity of urea formed in the twenty-four hours is lessened. It is probable that far too little consideration has been given to the action of the liver in the treatment of disturbances resulting in the formation and excretion of more than the normal amount of urea and uric acid. In some of these cases our attention should be mainly DIAGNOSIS AND TREATMENT. 33 directed to the action of the liver and intestinal canal, and we shall often find that as soon as the work performed by these or- gans is properly discharged, the urine will return to its normal condition. The large proportion of urea excreted in fevers and inflamma- tions has been supposed by some authorities to be proof of ex-_^ cessive oxidation, and to be necessarily connected with the high temperature of the body. In spite of the blood being stagnant in the vessels, and the air-cells of the lungs choked up, this ill- considered theory has been so forced upon us, that it will probably be some time before any view more in accordance with well- known facts will be accepted. It need scarcely be said that a rise in temperature may be brought about in many ways, while it may be regarded as certain that the increased heat in fever and inflammation, and the increased quantity of urea formed, do not depend upon peroxidation ; indeed, it will be found that there is usually a very large excretion of urea in diseases in which the activity of the processes concerned in oxidation is much reduced, instead of being in excess. The amount of urea excreted is often very great. Vogel mentions a case of pyaemia, in which 1 235 grains of urea were removed in the course of twenty-four hours. Dr. Parkes obtained as much as 885 grains in a case of typhoid fever. These quantities are very large, if the patients did not exceed the average weight of adult men ; but, unfortunately, their weight was not recorded. Excess of Urea. — This phrase is not restricted to those cases in which the total quantity excreted in the twenty-four hours is greater than in health ; but a specimen of urine which yields crystals of nitrate of urea when an equal bulk of nitric acid is. added to it in the cold, without having been previously concen- trated, is said to contain "excess of urea." The quantity of urea dissolved in the fluid is so great, that nitrate of urea is formed, and crystallizes, just as if the urine had been concentrated by previous evaporation. This result may be brought about in several ways. In cases in which but a small quantity of fluid is taken in proportion to the urea to be removed ; when an unusually large amount of water escapes by the skin and other emunctories ; c 34 URINARY DERANGEMENTS. as well as in many cases in which an unusual amount of urea is formed in the organism, we shall frequently find excess of urea in a specimen of the urine. " Excess of urea " is frequently found in the urine of persons suffering from acute febrile attacks. It is very common in cases of acute rheumatism, and is often met with in pneumonia and acute febrile conditions generally, in which cases there is also an actual increase in the quantity excreted in the twenty-^four hours. In England, we meet with cases of "excess of urea" very frequently; but on the Cpntinent they appear to be so rare that many authorities seem to doubt the truth of what Eng- lish observers have stated on this point. Lehmann, I think, states that he had never seen a case in which crystals of nitrate of urea were thrown down upon the addition of nitric acid, without previous concentration. Urine containing excess of urea is generally perfectly clear, of rather a dark yellow color, and of a strong urinous smell. Its specific gravity is about 1.030, and it contains 50 or 60 grains, or more, of solid matter per 1000. At ordinary temperatures, an aqueous solution which forms crystals of the nitrate upon the addition of nitric acid without previous evaporation will contain at least 60 grains of urea per 1000; 50 grains of urea per 1000 hardly gave the slightest precipitate after the lapse of a considerable time. But it would seem that the salts, extractive matters, etc., in urine, favor the crystallization of the nitrate when even a smaller quantity of urea than 5 per cent, is present. It should be mentioned that the above experiments were per- formed in the summer, in very hot weather. In one case, in which the urea readily crystallized on the addition of nitric acid, the urine had a specific gravity of 1.028, and contained — ANALYSIS. Water 940.18 Solid matter 59-82 Organic matter 50.57 Fixed salts o 2C Urine containing excess of urea is generally acid, but I re- ceived a specimen from Dr. Fergus, of Marlborough, which was DIAGNOSIS AND TREATMENT. 35 alkaline, and contained crystals of triple phosphate. It came from a patient, i8 years old, who was feverish, with gastric and biliary disturbance. The urine was highly colored, sp. gr. 1.033, and became nearly solid upon the addition of an equal bulk of nitric acid, from the formation of crystals of nitrate of urea. (April, 1862.) There are some peculiar and not very common cases in which the urine persistently contains more than the healthy amount of urea. The patient is weak, and grows thin, in spite, it may be, of taking a considerable quantity of the most nutritious food. He feels languid and indisposed to take active exercise. In some cases digestion is impaired ; in others the patient eats well, experiences no pain or uneasiness after food, and perhaps has a good appetite. Sometimes there is lumbar pain. It would seem that most of the substances taken as nu- trient material become rapidly Converted into urea, and are ex- creted in that form. The waste of the tissues is not properly repaired, and the patient gets very thin. To refer these symp- toms to the existence of a particular diathesis, affords no explanation of the facts, but it must be admitted that the pa- thology of these remarkable cases has not yet been satisfactorily made out. Mineral acids, rest, shower-baths, and good air, often do good ; but some of these patients are not in the least benefited by remedial measures, and they continue for years very thin, passing large quantities of highly concentrated urine, while the appetite remains good, and a considerable quantity of nitro- genous food is digested. In some, which have resisted the usual plans of treatment, benefit has been derived from the use of pep- sine, with diminished quantity of meat, afid a larger amount of farinaceous food. Sometimes it is necessary to keep the patient on milk and farinaceous food only for several days together, not allowing him any meat, or even soup or fish. It is very remarkable, that in many instances the secretion of the urine which is so rich in sorlid constituents occurs only at one time during the twenty-four hours. It is, therefore, neces- sary, if we desire to estimate the total quantity of the various solid matters passed in the day, to mix all the urine passed in the twenty-four hours, and having, carefully measured it, to 36 URINARY DERANGEMENTS. analyze a portion of the mixture. The variation in the activity of the secreting process is very great. At a particular period of the day, usually in the afternoon and evening, the patient will complain of coldness of the surface of the body generally. This is soon followed by lumbar pain and some congestion of the kidneys. The secretion of urine of very high sp. gr. soon takes place, and not unfrequently a small quantity of albumen is found in it. When the patient gets warm and freely perspires, the symptoms pass off and the free secretion of normal urine fol- lows. Some of these cases are closely allied to ague, and are cured by those remedies which act favorably in intermittents generally. Quinine in five or ten grain doses is often of use. When the formation of urine containing " excess of urea " has gone on for a considerable period, no change in diet for a short time will alter the condition. There seems to be a ten- dency to the excessive formation of urea in the system, and this often persists for a considerable time. It cannot be explained, but it may be compared with the " tendency " to the formation of sugar or cystine. The facts cannot be accounted for by sup- posing that an accumulation of urea in the system has taken place, and that it is gradually removed. To discourage or prevent this excessive formation of urea, it is necessary for the patient to diet himself with care and regulate his exercise for several weeks if any good and lasting benefit is to be obtained. The meat consumed should be reduced to three or four ounces daily, or less, and advantage will result from the substitution of fish for meat on at least two days in the week. Farinaceous puddings and stewed fruit may be taken, and baked apples, stewed prunes, and various kinds of jam may be obtained, even in the winter months. Benefit also results from taking lettuces, mustard and cress, and water-cresses in this condition. There is no doubt that, as long ago observed by Prout, in many cases that come under our notice, an actual excess of urea in proportion to the body weight is habitually, and, under ordi- nary circumstances, excreted. In some of these cases it is re- markable, that although little nitrogen is taken in the food, an unusually large quantity of urea nevertheless passes away from DIAGNOSIS AND TREATMENT. 37 the organism. It would seem probable that substances from which urea may, by chemical change, be readily produced, may go on accumulating in the blood, and possibly in the interstitial tissue fluids, for some consiflerable time, and that then some spe- cial chemical disturbance is started, and the nitrogen of these substances goes to form urea, instead of many other nitrogenous compounds as well as urea. For many days larger quantities of urea are excreted than can be accounted for by the ordinary changes. This formation of urea may be associated or not with febrile symptoms. After a time, at least iri most of the cases that come under observation, this free excretion of urea be- comes reduced and the patient returns to his normal state of health. In another class of cases, there can be no doubt that a large quantity of the urea excreted is actually formed from the tissues of the body. The tissues accordingly waste, and this process may continue for a considerable period of time. No matter how much food the patient may take, he continues to get thin and loses considerably in weight. The nitrogenous constituents of the food, instead of supplying the tissues and compensating for the tissue waste, are themselves resolved into urea, and thus the quantity formed is largely increased. Why the food which is usually appropriated and applied to the nutrition of the body is, in -certain cases, resolved into urea, or into this and other excrementitious matter without being employed at all in the nutritive processes, I cannot say, but I have no doubt that this is so in a number of cases, the exact nature of which is still ob- scure, as well as in many cases of fever where the removal of large quantities of urea is associated with extreme weakness and continued emaciation. The copper test for sugar, known as Trommer's test, Fehling's solution, and other tests of the kind, afford indications of the presence of sugar in many specimens of urine which contain a large quantity of urea. The reduction of the copper does not, however, depend upon sugar. The presumption that the change in question was due to the presence of sugar, has led some ob- servers to believe that there was a tendency for cases in which 38 URINARY DERANGEMENTS. an unusual quantity of urea was formed in the body to pass into the diabetic condition. As far as has been ascertained, there is, however, no very conclusive evidence in favor of this vie\v, and it is very doubtful whether there is really any causative relation between the state of system in which diabetes occurs and that which is characterized by the formation of large quantities of urea, or by the frequent secretion of urine in a highly concen- trated state and containing a high percentage of urea. In test- ing the urine of cases supposed to belong to one of these classes, the greatest care must be taken not to be misled by the change in the copper test above referred to. It has happened to me on more than one occasion to have to prove to a medical friend, who had frightened himself into the idea that he had diabetes, that his chemical skill only was at fault, and that urea or some other constituent had caused the reduction of oxide of copper which had alarmed him. And although it is satisfactory to con- vince a friend that he is more likely to live to be old and to enjoy better health than he had concluded had fallen to his lot, it is not pleasant to have to convict him of a blunder, though it be chemical only. Deficiency of Urea. — Sometimes the quantity of urea excreted is very small. A lady suffering from an ovarian tumor only excreted 75 grains of urea in 200 fluid drachms of pale, faintly alkaline urine in the course of twenty-four hours. (Thudichum.) In a case of cancer of the uterus, under the care of Dr. Arthur Fart-e, only a few drachms of fluid were passed from the bladder during a week; and this contained a small quantity of solid matter, in which no urea could be detected. In a case which proved to be complete degeneration of the kidneys from stones in each pelvis, while the patient yet seemed to be in good health, less than half a pint of urine of very low sp. gr. (1.004) was formed for many days at a time, and there was no evidence to show that the urinary constituents passed off" by the bowel. The probability is that the chemical changes ordinarily resulting in the formation of urea were reduced to the minimum con- sistent with life. In chronic structural disease of the kidney, the urine is of DIAGNOSIS AND TREATMENT. 39 very low specific gravity, and but a very small proportion of urea is excreted in the twenty-four hours. This arises from the alteratton in the gland structure, and the amount of urea sepa- rated may be .regarded as a rough indication of the extent of the organ involved. In some cases, the morbid condition affects the whole structure ; but in others the greater part of the kidney remains healthy. In the latter case a fair amount of urea will be excreted ; and, although the urine contains albumen, the case may be looked upon as of a hopeful class — qases of the kind often living for twenty years or longer. In -certain cases, urea almost entirely disappears from the urine, and is replaced by leucine and tyrosine. Frerichs men- tions a case of acute yellow atrophy of the liver, in which only a trace of urea could be detected, while a very large quantity of leucine and tyrosine crystallized from the concentrated urine. (" Klinik der Leberkranheiten." Erster Band. Seite 221.) In low forms of typhoid fever, the urine also frequently yields leucine and tyrosine' in considerable quantity. In a case of chronic yellow wasting, which came under my own notice (F. C, vol. VI, p. 37), the liver was of a yellow color, and weighed only i^ lb. The patient was a young woman, age 26. Jaundice had existed "foi;. six weeks, but urgent symptoms — delirium and coma — had only supervened a few days before death. Leucine was obtained from the urine by evaporation, but only in small quantity. In a remarkable case of enlarged spleen (leucocythemia) under my care, much leucine was found in the urine. In many cases there is a deficiency of urea in the urine in consequence of it not being formed in the body. This is remarkable in cholera, in which disease only a mere trace of urea is sometimes produced during many hours. Uraemia is the term applied to that condition of the system which soon results from the retention of the excrementitious urinary substances in the blood. Long-continued organic dis- ease of the kidneys -often ends in urxmia, but it may depend upon acute disease. The nervous phenomena are generally con- sidered to be caused by the accumulation in the blood of urea, but later researches have shown that neither Urea, Carbonate of 40 URINARY DERANGEME TS. Ammonia, nor Nitrate of Potash injected into the blood of animals proves speedily fatal, unless the kidneys be previpusly extirpated the urine is augmented. ("The Influence of Liquor Potassfe on the Urine in Rheumatic Fever." Med.-Chir. Review, Vol. XIII, p. 248.) An increase in the quantity of sulphate in the urine, in cases of rheumatic fever, is noticed in some of Dr. Bence Jones' analyses. In one case, on the fifth day, the urine had a specific gravity of 1.026, and yielded 11.89 grains of sulphate of baryta. In many cases of skin disease I have found the relative pro- portion of the sulphates to be considerably augmented. This is well illustrated in the composition of the urine of a boy suffer- ing from eczema. It must not be forgotten that a great increase of the sulphates in the urine takes place if sulphates be taken as medicine. Sulphates of soda and magnesia are those which are most com- monly given, and the proportion found in the urine is by this means frequently doubled or trebled, and the increase continues for some days after the sulphates are taken. Sometimes the sulphates themselves, on the other hand, instead of sulphur being oxidized, seem to be deoxidized in the organ- ism, with the setting free of very appreciable quantities of com- pounds rich in sulphur. It is not uncommon for patients who are taking waters containing sulphates, as well as those in which hydrosulphuric acid predominates, to discover that any silver they have about them- has been completely blackened, from the formation of a film of sulphur upon the surface. This setting free of sulphides may continue for a considerable period of time. I have known the process to continue over several weeks, but have not been able to get any satisfactory explanation of the fact. If we could ascertain the causes of the change, and bring it on at will, it might be advantageous in the treatment of scabies, and possibly of many conditions depending upon the presence of animal or vegetable parasitic organisms. In taurine and cystine large quantities of sulphur exist, and it may be to some change in the former of these compounds which is con- stantly produced in the organism, that the chemical changes resulting in the formation of free hydric sulphide or hydro- sulphuric acid, or compounds which readily yield it, are due. 64 URINARY DERANGEMENTS. Excess and Deficiency of Alkaline Phosphates.— I have adduced evidence which indicates that the greater part of the phosphoric acid eliminated is carried into the organism in the food. Dr. Ralfe has shown that " alkaline phosphates are retained in the system. when the alkaline carbonates are with- drawn, and discharged when these are again supplied." (" In- quiry into the Pathology of Scurvy," by C. H. Ralfe, M.A., M. D., Lewis, 1877.) A certain proportion, however, of the phosphoric acid, there can be little doubt, is formed in the body by the oxidation of the phosphorus of albuminous textures. Con- trary to what has been most positively affirmed, it is probable that the amount formed in the nervous textures is exceedingly small. In diseases generally, the alterations which have been observed in the quantity of phosphate removed in the urine are to be attributed mainly to the altered diet of the patient. It is, how- ever, but reasonable to suppose that, in some conditions of the system in which a moie than usual disintegration of tissues rich in phosphorus takes place, more phosphoric acid would be pro- duced in the organism than in health. This excess should be found in the urine in the form of alkaline phosphate, and it was said the amount corresponded to the activity of the changes taking place. Then it was assumed that by ascertaining the proportion, we should be able to form an estimate of the quantity of phos- phorus oxidized — and therefore of nerve tissue disintegrated. Those who labor to prove this, and further that all the changes in the body are the direct result of certain chemical decompositions, have not hesitated to appeal to the results of the observations referred to above in favor of their theory. Some years ago it was accepted as a settled point, that the quantity of phosphate in the urine varied according to the a mount of nervous tissue disintegrated ; and it was too hastily assumed that the quantity of work done by the brain varied in direct proportion to the activity of the chemical changes going on in the nervous tissue. But it has never been shown that the quantity of phosphate depends upon and varies according to the activity of the changes in question. The problem is much more intricate and more difficult of solution than at first appears. DIAGNOSIS AND TREATMENT. 65 The excretion of an unusual quantity of alkaline phosphate is not, as far as I have been able to ascertain, productive of any definite symptoras, nor does it, as far as I am aware, result in any derangement of the health. An extra amount simply filters through the organism and escapes partly in the urine, and is partly discharged from the intestinal surface. When one considers the large amount of alkaline phosphates in wheat, in meat, and in other kinds of food habitually con- sumed, one wonders at remarks being made about the deficiency of phosphorus in the organism, and suggestions that this de- ficiency can be made up if phosphorus or some compound be taken as medicine or with the food. That phosphoric acid is useful in some disturbances of the digestive system I have no doubt, and that some phosphatic salts are of use in the treatment of certain disturbances of the health, is likely, but that phos- phatic salts act by furnishing phosphorus to the nervous system is most improbable. There are, no doubt, circumstances under which a proportion of the alkaline phosphates present becomes decomposed, the phosphoric acid combining with calcium or magnesium to form earthy phosphates which may be held in solution in the blood and intertextural fluid, or may be precipitated in an insoluble form in the tissues ; or finding its way into the urine in a state of solution, may be precipitated from that fluid, either before or after it has left the organism. In the former case the earthy salt may be deposited on the epithelial surface of the pelvis of the kidney, ureters, or bladder, causing grave disease of the mucous membrane, and leading to the formation of stone, or the estab- lishment of disease of .the mucous membrane ; in the latter it forms a deposit in the urine, partly amorphous, partly crystalline, well known to all who are familiar with the ordinary urinary deposits. It has often been suggested, in cases where an unusual quantity of phosphatic salts are being carried off by the urine, that phosphate should be prescribed, but it is hardly likely any advantage can result from the proceeding. There is no defect as regards the mere quantity of phosphate in the organism, but D* 66 URINARY DERANGEMENTS. the increased excretion seems to be due to some derangement of the processes by which the phosphates are taken up by the tissues which should contain them, or to an unusual activity of the changes by which phosphates are removed and ultimately excreted from the body. We should endeavor, therefore, to put right any derangement of digestion or assimilation of the exist- ence of which we could obtain some evidence or indication, rather than pour in at one part of the bodysalts of the same kind as those which are being rapidly carried off from another. The earthy phosphates — phosphate of ammonia and magnesia, or, ammonio-magnesian phosphatie, and phosphate of lime, or calcium phosphate, are referred to on page 104. URINARY DEPOSITS. The subject of urinary deposits must always be of interest to the practitioner, and it is of considerable practical importance. In consequence of the expansion of other departments of medi- cal inquiry, less attention has been given to urinary deposits of late years than formerly, but as no one can successfully treat _many forms of urinary disease, unless he is familiar with the characters of urinary deposits and acquainted with the methods, chemical as well as microscopical, of identifying them and de- monstrating their exact nature, the practitioner should take every opportunity of studying the character of the deposits commonly found in urine in various cases of derangement and of actual disease. Considerable practice in the wards of the hospital and some patience are necessary for any one who would become familiar with the multitudinous forms of the substances which constitute urinary deposits. Far too little attention is now given by the student to practical work in this department. Looking occasion- ally at a few deposits mounted in Canada balsam is of little real service. Nothing short of examining a number of specimens of urine obtained in the wards will enal)le the practitioner to gain that confidence in his power of identification which he desires. The presence of a deposit in the urine is of itself evidence that the secretion is not in its perfectly normal or healthy state, for healthy urine contains all its constituents dissolved, and the only thing that approaches deposit is a trace of mucus which forms a flocculent cloud, which subsides to the lower part of the fluid after the urine has been allowed to stand for a time. The presence of some deposits in the urine may be taken as an indi- cation either that the oxidizing processes are not duly performed, or that the materials to be oxidized are in unusual amount, in consequence of the food taken being in excess of the amount the system requires. 67 68 URINARY DERANGEMENTS. Although, as a general rule, our treatment of a case is deter- mined by various circumstances taken in conjunction with the results of a careful examination of the urine, there are a few urinary deposits, just as there are certain morbid constituents dis- solved in the urine in certain cases, by which the nature of the disease may be conclusively determined. Care must be taken not to allow the judgment to be influenced only by the character of the urine or the urinary deposit, for serious mistakes are some- times made if the practitioner ventures to found a diagnosis exclusively upon one fact or upon a series of facts, instead of allowing his conclusion to be based upon everything that can be ascertained in connection with the case. Moreover, by concen- trating his attention too exclusively upon one symptom or one special feature of disease, the student runs the risk of neglecting to take into account broad general facts of far greater con- sequence, and of thus making serious mistakes of both diagnosis and treatment. The experienced practitioner tries to grasp all the broad general features of a case, and in grave maladies he is careful to have well before his mind the tendency to death, be- fore he allows his attention to be concentrated upon any one or two special matters which, although of some consequence, are probably of considerably less importance as regards the welfare of the patient than a thorough grasp of his pathological condition at the time, and of the changes which take place in his symptoms from day to day. For these and many other reasons that might be urged, it is important that while the great value of the careful microscopical and chemical characters of urinary deposits is fully recognized, the investigation of a case should not be limited to these methods, but the diagnosis grounded upon all the clinical facts of the case. Urine Opalescent from Insoluble Matter being sus- pended in it. — Urine often appears opalescent in consequence of insoluble or very imperfectly soluble matter, in a state of ex- tremely minute division, being evenly distributed through it So very minute are the particles which cause the opalescence, that few of them, and sometimes none, subside after the urine has been allowed to stand even for a considerable time. Many sub- DIAGNOSIS AND TREATMENT. 69 Stances may cause the appearance in question. Among the least common forms of opalescent urine, is that which depends upon an admixture of chyle, known as "chylous urine." The fluid is white and opaque, and looks like milk to which a considerable quantity of water had been added. Fatty matter in an extremely minute state of division is suspended uniformly through the fluid in these cases. It will neither rise to the surface nor subside to the bottom, if the urine be left to stand for many hours. Opalescence may also be caused by the presence of multitudes of bacteria, which increase enormously as decomposition pro- ceeds. Earthy phosphate also may be diffused through the urine, and cause it to be opalescent. Mucus from the urinary passages, perhaps, holding in suspension very minute crystals of oxalate of lime, is another cause of an opalescent appearance; but deposit which most frequently gives* rise to an opalescent appearance of the urine consists of urates, which gradually pass into an insoluble form in a varying time after the urine has left the bladder. This deposit is instantly dissolved if a little warm water be added to the urine, or if the latter be exposed to a gentle heat. The particles themselves are excessively minute, many of them so small as to be only just visible under the highest powers. There is no indication of crystalline forms in the largest of them. CHYLOUS. URINE. " Chylous " urine will not be seen many times by any physi- cian in this country, even though he be in large practice. Most of the cases observed, it will be found, originated in the tropics, where the condition is by no means uncommon. The urine, as I have already remarked, looks as if a little milk had been added to it. Indeed, such "chylous urine " is sometimes pre- pared for the purpose of deceiving us. The fact can, however, be at once determined by careful microscopical examination with a quarter of an inch object-glass, when the fat-globules of the milk at once come into view. In true chylous urine the matter in suspension which gives to the urine its whiteness and its opacity is fatty matter in an extremely minute state of division ; in fact, it is the so-called " molecular base " of the chyle which 70 URINARY DERANGEMENTS. has found its way into the urine. Under the microscope the minute particles resemble those of urate of soda, but they are not dissolved when the urine is warmed, or when a little alkali is added. Chylous urine is so rarely seen in this country that the practitioner is very likely to regard the urine as a case in which ordinary urates of an unusually pale color are held in sus- pension. Both urates and fatty matter in a molecular state as it exists in chylous -urine exhibit molecular movements, but the latter, though not altered by a moderate heat, are dissolved if the urine be agitated with ether. Blood is often found in chylous urine, and gives to it a' pinkish hue. Cases of chylous urine are comparatively common in Brazil, Cuba, the West Indies, the Mauritius, and India. The following interesting case occurred in the practice of my friend Mr. Cubitt, of Stroud, to whom I am indebted for the notes, and also for the specimens of urine which I analyzed : " Mrs. S., aged 50, native of Nor- folk, in which county she had always resided, has been married twenty-nine years, and has had five children, the last of whom died in its second year. The youngest now living is 20. The catamenia ceased at 43. Till within the last four years, she has usually enjoyed good health, but at that time had a severe attack of influenza. She continued more or less out of health during the six or nine following months, and soon after this period her urine assumed a milky appearance, which character it has retained up to the present time (November, 1849), except at intervals of unfrequent occurrence and of short duration. The disorder would seem to have been gradually progressive, as the urine, which was at first only turbid and opalescent, has become by degrees more and more opaque, so that when I saw it, the unas- sisted eye could not distinguish between it and milk ; moreover, after the lapse of a few days, a rich kind of cream rises to the surface. It is almost entirely free from any urinous odor, and has a faint, sweetish smell, something resembling that of ripe apples. In the meantime, the general health has been more and more failing, and the digestive functions imperfectly per- formed ; the patient has complained of loss of appetite, pain at the epigastrium after eating, slight headache with nausea, palpi- DIAGNOSIS AND TREATMENT. 71 tations, and other dyspeptic symptoms. She has been losing flesh, suffering from pain in the back and loins without tender- ness, from aching of the limbs, incapability of exertion, and other evidences of general debility; but still, when the duration of the disease is taken into account, the general health may, upon the whole, be said to have suffered little. She states that, throughout the affection, fatigue, whether of mind or body, unusual exertion, excitement, late hours, distress, anxiety, immediately render the milky character of the urine more marked. She has been under the care of several medical men, as well as of some professed quacks (none of whom have ever examined the urine), without benefit ; nevertheless, she has found that, for the time, brandy and isinglass, or compound spirits of lavender, have never failed to clear the urine, but without at all improving the general health. She seems to derive temporary relief from all kinds of stimulants. Occasion- ally and without any apparent cause, the urine resumes its ordinary appearance, but this is of rare occurrence, and its duration never exceeds two or three days. At no one time has she passed milky urine during the day. It is only the urine passed in the morning, after the night's sleep, which has ever presented a milky character. Occasionally, this urine' settles down into a tremulous jelly, which takes the shape of the containing vessel, and more than once this spontaneous coagulation has taken place within the bladder itself \ and in consequence of the impaction of small masses in the urethra, the patient has suffered from temporary retention of urine. She has tried various kinds of diet, but without any visible effect upon the urine. The quan- tity secreted appears normal, and there is no unusual frequency of micturition. The appetite has never been inordinate, or the thirst unnatural ; the bowels are inclined to be costive. There is nothing remarkable about the state of the skin. She has suf- fered a good deal from pain in the back and loins, but there is no tenderness in this locality, and thg uneasiness seems to depend upon exertion, and appears to be connected with general debility. There has never been any dropsy, and she has suffered from no cardiac or pulmonary symptoms, but such as may be 72 URINARY DERANGEMENTS. accounted for by the dyspepsia ; but I have not had an oppor- tunity of examining the chest. She has never had severe head- ache, vertigo, vomiting, or other cerebral symptoms. Has never had rheumatism, fever, or any inflammatory attack, has not been salivated, and has no reason to suppose she has suffered from exposure to cold. At the time when I saw her, the tongue was slightly furred, pulse 70, small and soft, respiration 20, and the skin cool ; but there was a haggard appearance about the countenance, and a dark circle around the eyes, with slight bagging of the skin in this situation." The first specimen of urine was passed in the morning, Analysis I. It was perfectly fluid, and had all the appearance of fresh milk. It had neither a urinous smell nor taste. Upon the ad- dition of an equal volume of ether it became perfectly clear; but when the ether was allowed to evaporate by the application of a gentle heat, the fatty matter could be again diff'used, by agitation, through the urine, which regained its milky appearance, although it appeared rather more transparent than before the addition of the ether, and upon examination by the microscope, instead of the minute granules visible in the first instance, numerous large and well-defined oil globules were observed. Urine. Specific gravity, 1.013. Reaction, neutral. A little of the urine was evaporated to dryness. The dry residue was very greasy to the touch. It was treated with ether ; and upon evaporating the ethereal solution, a considerable quantity of hard and colorless fat was obtained. ANALYSES I 2 Water .- 947-4 978.8 Solid matter 52.6 21.2 Urea 7.73 6.95 Albumen 13.00 Uric acid ... .15 Extractive matter with uric acid 11.66 7.31 Fat insoluble in hot and cold alcohol, but soluble in ether 9-20') Fat insoluble in cold alcohol." 2.70 [• 13.9 .0 Fat soluble in cold alcohol 2.00 I Alkaline sulphates and chlorides 1.65 5.34 Alkaline Phospfiates 1 ^^ f i j.i; Earthy Phosphates /4-^ ( ;,^ DIAGNOSIS AND TREATMENT. 73 The second specimen {Analysts 2) was passed during the same day. Specific gravity, 1. 010. Reaction, very slightly acid. It was almost clear and contained a mere trace of deposit, consist- ing of a little epithelium, with a few cells larger than lymph corpuscles, and a few small cells, probably minute fungi. Not the slightest precipitate was produced by the application of heat, or upon the addition of nitric acid. The presence of so large a proportion of fatty matter, perhaps, . combined with the albumen (13.9 grains) in the first specimen, and its complete absence in the second, which was passed only a few hours afterward, is very interesting, and bears upon the pathology of this strange condition. The fatty matter was care- fully examined for cholesterine, but not a trace could be detected. The characters of this substance are described in " The Micro- scope in Medicine." The proportion of the constituents in 100 grains of the solid matter of these two specimens of urine, is given in the following table. I is the chylous, 2 the clear specimen : — ANALYSES I 2 Solid Matter loo.oo loo.oo Urea 1469 32.78 Albumen 24.71 Extractive matter, uric acid 22.17 3S-'8 Fatty matter '. 26.43 Alkaline sulphates and cTilorides 3.14 25.18 Phosphates 8.86 7.54 The slight deposit-which formed after the chylous urine had been allowed to stand for some time in a conical glass vessel, consisted of a small quantity of vesical epithelium, and some small, slightly granular, circular cells, resembling chyle or lymph corpuscles. No oil globules could be detected upon the surface of the urine or amongst the deposit, and the fatty matter, which was equally diffused throughout, was in a molecular or granular form. By examining the urine with the highest powers, only very minute granules could be detected. These exhibited mole- cular movements. Indeed, it may be said that the microscopical 74 URINARY DERANGEMENTS. characters of this urine closely resembled those of chyle. (loo Urinary Deposits, PL I, Fig. 2.) My analyses conclusively proved that while one specimen of urine contained the large proportion of nearly fourteen grains per 1000 of fatty matter, another taken only a few hours later contained a mere trace. This remarkable fact led me to make the remark, "that the condition does not depend upon any per- manent morbid change in the secreting structure of the kidney, and that the chylous character of the urine is intimately con- nected with the absorption of chyle. The debility and emaciation show that the fatty matter, albumen and other nutritious sub- stances are diverted from their proper course, and removed in the urine, instead of being appropriated to the nutrition of the system. ("Urine, Urinary Deposits and Calculi," published in March, 1861.) In a paper, in the same year, by Dr. Vandyke Carter, concerning a case of dilatation of the cutaneous lym- phatics with discharge of a milky fluid, it was suggested that the admixture of chyle and lymph was due to a direct communica- tion between the cutaneous lymphatic vessels of the scrotum and lower part of the body with the thoracic duct. In the cases adduced by Dr. Carter, chyle escaped from the cutaneous lymphatic vessels. There was evidently an accumulation of chyle which, as the vessels became distended, was occasionally discharged from the cutaneous surface. Dr. Carter remarks: "Had the chylous fluid, which in this case poured out on the cutaneous surface, been turned upon the urinary mucous tract, we should have had all the phenomena of chylous ««W."—"Med.-Chir. Trans.," vol. XLV, 1862, p. 195. As respects another case, to which he refers in his paper, he says, " this (the escape of chyle in the urinary tract) must in reality have occurred." In all these cases there was accumulation in the lymphatics. In the first the chyle was occasionally dis- charged from the cutaneous surface, the urine being unaffected. The opening in the lymphatic vessel, from which the chyle escaped, was situated a few inches below Poupart's ligament, and sometimes a pint could be collected in a day. In the DIAGNOSIS AND TREATMENT. 75 second case there was an external discharge of chyle, and the urine was frequently chylous. The third was a case of chylous urine without any external discharge of chyle. These cases proved the existence of a dilated condition of the lymphatic vessels. If the dilatation extend as high as the lower part of the thoracic duct, the chyle might pass from this tube into the lymphatics through communicating branches. The lymphatic tubes would soon be stretched so as to render the valves inoper- ative. Dr. Buchanan has reported a very interesting case in which a fluid like chyle was discharged from the surface of the thigh.— " Med.-Chir. Trans.," 1862, vol. XLVI. The patient was a woman in humble circumstances, forty-six years of age, pale, but not emaciated. She was weak, in consequence of an excessive discharge, which could not be cured, from the inner and posterior aspect of the left thigh. The fluid which escaped resembled milk. It flowed from a semi-excoriated surface about the size of the palm of the hand. Over this space were numer- ous pearly vesicles, and from the excoriations resulting from the rupture of some of these there was a constant stredm of milky fluid, more copious and more persistent when the patient was in the erect posture and moving about. In the after part of the day, so free was the flow that her "garments were drenched, even through the cloths which were applied to protect them." Five ounces of the fluid were collected in the course of an hour. The affected thigh was much swollen, its girth being nineteen inches, while the opposite limb only measured sixteen inches. The inguinal glands were not enlarged. Variation in the food pro- duced no alteration either in the quantity or quality of the secretion. The patient had had several attacks of phlebitis in the affected limb, which commenced after her second confinement. A few vesicles made their appearance about fifteen years ago. The number of these increased on a subsequent attack. She seems to have had many attacks of inflimmation of the left inguinal region, ushered in by shivering fits. Dr. Buchanan advised the patient to wear an elastic stocking, which relieved her very much, although the discharge recurred whenever the pressure was removed. The discharge resembled chyle. Fibrin 76 URINARY DERANGEMENTS. coagulated from it. Its specific gravity ranged between i.oii andi.015. Bodies like white blood corpuscles were detected upon microscopical examination, and the fluid contained minute particles which exhibited molecular movements and were soluble in ether. These cases, and many more that might be referred to, establish the fact of free communication between the lacteals and lymphatics of the lower part of the abdomen and of the lower extremities. They naturally lead to the adoption of the con- clusion that in cases of chylous urine a direct communication is somehow established between the lacteals and the lymphatic vessels of the urinary apparatus. Another link in the chain of evidence required to show the true nature of these remarkable cases was discovered by Dr. Timothy Lewis, who, in March, 1870, detected small nematoid worms in the urine of a case of chyluria in Calcutta. Dl W. J. Palmer and Dr. Charles found similar entozoa in the urine of other patients. In July, 1872, similar nematoid worms were discovered by Dr. Lewis in the blood from the finger of a Hindoo, and were named by him Filaria Sanguinis hominis. Since this time the filaria has been detected many times, both in the blood and in the urine of many cases of chyluria, by Dr. Lewis, and his observations have been fully confirmed by a great number of observers. These parasites probably accumulate and cause dilatations in the lacteals, and ultimately lead to the establishment of free communications between the vessels in which they collect and the lymphatic channels in the neighborhood. Much further highly interesting information concerning the manner in which the filariae get into the organism has since been obtained. Dr. Manson, of Amoy, proved that a special " Filaria Mosquito " takes up living embryonic filarise with the patient's blood, and that in the body of the mosquito these undergo further change and are transferred to the water of ponds. The embryo Filaria, Dr. Manson shows, undergoesgreat developmental changes in the body of the mosquito, and that " it finally quits this insect as a large and powerful animal equipped for an inde- pendent life. ' ' These creatures being taken with the water find DIAGNOSIS AND TREATMENT. 77 their way into the stomach of man, and probably there undergo further change, and after passing into the ijitestinal canal some make their way into lacteal and lymphatic trunks, and most likely become parent filarise. Many of the above facts have been confirmed by Dr. Lewis and by Sonsino in Egypt (" Medi- cal Times and Gazette," May 13th, 1883, p. 494; also Septem- ber 22d, of the same year, p. 340). Dr. Manson's paper on " The Metamorphosis of Filaria Sanguinis hominis in the Mos- quito" was communicated by Dr. Cobbold to the Linnean Society, and read March 6th, 1884. See Transactions, vol. II, part 10, April, 1884. For drawings of the Filaria Sanguinis hominis, see " The Microscope in Medicine," Fourth Edition, Plates 77, 78, and 86. A very important case of "Filarial haemato-chyluria " was communicated to the Pathological Society in 1882 and pub- lished in the "Transactions" for that year, by Dr. Stephen Mackenzie, in which great dilatation of the iliac lumbar and renal lymphatics was observed, with great changes in the glands, receptaculum chyli and thoracic duct, and calculi in the renal lymphatics of the left side. 0/ the Treatment of Cases of Chylous Urine. — Various plans of treatment have been tried in cases of chylous urine, but without very satisfactory results. Astringents have proved use- ful in many instances ; and in one of Dr. Bence Jones' cases the pressure of a tight belt "relieved the pain, and rendered the urine slightly less chylous." Dr. Prout found that in some of his cases temporary relief resulted from the use of mineral acids and astringents, as alum and acetate of lead. Opium also arrested some of the symptoms for a while. Dr. Bence Jones has tried a variety of remedies, but the greatest advantage seems to have been derived from the use of astringents. Tannic acid, acetate of lead and nitrate of silver were employed. Matico afforded some relief, but the most valuable remedy in Dr. Bence Jones' hands was gallic acid. Its good effects were probably due to its astringent properties, and not to any specific action. The chylous chara'cter of the urine and the albumen disappeared two days after the commencement of the use of this drug; and 78 URINARY DERANGEMENTS. in one case the patient seems to have been cured by its long continued use. (For the results of a daily examination of the urine for some weeks whfle the patient was on gallic acid, see "Phil. Trans., 1850.) In Dr. Priestley's case, the gallic acid caused such nausea that it was considered expedient to give it up. The same remedy was tried by Dr. Goodwin, of Norwich, in a case which came under his care. He says: "Gallic acid appeared to exert great influence in restraining the milky appear- ance of the urine. The patient took it for about nine months in 185 s and 1856 ; and I found his water perfectly normal in color after six months' steady use of it in doses of half a drachm three times a day. He then discontinued its use and went to work. In four or five days the same milky appearance presented itself, and was again removed by taking the gallic acid. He could at any time render the urine nearly normal in appear- ance by taking this drug ; but it was necessary to avoid hard work. He only complained of occasional dimness of sight and deafness ; but it was not easy to make out to what cause these symptoms were due. He left off attending the hospital in Sep- tember last, when my note is as follows : Has not had any gallic acid for three weeks, and the urine is now slightly opaline in appearance. Specific gravity, i.oio; the temperature of the air was about 50°- He passes seven pints and a half daily, on the average. It does not coagulate with heat or nitric acid, or both combined." Dr. Goodwin has not been able to ascertain anything of the further history of this case. In Dr. Waters' case, gallic acid was given in doses commenc- ing at 30 grains a day, gradually increased to 1 35 grains a day, and then gradually reduced. The patient was under treatment less than nine weeks and got quite well. His weight increased from 8 stone 6 lbs., to 10 stone 6 lbs. Four months after his dis- charge from the hospital, he continued in good health. There was no albumen or fatty matter in this patient's urine. The gen- eral debility in these cases will be relieved by iron, tonics and carefully regulated diet. The patient suffering from chylous urine should rest much in the recumbent posture, and should avoid jolting and all movements likely to disturb the circulation. DIAGNOSIS AND TREATMENT. 79 DEPOSITS OF URATES. Urates diffused through the urine which occasion an opales- cent appearance, consist of several different salts of uric acid mixed together. Urates of soda, lime, ammonia and magnesia are the most important. In a few cases the deposit which looks like urate and is often mistaken for it, is really uric acid in a state of extremely minute division. By careful microscopical examination, the little crystals can be demonstrated without difficulty, and if the deposit be left to stand for twenty-four hours, the small crystals will be found to have considerably in- creased in size, and can be easily identified. Although much has been said and written on the subject of deposits of urates, we have still much to learn concerning the conditions which favor the deposition of this salt as well as its exact significance. The occasional precipitation of urates of soda and ammonia, with traces of urate of lime and magnesia, occurs in the urine of almost every person from time to time. Very slight disturbance of the chemistry of the body seems to cause this sediment, which persists for a few days and then ceases. Injudicious living, excess of nitrogenous food, over- fatigue, the influence of cold, a tendency to gout, improper action of the skin, close rooms, stomach disturbance, are a few among the numerous circumstances to which the formation of this urinary deposit has been attributed, but the deposit has occurred often enough in the absence of every one of these supposed causes, and has been absent when these have been present, and in a marked degree. Nevertheless, it must be ad- mitted that these deposits ought not to be very frequently present in the water, and when they occur day after day, means should be taken to assist their removal in a soluble form, and to prevent their formation. In an ordinary cold, in a bilious attack, during indigestion, the deposit is very generally observed. The gene- ral conditions which determine the presence of an increased quantity of urates seem to be the same as those which cause excess of uric acid. There may be a deposit of urates without excess, and there may be excess without any deposit whatever. Deposits of urates are 80 URINARY DERANGEMENTS. very common in many cases of heart disease, emphysema, and chronic bronchitis. It is probable that the passive congestion of the liver and the slow circulation of blood through this organ has much to do with the formation. In cases where there is a gouty tendency for weeks or months, urates may be constantly present. These deposits are almost invariably present in acute febrile conditions ; and an enormous deposit of urates, sometimes red, sometimes pale, marks the occurrence of " resolution " of many acute inflammatory attacks. A "critical deposit of urates" is commonly seen in acute pneumonia, scarlatina, continued fever, rheumatic fever, etc. It need scarcely be said that no special treatment is required to prevent the formation of the deposit in such a case, but it is well to promote its solution, and to favor its elimination. In many cases of acute disease I am in the habit of giving weak solutions of acetates or citrates. In pneu- monia I often give as much as 12 ounces of the liquor ammonia acetatis in the 24 hours. No doubt by this treatment many imperfectly oxidized products, and urates amongst the number, are eliminated. One of my patients, who suffered from acid eructations, and what he called acidity of the stomach, not associated with any. gouty symptoms, passed urine which always exhibited a deposit of urate. An increased quantity of fluid, and a little bicarbonate of potash or soda, or liquor potassae, will generally cause the dis- appearance of these deposits. When the liver is inactive, a small dose of calomel, blue pill, or gray powder, chloride of ammonium, or solution of acetate of ammonia, will set matters to rights. Some people make themselves very nervous about the appearance of this sediment. A little more exercise in the opeii air, moderation in diet, simple food, a little less wine than usual, no beer or porter, and a glass or two of Vichy or potash water with the dinner and the last thing at night, will generally have the desired effect. All sorts of remedies have been devised for the treatment of this condition. Benzoic acid and benzoate of ammonia, among other things, have been given with advan- tage. Sometimes a little more liquid will stop the deposition; DIAGNOSIS AND TREATMENT. 81 alkalies of any kind in small quantity, with linseed tea or barley water, salts of the vegetable acids, a diet largely composed of fruit and vegetables, plenty of milk, are some of the means which are usually effective in stopping, at any rate for a time, the deposition of urates. In many cases it is necessary to see that the bowels are cleared out, and oftentimes the condition which gives rise to the deposit is relieved by remedies which, as I have remarked, act upon the liver. But it is nevertheless certain that mercurial preparations which often afford great relief in these cases, effecting not only the removal of the deposit, but of a number of unpleasant symptoms and discomfort which have, perhaps, long troubled the patient, will actually occasion a deposit of urate, particularly if persisted in day after day for some time. In former days, when mercurials used to be given systematically, urate deposits were constantly noticed, and I think there is no doubt that the means taken for their removal did sometimes cause their appearance and promote their per- sistence. Neither urate nor any other deposit ought to be found in healthy urine, but urate deposit often occurs when the de- parture from the healthy state is not perceptible; and there is no evidence that when it occurs only now and then any harm results. Its frequent occurrence should certainly b^ prevented , because the formation of urinary calculi might be favored by the presence of this deposit; indeed, both uric acid and urates often form minute concretions, which are, in fact, microscopic calculi, and which, being present in the pelvis of the kidney or in the bladder, may increase in size if the state of the urine referred to persist for any considerable time. Often the urate remains suspended in the urine, without form- ing a visible deposit, and produces a decided opalescence. If albumen be present in urine containing urates, the urine will not become clear by heat, or rather, the urine will at first clear, but soon become turbid again, in consequence of the pre- cipitation of the albumen. With a little care, however, in applying heat, the upper stratum of urine in the test-tube may be made hot enough to coagulate the albumen, the middle stratum being cleared by the solution of the urate without the E 82 URINARY DERANGEMENTS. albumen being thrown down, while in the bottom of the tube the deposit remains unchanged. In performing this experiment, the test-tube should be held by the lower part. The urine of a child suffering from scarlatina, with delirium and unconsciousness, contained an abundant deposit of urates. It was acid ; specific gravity, 1.025. ANALYSIS. Water 932.2 Solid matter 67.8 100. Organic matter S9-03 87.07 Fixed salts , , 8.77 12.93 Uric acid 1.19 1.75 In a deposit, which was composed of rounded globules, with small, sharp spicules projecting from them (uric acid), I found the following constituents : Phosphate of lime, urate of soda, and other urates. A considerable quantity of these spherules existed in the urine of a man suffering from pneumonia, and they had the following chemical characters : There was a distinct evidence of the presence of uric acid by the murexide test. The deposit was soluble in boiling potash ; and when, to the alkaline solution, excess of hydrochloric acid was added, well defined crystals of uric acid were formed. Upon exposure to red heat, an odor like that of burnt horn was exhaled ; and, after decar- bonization, a moderate quantity of a white ash remained, which dissolved in acids with effervescence ; and, from the acetic acid solution a precipitate was thrown down, upon the addition of oxalate of ammonia. I conclude, therefore, that urate of lime entered into the formation of these crystals. The quantity of crystals at my disposal was far too small to make a quantitative analysis. In cases where the ordinary remedies fail, a number of others may be tried, which will suggest themselves to the practitioner, if he bears in mind the conditions under which this deposit occurs, and inquires carefully into the general habits of the patient. Many of the salts of vegetable acids do good in cases where urates are deposited day after day ; and many fruits, such DIAGNOSIS AND TREATMENT. 83 as apples,. Strawberries, oranges, lemons, grapes, etc., may be taken. The salts of these vegetable acids become converted into carbonates in the organism, and they may be given in cases in which alkalies derange the action of the stomach. Phos- phate of soda is often prescribed, and benzoic acid has been strongly recommended by Mr. Ure ; but it is of the greatest importance, when these deposits are constant, and especially when associated with rheumatic pains, to pay attention to the action of the skin and bowels. The vapor bath, the hot-air bath and the Turkish bath, are of great service by promoting sweating. The vapor bath is sufficiently potent, and does not produce depression, which sometimes follows the use of the hot bath, especially if it be taken very frequently. DEPOSITS OF URIC ACID. The deposition of urio acid crystals, or of urates in an amor- phous state, or as small spherules, or in all these forms, is not of itself an indication of a morbid condition. Slight change in the acidity of the urine will cause the deposit to form, and though no more may be present than in ordinary health, being in an insoluble form and constituting a deposit visible to the unaided eye, it usually attracts the patient's attention, and if it occurs often, the fact will very probably be brought under the notice of the medical adviser, and the patient will feel anxious to be relieved. This deposition of the slightly soluble uric acid and urates is a fact of real consequence, and if allowed to con- tinue for some time, the result may be the formation of a stone. In the majority of cases, there is no doubt the formation of a cal- culus is preventable. If the attention of the practitioner is directed to the state of the water at a sufficiently early period of the case, he will probably prescribe remedies which will interfere with the formation of the deposit. Many patients suffer from this deposit for years without .even noticing the fact, until, per- haps, one day they are surprised by passing a small stone, or by symptoms which are clearly due to its presence in the bladder. Sometimes small uric acid concretions are produced in im- mense numbers. The urine being secreted in a state favorable 84 URINARY DERANGEMENTS. to the precipitation of uric acid, the presence of a dumb-bell crystal of oxalate of lime, or a few blood corpuscles or particles of epithelium or epithelial debris in the uriniferous tube may- serve as the nucleus of a calculus. Around this particle uric acid is precipitated and is deposited layer by layer until an actual concretion results. This may make its way to the blad- der, where further deposition takes place, until a stone of con- siderable size is formed. In one remarkable case under my care for some time, minute calculi of uric acid were formed in the kidney, literally by the thousand. Hundreds as large as mignon- ette seeds could often be counted in a single specimen of urine. The quantity of uric acid in the urine depends, to a certain extent, on the activity of the skin ; and, as a general rule, when there is profuse cutaneous perspiration, the amount of uric acid in the urine will be found to diminish. If, on the other hand, the function of the skin be in any way impaired, or perspiration be impeded by cold, a considerable increase in the quantity of uric acid sometimes takes place. Marcet found that the amount of uric acid diminished after severe perspiration ; and Fourcroy. noticed more uric acid in the urine of a man in winter than in summer. In this way may be explained the presence of the large quantity of uric acid in the urine of persons affected with acute dropsy, or dropsy after scarlatina, and it seems probable that the frequency with which these deposits are met with in the urine of persons affected with skin diseases (especially eczema and lepra) may be due simply to the impaired function of the skin. After increased muscular exertion, accompanied with im- perfect respiratory action, uric acid occurs in abnormal propor- tion. It is present as a deposit in very many cases of chorea. It should, however, be borne in mind that considerable quanti- ties of uric acid are often dissolved in the urine as a urate at the time it is passed. This may afterwards be precipitated, being separated from its combination with soda (urate of soda) by a process of acid fermentation. The various forms which uric acid assumes in urine may often be traced, by intermediate stages, from one into the other ; but the conditions which determine the changes have not yet been DIAGNOSIS AND TREATMENT. 85 satisfactorily explained. Doubtless the length of time occupied in the formation of the crystal, and the extractive matters present, have much influence in determining its form ; for not unfre- quently one crystal is observed to acquire entirely different char- acters if it be allowed to remain for a longer period immersed in the urine. Some of the commonest forms met with are represented in loo Urinary Deposits, Plates V, VI, VII, Figs. 68 to 96. The dumb-bell form of crystals is occasionally met with in deposits ; but it may often be readily obtained by the addi- tion of acid to urine. These crystals must not be mistaken for dumb-bells of oxalate of lime, from which they may be distin- guished by their large size and darker color, and by their being readily soluble in alkalies. Pure uric acid often crystallizes in micaceous plates. Uric acid deposited in urine can generally be distinguished by its color from other crystalline deposits, although two or three instances have come under my notice in which the crystals were found to be perfectly colorless. In the plates of "Urine, Urinary Deposits- and Calculi," as • many as thirty-six different forms of uric acid are represented, but were the number greatly increased, the practitioner who made frequent examinations of the urine would, from tirrie to time, meet with crystals not exactly resembling any of ray figures. I think, however, that any one familiar with the repre- sentations here given, and with the most common forms as actually seen in the microscope, would be able to recognize without difficulty any forms of uric acid which he is likely to meet with. Uric acid is sometimes deposited very rapidly, when it forms a thin, glistening film, in which no indication of crystalline form can be detected. A film of this kind was brought to me some time since by Dr. Chambers. After the lapse of a day or two, however,, well-marked crystals made their appearance. Some of these films are composed of layers of small crystals, closely matted together. After the lapse of a short time, the larger crystals grow, while the smaller ones disappear ; so that at length a number of large, well-defined crystals are produced. A deposit of uric acid sometimes resembles amorphous urate, and even 86 URINARY DERANGEMENTS. under very high powers of the microscope nothing but minute granules can be detected, even for some hours after the urine has been passed. This deposit is not soluble in boiling water, and in the course of from 24 to 48 hours the granules will be found to have increased considerably in size, while many ex- hibit well-defined crystalline forms. Uric acid exists in the blood, in combination with a base, as an alkaline or earthy urate, which is comparatively soluble. The soluble urate may be decomposed ; i, when it arrives in the uriniferous tubes ; 2, subsequently, when the urine reaches the bladder ; or 3, the acid may not be set free until some time after the urine has been passed. In the first case, the acid may accumulate and block up the uriniferous tubes, or perhaps form a small concretion. I have shown that oxalate of lime usually forms the nucleus of uric acid calculi, which are so common. In the second case, if a small concretion of any kind, as, for example, a few epithelial cells or a dumb-bell crystal of oxalate of lime, exist in the blad- der, uric acid may be deposited around it, and a uric acid cal- culus become rapidly formed. The acid crystallizes sometimes very soon after the urine has been voided, sometimes not for some days afterwards. I have before alluded to the importance of not regarding the deposition of uric acid crystals as in all cases depending upon excess of the acid in the urine. There may be actually less uric acid than is present in health, although it may be deposited entirely in an insoluble form, and being bulky, a very small amount in weight appears as a considerable deposit to the unaided eye. Uric acid is more commonly met with in summer than in cold weather. In chronic diseases of the respiratory organs, we often meet with uric acid and urates in the urine. It is common in emphysema of the lungs and in chronic bronchitis. In pneu- monia and rheumatic fever it is often found. It is seldom absent from the urine in chorea, and very often exists in various forms of skin disease and in cases of acute inflammation of the kidney. Some children are very liable to suffer from these deposits, and their appearance is accompanied by frequent DIAGNOSIS AND TREATMENT. 87 desire to pass urine. Uric acid and urates will be found in some children's urine for weeks at a time. Generally there is dis- turbed health, and there are indications for the employment of small doses of gray powder or calomel, which treatment often cures the patient in two or three days. The presence of uric acid in the water is not unfrequently associated with pain in the centre of the back, often considered to be "rheumatic" in its nature, but probably more often due to a vitiated state of blood acting upon the nerves distributed to the lumbar muscles, or upon the centres through which these pass to their peripheral distribution. A dose of alkali will often relieve this pain in the course of a few hours. A gouty tendency is often accompanied by eczema, lasting, perhaps, for many years, and in such conditions uric acid deposits are common. One patient who sufiFered in this way could not be persuaded to give up wine and beer, although it is certain both the eczema and the urinary deposit were aggra- vated thereby, and almost as certain that the patient might have been cured if he had given up these beverages. Those who will indulge in good living in spite of these continual warnings and disturbances of the health, must adopt the principle of free and frequent purgatives, or be content to suffer from serious disease of liver or kidneys, or both, as age advances. When uric acid gravel is passed in considerable quantity, its passage down the ureter sometimes causes pain like that of cal- culus. A young woman only 22 suffered from attacks of gravel every three weeks for two or three years. There was also irrita- bility of the bladder and frequent micturition at night. Such cases are almost invariably cured by alkalies, purgatives, and a carefully regulated diet, but the treatment has to be continued for three months or longer. A lady of 55, who had had frequent attacks during ten years, with bearing down pain and ter- rible irritability of the bladder, interfering with sleep and preventing her from taking exercise, was greatly relieved by taking iron and henbane for some time. Not only was the irritability of the bladder relieved, but the stream became larger, and the organ emptied itself more thoroughly — once in two or 88 URINARY DERANGEMENTS. three hours instead of every half hour ; and, in fact, this patient was on the high road to recovery four or five months after the commencement of the treatment. In this case alkalies, carried to any great extent, would have done harm instead of good. I have seen several instances of irritable bladder with secretion of quantities of muco-pus which have resulted from the persistent use of alkalies by the patients themselves. The most severe sensation of scalding, as the urine passes along the urethra, with or without pain, or a feeling of soreness at the tip of the penis, is sometimes associated with the secretion of highly acid urine, with an abundant deposit of urates or uric acid, or both, and rich in urea. Such cases are cured in a very short time by diluents, especially linseed tea, with a dose of citrate of potash or the effervescing citrate of magnesia every two or three hours, and continued for a few days. I generally also give a pill containing half a grain of gray powder or calo- mel, at bedtime, for two or three nights running. Patients who suffer in this way should live carefully, taking little or no meat and no stimulants — at any rate while the symptoms continue. In the case of a man of 41 years of age, uric acid (gravel) had been constantly present in the urine for fifteen years, during five of which he had passed from time to time numerous small calculi of uric acid. The patient's liver was often inactive, but upon the whole he had good health. When 64 he had a very bad attack of shingles. He quite recovered his health at 66, and no longer passed gravel or calculi. This patient's mother had suffered from gravel, and a brother had died of acute rheuma- tism. It is curious in how many cases uric acid is passed for several years, and perhaps numerous uric acid stones formed, over a considerable period, when an attack of fever or some other illness occurs, and the "constitution" seems to undergo a change. The general health is altered. . Numerous slight ailments disappear and never recur, and the patient is compen- sated for much wretchedness, caused by bad health and constant discomfort, and perhaps frequent attacks of severe pain in early life, by a glorious old age of sustained health and strength, lasting possibly far beyond the ordinary period of life. DIAGNOSIS AND TREATMENT. 8i) In one case in which the urine contained large excess of urea as well as almost constant deposit of uric acid, I found that from the age of 20 to 41 the uric acid had been constantly present in the urine in the form of crystals. The man was engaged in out-door work. His uncle had had stone in the bladder, and his father had suffered much from sciatica. Uric acid is not generally present in diabetic urine, but it is sometimes noticed, and in considerable quantity. In a child aged 8, who was in a diabetic condition, an abundant deposit of uric acid occurred and lasted for a considerable time. This deposit seemed to be consequent upon a course of mineral acids. Some authorities have affirmed that diabetic urine never contains uric acid, but such a statement is certainly erroneous. In this country, at least, it is no uncommon thing to find uric acid in the urine of diabetics. Occasionally we meet with patients who appear generally in good health, but who complain of getting thin, although they live well, in many instances perhaps too well, and suffer from an almost constant deposition of uric acid. It is very difficult to ex- plain this symptom in every case in which it occurs ; but I feel sure that many of these persons constantly overtax their digest- ive organs, and are in the habit of consuming far more than their systems require. They think that the only way to gain flesh is to eat a large quantity of food ; and, in consequence of too much work being thrown upon their digestive organs, es- pecially the liver, assimilation is not properly carried on, and a quantity of material is formed which is unfitted for the wants of the organism, and much of this is, perhaps, got rid of in the state of urea, uric acid, and urates, and the processes concerned in the production of these compounds may overtax the power of certain organs. By cutting off a certain part of the supply, their anxiety as to the gravel is soon relieved, and at the same time, to their surprise, they gain strength and increase in weight. The value of benzoic acid and benzoate of ammonia in the treatment of the gouty state has long been known, and for more than thirty years I have been in the habit of prescribing it in cases of uric acid and urate deposit, in various conditions which E* 90 URINARY DERANGEMENTS. seem to be due to a gouty disposition or tendency,, and in many forms of hepatic derangement. This method of treatment was employed for many years by Dr. Todd, and I think before him by Mr. Ure, one of the surgeons of St. Mary's Hospital. Ben- zoic acid acts upon glycocine in the liver, to form hippuric acid, and it is probably to this chemical action that the benefit result- ing from its use should be attributed. The reader will gain important information on this matter, as well as concerning the probable action of many chemical remedies in gout and allied affections, from Professor Latham's work "On the Formation of Uric Acid in Animals : its relation to Gout and Gravel." Cam- bridge: Deighton Bell. 1884. I have seen instances of uric acid deposits occurring in adults, over which ordinary remedies appeared to exert little influence. The urine of a patient suffering from emphysema of the lungs always contained a large quantity ; and it appeared while she was taking considerable doses of alkalies, and also when she was put upon mineral acids. The occasional deposition of uric acid crystals from the urine requires no medical treatment, or at most a dose of bicarbonate of potash after meals or the last thing at night. In some cases in which these deposits are frequent, and in people of a gouty tendency, small doses of hydrochloric acid with pepsin before meals, and twenty grains of bicarbonate of potash in half a tumbler of water after meals, is a plan which answers admirably, and often cures the patient after other methods have completely failed. Of all the remedies employed for carrying off uric acid from the system liquor potassae is, in my opinion, the most efficacious. The objections sometimes urged against the use of liquor potassae are not established by the facts of experience, unless it is per- sisted in for too long a time, or given in cases when its use is contraindicated. Where an unusual proportion of uric acid is formed, as much as a drachm of liquor potassae has been taken daily for many months without any ill effects, though, as a gen- eral rule, I should not advise the drug to be given in more than half the proportion, or for more than a fortnight at a time DIAGNOSIS AND TREATMENT. 91 without an interval during which it is withheld altogether. A gentleman of 60, who had been passing small uric acid concre- tions from the kidney, sometimes to the number of 100 or more in a single week, was ordered to take liquor potassae. After a time, the stones ceased to appear. But, without the knowledge of his medical adviser, this gentleman continued to take liquor potassae daily for upwards of twelve months, in quantities of from twenty to sixty drops daily. The acid reaction of the urine continued during the whole time. Such a case conclusively proves what a large amount of alkali may be taken for a con- siderable time without detriment — indeed, with great advantage to the patient. This patient was muscularly weak, but he found that he felt better and stronger when taking liquor potassae than he had done for many years before, while his lumbar pain ceased to trouble him, and the calculi only made their appearance very occasionally. However, as I have already remarked, it is de- sirable not to give liquor potassae for longer than a fortnight at a tirne. After an interval of a week or two, the remedy may be resumed for a like period. In prescribing acids and alkalies, and, indeed, all other remedies, the practitioner should feel sure that the patient understands how long he is to continue the drug. It is very important we should know how far the frequent ad- ministration of potent remedies may be pushed with advantage, and without being detrimental to the patient. Unfortunately information of this kind is for the most part in the heads of practitioners, and so far little exact knowledge on the matter has found its way into treatises on medicine and therapeutics. We are instructed as to the doses in which a drug should be pre- scribed, but it is seldom we meet with exact directions which we can apply to the management of a given case. Much is still left to the experience, judgment and medical sagacity of the indi- vidual practitioner. Unfortunately, it is almost impossible to record in a form that would be practically helpful the results of individual observation and experience by the bedside, and, indeed, when attempts are made to do this, except in the most broad and general way, it is not possible to avoid prolixity and detail which would be tedious to read, and would practically be 92 URINARY DERANGEMENTS. of little assistance even to the few who took the trouble to wade through what was written. This is no doubt why, as students and practitioners often complain, many practical questions of the simplest and broadest character remain almost unanswered, not only in our text-books, but in our books of reference, en- cyclopsedias, and dictionaries. Nay, still there remains much uncertainty concerning broad, principles upon which the treat- ment of well-known and common forms of disease should be conducted. We still have to appeal to the judgment of those who have had greater experience than ourselves, or to trust to our own. The actual practice of medicine, the treatment of actual cases of illness, changes so much from decade to decade, that it is not to be wondered at that our so-called "principles " are often called in question, and are regarded as prejudices and fads of advisers full of confidence in themselves, more positive than thoughtful — "principles" founded upon egotistic imagina- tion, upon dictum, upon fashion, rather than upon fact and ob- servation. Nevertheless, there are principles by which we may be guided, and which rest upon a very firm and solid basis of fact. XANTHINE. Uric or Xanthic Oxide -(CioH^NiO) is a substance closely resembling uric acid in many of its characters. It is very rarely met with in urine. It was described first by Marcet, and has since been detected in the blood, and also in the spleen, muscles, liver and brain. It is rarely met with in the crystalline form, but Bence Jones reports the case of a boy, aged gyi years, suf- fering from a feverish attack, in whose urine xanthine crystallized in lozenge-shaped crystals, which were first mistaken for uric acid. ("Journal of the Chemical Society," 1862.) The crys- tals were dissolved when the urine was boiled, and were found to be soluble in water, nitric and hydrochloric acids, and in all alkalies. Douglas Maclagan also reports a case in which xanthine occurred in a urinary deposit. The synthesis of xanthine has been effected by Gautier, from hydrocyanic acid, and no doubt ere long uric acid will be obtained from xanthine. Xanthine is probably a common constituent of urine, but exists in very small DIAGNOSIS AND TREATMENT. 93 quantity. According to Dr. John Davy, it is the constituent of the urine of spiders and scorpions. A rare form of calculus is entirely composed of it. Dr. G. Durr, after bathing in natural sulphuretted waters, found xanthine in his urine, and also in the urine of a patient who had had strong sulphur ointment rubbed into his skin, but not after taking milk of sulphur into his stomach. DEPOSITS OF OXALATE OF LIME. Oxalate of lime was first shown to be a common urinary deposit by Dr. Golding Bird. It is seldom deposited in quantity sufficient to be recognized by the naked eye, or to be tested chemically. Oxalate of lime crystallizes in well-defined octa- hedra — easily seen, if very minute, under a quarter of an inch object-glass. There is still much difference of opinion among practitioners as to the clinical importance of oxalate of lime. There can be no doubt that, in many instances, the crystals form after the urine has left the bladder. The conclusions of Dr. Owen Rees, and the experiments of Dr. Aldridge, indicate that the oxalic acid is produced by decomposition of the urates after the urine has been secreted. Oxalate is often found in the urine of gouty cases, and it is certainly very commonly detected among urate deposits. Although there are many abnormal conditions of the system, in which both oxalates and urates are very common, both deposits may be present, and, indeed, very commonly are present in the urine of healthy persons. Hence, it is obvious ' that such deposits do not necessarily establish the existence of any particular diathesis. What is termed the "oxalic diathesis, ^^ seems to have derived its name from the fact that oxalate of lime is present in the urine ; but this is not the most important part of the case, and the practitioner cannot make a greater mistake than to direct his attention to the urinary deposit alone, or to consider this as a special indication for treatment. In the same case, at one period we find uric acid and urates; after a time, these mixed with oxalates ; and lastly, oxalate alone, and there will probably be found in connection with the symptoms, clinical facts of far greater consequence, especially as regards the ques- 94 URINARY DERANGEMENTS. tion of treatment, than the presence of oxalate of lime in the patient's urine. Wohler and Frerichs injected uric acid into the blood of a dog, and found oxalate of lime in the urine. Oxalate of lime passes through the alimentary canal unchanged ; but oxalic acid is, in part, excreted in the urine, while part is decomposed in the system. Buchheim and Piotrowsky have shown that small re- peated doses of oxalic acid (fifteen grains every hour for six hours) are not poisonous. I should, however, strongly dissuade any one' from repeating such an experiment. Not more than 12 per cent, of the oxalic acid taken by the mouth appears in the urine. I have detected oxalate of lime in the urine of several persons who have attempted to poison themselves with oxalic acid. In "loo^Urinary Deposits," PI. VII, Fig. 90, are some very marked six-sided crystals of oxalate of lime, obtained from the urine of a patient who had taken a large quantity of oxalic acid. They were insoluble in water, and were not dissolved by potash or acetic acid. The refraction of the crystals corres- ponded with that of oxalate. Oxalate of lime is, however, not always formed after the urine has been passed, indeed, it is often present while the urine remains in the bladder. Besides being found in octahedra in the urinary organs, or after the urine has left the bladder, oxalate of lime crystallizes in a different form altogether. It crystallizes in mucus in the form of spherules or "dumb-bells," and these, as I have shown, are often deposited in the tubes of the kidney during life. The crystal must, therefore, have been formed at the time of the separation of the urine from the blood, if, indeed, the salt did not exist in solution in the blood itself. The spheri- cal and dumb-bell crystals, I have proved, often constitute the nucleus of uric acid and other calculi, and around it the other constituents are deposited in successive layers. It appears, then, that oxalate of lime may be excreted in the urine when oxalic acid or oxalates are taken in the food. It may be formed in the organism itself. It may be produced by the decomposition of uric acid and urates after the urine has left the bladder, and it may be deposited in the uriniferous tubes. DIAGNOSIS AND TREATMENT. 95 It must be borne in mind that oxalate of lime is often dis- covered in almost opposite conditions. Thus it is sometimes present in poor, broken-down subjects, and it is found in the urine of well-to-do country gentlemen. It will appear when we live too well and take too little exercise, and will be found when we subject ourselves to very low diet. It is common in chronic pulmonary affections, as bronchitis, and it is often observed in old cases of emphysema. It is common enough in dyspeptics, and is usually met with in cases of jaundice. In various forms of general debility, in cases of over-fatigue, and in men who have overworked their minds, it is, perhaps, the commonest of urinary deposits. Lastly, as I have already remarked, it is often found, and sometimes in very large quantity, in the urine of men who appear to be in all other respects in perfect health. Anything which improves the general health, and promotes oxidation, will diminish the tendency to the deposition of this substance. Cold bathing, exercise, attention to diet, and the mineral acids, bitter tonics, and iron, are usually prescribed with advantage. I feel that by many writers too much has been made of the indications for treatment afforded by urinary deposits. Many cases of what has been called the "oxalic acid diathesis," because the urine contains octahedra of oxalate of lime, may, in truth, be treated by the practitioner just as suc- cessfully, without taking into consideration the presence of the oxalate, as by laying stress upon this fact. The patient will, probably, in either case, be treated with tonic infusions and dilute acids (nitric, hydrochloric, or phosphoric), with a gentle purgative (mercurial in some cases), now and then. Pepsine may also be given. The diet should be simple, and small quantities of whisky or brandy in Seltzer or Vichy water may, in some cases, do good. Some patients must have change of air, and a sea voyage is often the best, as it is the cheapest, way of obtaining rest and fresh air, and change of scene. Although the octahedra of oxalate of lime afford no special indication for treatment, the dumb-bells, on the other hand, unquestionably do so ; for these bodies may form the nuclei of renal calculi. These dumb-bells of oxalate of lime have, in fact, 96 URINARY DERANGEMENTS. a special significance, and, as I have pointed out, ought to be regarded as minute calculi. Deposited in the uriniferous tubes, they increase in size by the deposition of more oxalate on the surface, and often collect together to form small oval bodies around which, and between the individual dumb-bells, more oxalate is deposited. Thus is formed the nucleus of what may eventually become a calculus of considerable size. In cases, therefore, in which they are found, it is well to promote their expulsion, and endeavor to prevent the formation of more. Dumb-bell and oval crystals of oxalate of lime are represented in " loo Urinary Deposits," Pis. VII, VIII, Figs. 95, 96, 97, 98, III. These dumb bells ought to be expelled from the urini- ferous tubes as soon as possible after they are formed. Diluents usually effect this purpose. Two pints or more of linseed tea or barley water, flavored with lemon juice ; or mere water, or soda, potash, Vichy, or German Seltzer water may be given instead. These dumb-bell crystals sometimes give rise to the same symp- toms in mitigated form as actual renal calculi. Lumbar pain on one side, lasting for years, with occasional retraction of the corresponding testicle, and pus in the water, are not unfre- quently met with in cases in which dumb-bells are very often found in the urine. In the case of a man of 65, irritable bladder with the formation of minute renal calculi, was succeeded after ten years by the frequent appearance of oxalate of lime and uric acid in the urine. Much has been said and written concerning the pathological importance and clinical significance of deposits of octahedra of oxalate of lime, and many theories have been propounded, some of which are scarcely warranted by the facts of the case. The following points may, however, I think, be considered proved : — 1. That oxalate of lime crystals have been found in the urine of persons who are in excellent health, and whose constitution is sound, and at every period of life, even before birth. 2. That there are certain persons who are far more subject to these deposits than the majority, and that in these oxalate- producing individuals the quantity varies much from day to day, and is greatly influenced by diet, exercise, and a DIAGNOSIS AND TREATMENT. 97 number of different circumstances within the range of the healthy state. 3. That in many forms of functional and organic disease, as has been mentioned, deposits of oxalate are often formed in con- siderable quantity. The patient who habitually forms considerable quantities of oxalate of lime, and suffers from the malaise or gouty symptoms which not un frequently accompany this deposit, should be recommended change of air. When it is feasible, a good long sea voyage, say to New Zealand, is often of the greatest service. In this way, the health is restored, and the general condition of the system is often completely changed. A "bilious" person is sometimes cured for life. Residence in the South of Europe for a winter or two has often the effect of re-establishing the health in middle life, after derangement and many slight ail- ments have troubled the patient for years. But where this expensive but pleasant advice cannot be followed, we must needs do our utmost to relieve the patient in the condition under which he is obliged to live, though unfavorable forgetting rid of the deposit. Change from a diet rich in animal food to one consisting principally of vegetable food, fruit, milk, and farinaceous puddings, and an occasional small dose of mercury, twice a week, will sometimes effect a wonderful change in two or three months, so that the patient himself will be as astonished as pleased at the alteration in his health. Not only does he feel better, but he is able to do more, and his temper has improved for the better, to the advantage of all his friends as well as of himself. He is no longer despondent or irritable, and far from feeling the greatest difficulty in controlling his irritability, he discovers, to his satisfaction, that he has no distressing ill-temper to control. A little really hard work in the cases of many who never use their muscles will sometimes effect a cure. At first the patient will feel worse, but as his muscles get into order, the improvement in his health will be obvious enough. Carpenter- ing, gardening, or other work where a little labor, but not severe effort much taxing the strength, is required ; games of various kinds, when so great a luxury of labor can be indulged in, 98 URINARY DERANGEMENTS. cricket, rowing in moderation, or lawn tennis, or tricycling, if not carried to an extreme, will be found beneficial. I have no doubt that few of our modern exercises are more advantageous to men of middle age than tricycling, which with due care may be indulged in almost to advanced life. The practitioner must, however, be careful in recommending the tricycle. Before he does so, he must satisfy himself that his patient has no disease of the kidneys or liver, and that the heart and lungs are in good order. It is in the case of well-to-do men under 40, that the " labor cure" for oxalate of lime deposits, biliousness, constipa- tion, and other slight ailments, is so effective. There is, then, in my opinion, no doubt that the general view entertained by the practitioners of the last generation, that fre- quent deposit of oxalate of lime was associated with a general condition of the system sometimes called bilious, sometimes nervous or irritable, is correct, and it is certain that many of these cases, particularly when there is decided lowness and depression of spirits, are relieved by those medicines which relieve a congested state of the capillaries and retarded circula- tion in the- liver, stomach and intestinal canal. Small doses of calomel or gray powder every other day, or oftener, for a week, will often relieve patients who have "tried everything," and have even subjected themselves to a long course of waters, and a diet and mode of life which is more like a mild form of penal servitude than is a regimen which a sensible person having a knowledge of the structure and functions of the tissues and organs of his body would be inclined to voluntarily submit himself to. Even half a grain of calomel or gray powder will often relieve a state of system which has caused its owner the greatest discomfort, if not actual misery, it may be, for many weeks. CYSTINE. Cystine (CeHsNSaOt) occurs occasionally as a crystalline sediment in urine, and also enters into the composition of a rare form of calculus, which has been termed the cystine calculus. Cystine was formerly spoken of under the name of cystic oxide, and the same term was applied to the calculus. DIAGNOSIS AND TREATMENT. 99 From the glistening of the crystals a very small quantity of cystine makes a great show when diffused through a consider- able bulk of urine. Indeed, what would be described as an abundant deposit, may not amount to half a grain in a thousand grains of urine. Cystine forms a whitish deposit, which is found, upon microscopical examination, to consist of character- istic six-sided plates, " loo Urinary Deposits," PI. VII, Figs. 92, 93, 94, which may be distinguished from uric acid crystals of the same form by the solvent action of ammonia upon the deposit. Upon the spontaneous evaporation of this amraoni- acal solution, the cystine is again deposited unchanged in its hexagonal crystals. Uric acid would have been converted into urate of ammonia, which, on evaporation, would have remained as an amorphous residue. Ammonia, it appears, merely dis- solves the cystine, and does not enter into combination with it. Cystine is insoluble in boiling water, in strong acetic acid, and also in very weak hydrochloric acid ; but it is readily dissolved by oxalic, and by the strong mineral acids. The most remark- able property of this substance is, that it contains as much as 26 per cent, of sulphur — -a character in which it resembles tau- rine. Potash, like ammonia, readily dissolves cystine. The presence of sulphur in cystine may be proved by heating the substance in an alkaline solution of oxide of lead, when a black precipitate of sulphuret of lead occurs. This test cannot be regarded as characteristic of cystine, because all animal matters containing sulphur exhibit a similar reaction. Urine containing cystine is said to smell very much like sweet briar. Undoubtedl y it has a sweet smell, but I caanot say that to me the smell has any resemblance to sweet briar. Dr. Golding Bird observed that calculi composed of this sub- stance undergo a change of color by long keeping. From pale yellow or fawn colored, they assumed a greenish-gray, and some- times a fine greenish-blue tint. Crystals of cystine may be ob- tained from a calculus by dissolving a portion in a solution of potash, and adding excess of acetic acid to the alkaline solu- tion, when the cystine will be deposited, in its well-marked six- sided plates. Virchow and Cloatta have proved that cystin e is 100 URINARY DERANGEMENTS. sometimes found in the liver, while taurine as well as cystine have been detected in the urine. The proportion of cystine in urine is really very small, sel- dom amounting to more than two or three grains in looo of urine, although it occupies a considerable bulk; so that the opinion commonly entertained with reference to cystine being a compound in which the sulphur is removed from the organism in an unoxidized state, in consequence of the oxidizing pro- cesses being in a low condition, will not explain its formation, for in a case I carefully examined, it was found that a much larger quantity of sulphur passed off as sulphuric acid than in a state of combination in the form of cystine. Cystine has been met with in several different conditions of the system, but in most of the recorded cases the patients have been in a low, weak state of health. Little is known with reference to the origin of this substance. It has been supposed to result from hepatic derangement, and Scherer and Virchow have detected cystine in the liver in disease. It is curious that cystine deposits occur in families, and even appear to be hereditary. Dr. Geld- ing Bird speaks of an instance of its occurrence in three suc- cessive generations. Of the conditions of system which give rise to the elimination of this substance by the kidneys, little is at present known. In the majority of cases in which it has been found, the general health and nutrition of the patient have been bad. It is one of the most persistent of urinary deposits. After it has once appeared it may be produced, and in consider- able quantity, over a period of twenty years or more, or its pro- duction may only cease with life. It is among the least common of urinary deposits, and usually its presence is not associated with any symptoms more serious or definite than malaise, a feel- ing of weakness, fatigue or exhaustion, with depressed or very low spirits. One of the most remarkable cases of cystine deposit which I ever saw came under my notice many years ago, and has been under observation for fifteen years or more. During part of this time I saw the patient very frequently, and made many examina- tions of the urine, of the deposit, and of the calculi, which he DIAGNOSIS AND TREATMENT. 101 passed in considerable numbers. This case and the following were reported in the Lancet, of August 30th, 1884. The patient (E. H. O.) was a fairly healthy-looking man, of 30, 5 ft. sj^ in. in height, weighing 9 st. 6 lbs., who was by trade a packer, an occupation involving pretty hard work and long hours. For four years before he came to me he had suffered more or less from lumbar pam and discomfort about the thighs, especially on exertion, and he often felt weak and low. He, sometimes had to walk with a stick, and had had to give up work now and then for a week or two at a time. About two years after the first commencement of the symptoms he suffered from a fixed pain in the left groin, and soon afterward several stones were passed, sometimes to the number of twelve or more at once. One of the calculi, however, was so large that it remained in the bladder, and Mr. Coulson had to crush it. I put the patient on carbonate of ammonia, and told him to increase the dose gradually until it amounted to about fifty grains a day. He found the remedy agree with him so well that he soon exceeded this quantity, and for twelve months he took as much as fifty-five grains daily on the average, on some days con- suming iriuch more, on others considerably less, than this amount. In this time he did not pass as many calculi as before he had passed in a single month, and his weight increased to 9 st. 11 lbs. In the next year he took about thirty-five grains of carbonate of ammonia per diem, and in the following only an average of about twenty grains a day. This patient's family history was not very satisfactory. His mother died at the age of 52, of phthisis, and two sisters died under the age of 25, of the same disease. He did not look a strong man, and the muscles of his arms and legs were below the average size and prominence. When a young man he used to take violent exercise, and rowed in ra:ces. The quantity of urine passed was generally about the average, and never exceeded three pints. Every specimen that passed during a period extending over at least five years, he feels sure contained cystine. Afterward the cystine was very fre- quently detected in considerable quantity. The crystals could be seen in the urine immediately after it was passed, as small, 102 URINARY DERANGEMENTS. sparkling grains. The ammonia not only diminished the form- ation of the cystine, but the patient foimd that while he was taking it his bowels acted freely, and he never required an aperient, although previously he had been much troubled by ob- stinate constipation. When the ammonia was not taken he says he did not feel as well as when he was taking it. He found no inconvenience from taking these large doses of carbonate of ammonia, and soon became so accustomed to the taste that he did not object to it in the least. I have seen this patient at in- tervals during the last few years, and although cystine in small quantities was generally present in the urine, it gave him no inconvenience, and no calculi seem to have been formed for the last three or four years. In this case, then, cystine has been found in large or small quantity during a period of at least eighteen years, and for the first five or six years of this time hundreds of cystine calculi were passed, the largest being about three-eighths of an inch in diameter, the smallest not larger than the head of a very small pin. The cystine crystals formed a visible whitish deposit, which varied much in quantity, even from day to day, but sometimes formed a considerable sediment. Another case was that of a gentleman, about 50, who had suffered from abundant cystine deposit for two years before I saw him, and had passed seven or eight renal calculi, some of them beautifully crystalline, and entirely composed of cystine. This patient took fifty grains of carbonate of ammonia dissolved in two ounces of distilled water three times a day, after a meal, for upward of two years, without any inconvenience, and during this time he had not even once required an aperient. If he gave up the ammonia he did not feel "up to the mark." As the amount of ammonia seemed very large in proportion to the water in which it was dissolved, I had twenty-five grains of Howard's volcanic carbonate of ammonia dissolved in an ounce of distilled water, and found that, although it tasted very strongly, it was not caustic. On inquiry, Mr. D informed me it was only gradually that he reached this degree of concentration, but that he experienced no difficulty in taking it. He took it imme- diately after a meal — " on an empty stomach it produced nausea. ' ' DIAGNOSIS AND TREATMENT. 103 For three years, with scarcely an intermission, 1050 grains of carbonate of ammonia were taken per week. The cystine deposit ceased during the last year of taking the medicine, and three years have now passed without its recurrence. I think, therefore, we may regard this case as really "cured" by the large doses of carbonate of ammonia. It is to be feared that the tendency in the present day is rather to prescribe new remedies which are being continually intro- duced, than to select old ones such as are known to have valuable properties, and which have been proved by long experience to be really beneficial in certain pathological conditions. Far from condemning the new because .they are new, like all who know the extreme value of such things as salicylate of soda and bromide of potassium, I am most anxious to acknowledge my gratitude to those who devote themselves to the study and the discovery of the healing properties of every substance that can possibly be of use in treatment. But, while I am desirous not to say anything that could suggest to the reader that I am condemning the new things, I would impress upon the rising generation of practitioners the importance of being careful not to neglect the old. One cannot but desire that a drug like am- monia, so valuable in many forms of disease and departures from the healthy state, should not be forgotten or laid aside.* The cases I have adduced are sufficient to show that ammonia * In our endeavors to help those who have acquired the vicious habit of consuming too much alcohol, ammonia is of great use, but it ought to be given in doses far larger than those in which it is usually prescribed. One of my patients assured me that he found ammonia very beneficial ; that it relieved him of the feeling of tiredness from which he frequently suffered, and enabled him to perform hard work without getting exhausted. Not only have I found great benefit result from giving ammonia in considerable doses in many low forms of illness, but I have experienced its good effects by taking it myself. It acts very differently from any form of alcohol, although its effect upon the patient, as judged from his own sensations, appears to be somewhat similar. Though no feeling of hilarity seems to be induced by it, the lowness and de- pression of spirits and the tired feeling affecting the muscles, or rather the nerves and nerve centres by which they are supplied, are often removed in the course of half an hour or less, by a dose of ammonia. 101 URINARY DERANGEMENTS. may be given in much larger doses than are generally prescribed, and that it need not be diluted to the degree generally supposed to be necessary. We used to be taught that five grains of car- bonate of ammonia should be dissolved in at least an ounce of water, but as one of my patients took as much as twenty-five grains per ounce, and continued this three times a day for three years, we may feel satisfied that a solution of from ten to fifteen grains per ounce may be taken without difficulty, and I have prescribed this as often as once an hour in cases where the heart's action was very feeble and a decided stimulant was evidently necessary. The public have discovesed the value of sal volatile in cases of cold-catching and many minor ailments, but ammonia, like many other substances of real value in the treatment of many departures from the healthy state, has lately been somewhat neglected, and is, like some other valuable remedies, in danger of being forgotten amid the multitude of new preparations which are thrust upon our notice ; and it is therefore desirable that attention should be directed to its usefulness as well as to the value of many other drugs which have been of real service to past generations of patients. DEPOSITS OF EARTHY PHOSPHATES. The earthy phosphates soluble in acids, but insoluble in water and alkaline solutions, which are most commonly met with as deposits in urine, are the ordinary triple or ammoniaco-magnesian phosphate, or the phosphate of ammonia and magnesia ; and-phos- phate of lime. The triple phosphate crystallizes in two or three different forms ("loo Urinary Deposits, PI. V, Figs. 56, 57, 58, 64, 66 ; PI. VII, Fig. 91). When clear, and unmixed with other deposits, the crystals form beautiful microscopic objects. The most common form is that of the triangular prism, with obliquely truncated ends ; but these are sometimes complicated by the beveling of the terminal edges and angles. Not unfrequently the crystal is found much reduced in length, and the truncated extremities become so closely approximated as to give the ap- pearance of a square, the opposite angles of which are connected DIAGNOSIS AND TREATMENT. 105 by Straight lines; and thus a crystal very closely resembling that of an octahedron of oxalate of lime is produced. The urine which contains phosphatic deposits is generally neutral or alkaline, but crystals of triple phosphate are now and then found in add urine. If ammonia be added to fresh urine, or to a solution of phos- phate of soda and sulphate of magnesia, ammoniaco-magnesian pjjosphate is precipitated in the form of beautiful stellate crystals (" loo Urinary Deposits," PI. V, Fig. 58), and phosphate of lime is thrown down in the form of a fine granular amorphous precipi- tate. Ammoniaco-magnesian phosphate is slightly soluble in pure water, particularly if it contain carbonic acid. It is said to be insoluble in solutions of ammoniaeal salts, but this state- ment is not, I think, accurate. Phosphate of lime occurs in urine in a crystalline form, as well as in amorphous granujes. It is usually associated with the triple salt-— always, if deposited from alkaline urine. In cases of disease of the bladder, in which the urea becomes very rapidly decomposed into carbonate of ammonia, much amorphous phosphate of lime and many crystals of triple phosphate are precipitated. Crystals of phos- phate of lime are represented in "100 Urinary Deposits," PI. V, Figs. 59, 60. Phosphate of lime is soluble in albumen ; indeed, it is by reason of its solubility in this substance that the phosphate of lime formed by the action of phosphoric acid on the egg-shell becomes applied to the formation of the osseous system of the embryo chick. Mucus also is a solvent of this salt, and from the mucus of the gall-bladdera considerable quantity is deposited as decomposition proceeds. The conditions under which an excess of alkaline phosphates occurs, have already been considered on p. 64. The remarks made upon the question of "excess'' of a constituent and its precipitation as a visible deposit, must be borne in mind. In the great majority of cases in which there is a deposit of earthy phosphates, there is no "excess'' at all, and the deposition depends upon the urine being neutral or less acid than usual, or upon the decomposition of the urea, and consequently, the F 106 URINAKY DERANGEMENTS. formation of carbonate of ammonia after the urine has left the bladder. It is common enough to find triple phosphate in the urine in cases of dyspepsia, perhaps from the secretion of too large a quantity of highly acid gastric juice or from the formation of other acids. A good deal has been said and written concerning the signifi- cance of a deposit of earthy phosphates in the urine, and I have even heard it suggested that the deposit showed not only that large quantities of the salts passed from the system, but that it was necessary to supply their place and thus compensate for the removal of phosphate from the organism. I remember a case in which phosphates were prescribed for the patient, who was suffering from typhoid, on the ground that large quantities were being excreted in the urine, and that, therefore, more should be given by the mouth, as if this excreting of phosphate was really a very important clinical fact in connection with fever. The physician was, in truth, troubling himself very needlessly about the phosphate, while he was neglecting to treat the low febrile state, which was of the utmost consequence. If we refine too much concerning the smaller and less important attendant phe- nomena of many forms of disease, we shall be apt to regard too lightly or to pass over the broad clinical facts of the case. While carefully directing our attention to the removal of comparatively unimportant symptoms, we may neglect to suggest remedial measures for the pathological changes which are jeopardizing, and may shortly destroy, the patient's life. The fact is, these earthy phosphates, consisting of phosphates of lime and mag- nesia and ammoniaco-magnesian phosphate, are always present in healthy urine in a state of solution, and if the fluid becomes alkaline, or if an alkali be added to the urine, the earthy phos- phates are thrown down as an insoluble deposit, which is some- times crystalline, but generally contains a certain quantity of amorphous phosphate of lime. In some cases, however, it has been shown that these earthy phosphates are actually excreted in more than the average quantity, when it may be advisable to give medicines containing these salts, or food in which they exist in considerable proportion. It must, however, be borne DIAGNOSIS AND TREATMENT. 107 in mind that bread and milk, and meat and fish of various kinds, contain considerable quantities of phosphates, and it is, I think, impossible to assent to the general proposition that the presence of these salts in excessive quantity is pathognomonic of any definite condition or morbid state, which can be relieved or even modified by giving them in quantity by the mouth. Their presence in excess is to be regarded as a fact which may accompany a number of conditions without having any causative relation to any one in particular. The principal objection to be urged against the frequent presence of these deposits, is their tendency to form soft concre- tions in the urine, or to collect upon the surface of the mucous membrane. This depends upon the urine becoming alkaline, as explained on p. 28. In many cases, there is no doubt that by attention to diet and by giving mineral acids frequently during the day, in moderate doses, the deposition may be reduced or entirely prevented. Tincture of iron with free acid, and a grain or two of quinine three or four times daily, often has a beneficial effect ; but a purgative treatment is also requisite in most cases. The obstinate persistence of phosphatic deposit should be attended to, the practitioner directing his mind to the consider- ation of the state of digestion and to the general condition of the patient, instead of concentrating his attention on the fact of the phosphate deposit only, and endeavoring to counteract the discharge or to make up for the loss. In various cases of disease arising from more or less complete paralysis of the nerves, owing to changes occurring in the nervous centre itself, or at the distribution of the nerves in the mucous membrane, the action of the bladder may become impaired, and it may fail to expel its contents completely. The urine thus retained sometimes undergoes change, and the mucous mem- brane suffers in consequence. It has been supposed that the formation and excretion of large iquantities of earthy phosphate was somehow due to degenerative changes in nerve matter, but this is probably not the source of the phosphates in these cases. In general there is not really an excess, but the urine being alkaline the earthy phosphate it contains is thrown down in an 108 URINARY DERANGEMENTS. insoluble form. Earthy phosphate is precipitated, and the con- dition thus induced gradually increases, unless proper prevent- ive measures be adopted. There are cases in which phosphates are deposited upon every part of the urinary mucous membrane — bladder, ureters, and the pelvis of the kidneys — apparently depending upon changes which result originally from some affection of the nerves. Although the formation of epithelium and all the essential phenomena of nutrition and secretion may take place independently of nervous action, it is quite certain that. the regularity of these changes, the even flaw of nutrient pabulum, and the regulation of the proper proportion distributed, are determined by the nerves. Hence, it follows that if the nerves distributed to a structure be destroyed, or their action impaired, directly or indirectly, the tissue soon suffers, its struc- ture becomes altered, and its function is imperfectly performed or suspended. Such changes in the epithelium precede and favor the deposition of the phosphates upon the surface. Some of the cases of disease of the bladder with phosphatic deposit, perhaps the great majority, are due to local change. The condition known as chronic inflammation, affecting one part of the mucous membrane, is very prone to spread. It may extend from urethra to bladder, and even into the ureters and pelvis. A rough, almost ulcerated state of the mucous mem- brane may also spread in' the opposite direction ; beginning in the kidneys, it may pass downward to the bladder. In all cases, the urine in contact with any portion of such altered surface would be decomposed, and its earthy phosphates pre- cipitated. These, with the epithelium and mucus of the part, would form irregular projections with intervening depressions, in which more urine would be decomposed ; and so the process might proceed, unless the nutritive changes taking place below the surface return to their normal condition, when the matter deposited would soon be thrown off, the even growth of new, healthy epithelium would proceed below, and the s,urface would again assume its smooth, healthy character. For this, reason, in such cases, it is of the first importance to pay attention to the general health, for it is obvious that if the blood be in an DIAGNOSIS AND TREATMENT. 109 unhealthy condition, the action and nutrition of the nerve- centres will suffer. Until this is corrected, the normal state of the mucous membrane cannot be restored. Disease of the mucous membrane, and impaired action of its muscular coat, may also result from lesions of the central part of the nervous system, and some of these cases are among the most distressing which the physician is called upon to treat. The affection may begin in the nerve cells of the posterior roots and those of the cord itself. These gradually undergo change, and may cease to act, or the nerves arising from them may be pressed upon or degenerate in structure at some distance from their point of origin. Over such chronic structural changes, when firmly established, we can exert little influence by remedial agents. On the other hand, I have seen cases in which earthy phos- phates have been constantly present in every specimen of urine passed during several years — without any disorganization of mucous membrane of the bladder, ureters or pelvis, and with- out the formation of stones op any form of concretion. In these cases the reaction of the urine was decidedly, but not very strongly, alkaline. The phosphates were in an amorphous state, but after standing for several hours crystals of phosphate of lime were deposited (" loo Urinary Deposits," 1884, PI. V, Fig. 60). In the case of some of these patients the formation of phosphatic calculi undoubtedly occurs, but in others it is quite certain the condition is due to functional disturbance of the digestive pro- cess only — the patient being, for the most part, weak and thin, and in what may be called a low state of health ; various plans of treatment have been devised and tried, but occasionally the condition persists in spite of every attempt to alleviate it by ordinary remedies. In these cases, living in the open air in a good climate must be recommended, with complete change for a time in the usual routine of life. A sea-voyage usually does good ; the appetite improves, and the patient may gain many pounds in weight. But return to sedentary work in a town is too often followed by a return of the low state of health and the feebly alkaline phosphatic urine. Very likely the patient 110 URINARY DERANGEMENTS. will suffer from some degree of headache and stomach derange- ment. It is very remarkable to observe the change which takes place in many of these cases as age advances. Up to 30 or 35 the patient suffers almost constantly from some dyspeptic symp- toms, and no matter what he eats, digestion, which is slow, is always accompanied by discomfort or actual pain. Not un- commonly the patient will tell you he is utterly miserable, and jjerhaps his sufferings are so great that he will assure you he does not care to live. About the age of 40 he, perhaps, begins to improve — is able to eat a pretty good meal now and then, and only gets upset occasionally. Although seldom feeling strong or vigorous, or contented and happy, life seems to be endurable. By the age of 50 probably all is changed. The patient enjoj's good health, and is conscious of sensations which are quite new to him. His spirits are so good that he can scarcely believe he ever suffered from depression. His working power is greater than it ever was — he sleeps well, and, most wonderful of all, he can eat anything without discomfort, and in quantities which astonish him, and the despairing dyspeptic of early and middle life becomes cheerful and happy, and looks hopefully forward to a vigorous old age, and good health and strength to the end. It has been assumed by some, that when phosphates were pass- ing away the brain would suffer in nutrition, to prevent which phosphorus should be given. That so-called brain food is either required or can be supplied is an amusing fancy, but nothing more. Phosphorus used to be ordered some years ago in leucocythemia, upon the fanciful and quite unjustifiable hypothesis that deficiency of phosphorus in the blood interfered with the development of the red blood corpuscles. The only very decided effect I have seen resulting from the giving of phosphorus in any cases was, I regret to say, unfortunate. In one or two of my own patients there were pain and disturbance about the mouth and teeth, and in one, decided threatening of necrosis of the bone of the lower jaw. When the phosphatic condition of the urine is only occa- sional, small doses of dilute acids in a bitter infusion before DIAGNOSIS AND TREATMENT. Ill meals, or the tincture of the perchloride of iron, will generally cause the urine to become healthy by improving the action of the stomach. Pepsin ("On Slight Ailments," ad ed.,p. '86), may also be given with advantage in some of these cases. Ben- zoic acid and benzoate of ammonia, in doses of from ten to thirty grains three or four times a day, between meals, for a month at a time, have also been prescribed, and sulphate of zinc, and extract of nux vomica, are favorite remedies. If the intestinal canal be loaded, and the patient has been living too well, as is not unfrequently the case, a little blue pill and com- pound colocynth pill will cure him. Alkalies, as Dr. Owen Rees was the first to show, undoubtedly do good in some of these cases of phosphatic urine, probably by their action in promoting the normal chemical changes in the blood rather than by direct action upon the kidney or any part of the genito-urinary mucous membrane. Dr. Rees' explanation has been already referred to, p. 29. When the phosphate in the urine has persisted for some time, and is accompanied with any symptoms referable to probable affection of the cord, especially if the bladder be irritable, and there be nervous twitching of the muscles, with tingling or numbness of the skin in any part of the lower half of the body, or diminished control over the voluntary movements, acids and tonics, with small doses of opium, should be given. The prac- titioner will meet with many cases where disease of the cord has been diagnosed, which nevertheless get quite well as soon as the general health is improved. Before treating such cases we must find out how the patient lives, and ascertain whether he has been troubled with mental anxiety, excitement, over-mental work, etc. The patient must not be led to suspect that he is suffering from any serious organic disease, for not unfrequently people are ter- ribly nervous, and too prone to dwell upon every ache or pain they may have, and they are foolish enough to refer to medical books, with the view of ascertaining the nature of their ailments. The diagnosis in these cases should be very guarded, unless the symptoms clearly and positively indicate the real nature of the disease. 112 URINARY DERANGEMENTS. A patient for some time under my care, whose urine almost invariably yielded an abundant cloud of phosphates of lime and magnesia, on the application of heat, complained of a strange feeling of dread of some impending disaster. Whenever he heard of cases of fever or other disease in his neighborhood, he had the greatest difficulty to reason himself out of the conviction that he was about to have an attack. Although he admitted while talking to me that the probabilities were the other way, as soon as he got home and was alone the opposite conclusion took possession of his mind, and he suffered terribly from low spirits and a vague, indefinable fear or dread of something or other. When this patient's digestion and general health improved, the curious state of mental depression gradually disappeared, and he almost forgot that he had suffered from the symptoms which dis- tressed him so much at the time. OF BLOOD CORPUSCLES IN THE URINE — HjEMATURIA. The significance of blood in the urine must engage the con- sideration of every practitioner in medicine and surgery. The presence of blood may mean that a little has escaped from the vessels of some part of the urinary mucous membrane, of no more consequence than a very slight nose bleeding. On the other hand, a little blood in the urine may be the first evidence of the presence of stone, or of a very serious organic change which will almost certainly result in death. As in cases of hemoptysis, the practitioner cannot be too careful about committing himself to a definite opinion until he has well thought over all the facts of the case. Without care, and especially in cases where the patient or his friends may be inclined, as is said, "to insist" upon having the "candid" opinion of the practitioner at once, is there danger of asserting that a case of slight bleeding, which turns out to be serious, is nothing, or, of affirming that one which is of no consequence at all is the commencement of a terrible and necessarily fatal disorder. In many cases where blood is present in the urine, it is even more difficult to come to any positive conclusion on first seeing the patient, than it is in cases of haemoptysis, haemate- DIAGNOSIS. AND TREATMENT. 113 mesis, or bleeding from the bowels, to decide whether the bleed- ing is serious or only of trivial consequence. It is of the first importance to insist upon rest in any case of hsematuria— especially so in cases where the patient has passed the age of 45 or 50. Even when you are pretty sure that the blood comes from the urethra, in a young and apparently healthy man, it is nevertheless most desirable to act upon the cautious side, for by making the patient rest at once, you may save him from a somewhat severe illness, or from the occurrence of patho- logical changes which may result in stricture, abscess, or some other serious and troublesome lesion. Even where bleeding occurs from an inflamed surface of mucous membrane, where there is continued irritation and movement of the parts, the discharge is often followed by the pouring out of lymph, which results in thickening and formation of fibroid tissue. This change is especially damaging in the case of the mucous mem- brane of the ureters, bladder, or urethra. In cases of hemor- rhage we cannot be too strong in insisting upon rest for a few days or a week, or until we feel pretty certain that all danger of a repetition of the discharge of blood has ceased. Blood Corpuscles usually form a red or brownish-red gran- ular deposit, which sinks to the bottom of the vessel ; but a few .corpuscles are usually diffused through the urine. If the urine be perfectly neutral, or slightly alkaline in its reaction, the color of the blood will be bright red ; but in those instances in which the reaction is decidedly acid, it will be found of a brown color, imparting to the supernatant fluid a "smoky" hue. When the urine has a decidedly ^^ smoky appearance'^ it will often be found that the blood is derived from the kidney. If, however, the urine is decidedly alkaline, the blood will retain its florid red color. In the majority of cases in which the mixture of blood and urine is bright red, it is probable that it has escaped from the raucous membrane of the bladder, or from the prostate or urethra. If blood globules remain long in urine, they beconae much altered in form, the outline appearing irregular and ragged, and the surface granular. Sometimes, however, they appear swollen and very much enlarged. These changes are, no doubt, due to F* 114 URINARY DERANGEMENTS. physical actions. The characters of blood corpuscles are repre- sented in "loo Urinary Deposits," PI. VIII, Fig. loo. As a single grain of blood contains three hundred million blood cor- puscles or more, it must be obvious that only one drop diffused through a pint or more of urine would yield corpuscles enough to be discovered by microscopical examination, if time were allowed for the sediment to subside. If blood remains for some time stagnant in the uriniferous tubes, or in the capillary vessels, before it passes into the urine, crystals of haematoidin are often found. From five days to two weeks probably elapse before the crystals in question result. Blood in the urine may be derived from any part of the genito- urinary mucous membrane. In the female, it often escapes from the vessels of the uterus or vagina. At the time of the menstrual discharge a good deal of blood is, of course, found in the urine. For some days afterward a few blood corpuscles and disintegrated blood corpuscles may often be detected. In some cases it would appear that small quantities of blood get entangled in the mucus and amongst the papillae of the mucous membrane of the os and cervix, or in folds or depressions of the mucous membrane, for in some cases we find blood corpuscles in the water for many days after the catamenial discharge has ceased. Some of these cases are put down as renal calculus, while in others the blood corpuscles are regarded as evidence of the existence of ulceration of the OS uteri. From the urine of some females, who never- theless enjoy excellent health, blood corpuscles are hardly ever absent, and are almost always to be detected if a considerable quantity of the urine be allowed to stand for some time, and the slight deposit which subsides is submitted to microscopic ex- amination. Blood may come from the kidney, in consequence of recent inflammation or old-standing disease, causing distention and rupture of the vessels of the Malpighian body, or its escape may depend upon that peculiar condition of system in which there is a tendency to capillary hemorrhage in all parts of the body, a condition which is now known as Haemophilia (^aifia, blood,