THE IMPORTANCE OF CAREFUL EXAMINA- 
TION OF THE URINE BEFORE SUR- 
GICAL OPERATIONS. 
BY 
ARTHUR R. ELLIOTT, C. M., M. D. 
CH ICAQO. 
REPRINTED FROM 
The Chicago Medical Recorder, 
DECEMBER, 1895. 
PRE88 OF 
The McCluer Printing Company, 
300 DEARBORN ST.. CHICAGO. THE IMPORTANCE OF CAREFUL EXAMINATION OF 
THE URINE BEFORE SURGICAL OPERATIONS. 
By ARTHUR R. ELLIOTT, C. M., M. D. 
INSTRUCTOR IN URINARY ANALYSIS AT THE POST GRADUATE MEDICAL SCHOOL, CHICAGO. 
Among the "golden rules of surgical practice" that are laid 
down dogmatically from time to time in our medical journals I 
cannot recall having in a single instance seen adequately expressed 
the importance of invariable careful analysis of the urine before 
administration of anesthetics and operation. The importance of 
this procedure may not appear at first sight but the consideration 
of a few facts cannot fail to impress its necessity. 
That many avoidable deaths following operations are due to 
diseases of the kidneys is a fact attested by the surprising fre- 
quency with which such lesions are found post-mortem in these 
cases. Sometimes the lesions are so advanced as to preclude any 
possibility of recovery. Such fatalities indicate a superficial and 
cursory examination as to the patient's general health before 
operating or perhaps an entire neglect of the simple and always 
available procedure of urinary analysis. 
It is upon the power of resistance of a patient, his vitality, 
that we largely depend for his recovery from severe operative 
measures. This rather indefinite quality consists in his ability to 
get rid of the results of tissue waste and depends directly upon the 
activity of the metabolic processes and the integrity of the excre- 
tory organs. The results of the metabolism of nitrogenous tissue 
are certain waste products all of which are excreted by the kid- 
neys. They are urea, uric acid, creatinin and a few kindred sub- 
stances, which when retained cause profound interference with 
body nutrition and a depressant effect upon the vitality. It is 
thus clearly of the utmost importance to the surgeon to possess an 
accurate knowledge of the condition of the kidneys inasmuch as 
the progress of the patient depends largely upon the adequacy of 
these organs to remove effete material. Painstaking analysis of 
the urine cannot but result in more care in the selection of cases, 
better regulation of preparatory treatment and reduction of the 
mortality from complications arising after operations. 
Before considering the circumstances connected with surgical 
operations which have a special bearing upon the kidneys and 
which render an intimate knowledge of the condition of the urine 
a necessity I wish to call your attention briefly to a few practical 
Delivered during the special surgical course, October, 1895. 2 
points in conducting analysis of urine which while of importance 
under all circumstances are especially applicable to examination 
in surgical cases prior to operation. 
It is unfortunately true that the results of urinary analysis are 
not always a reliable index of the condition of the kidneys. Still 
the indications so derived if proper methods are employed may in 
the great majority of cases be depended upon and it is not justifi- 
able ever to undertake any major surgical operation without hav- 
ing first carefully examined the urine. 
The urinary analysis as ordinarily conducted is hardly a credit 
to the physician. It consists in the majority of instances of an 
appeal to one of the old and time-worn tests for albumen and 
sugar, possibly the estimation of the specific gravity and occa- 
sionally a microscopic examination of the urinary sediment. In 
my experience the number of practitioners who understand uri- 
nary microscopy and who habitually make microscopic examina- 
tion a part of their analysis is comparatively small. The impres- 
sion seems to be firmly fixed that the chemic part of the analysis 
is the most important. I cannot insist too strongly that such is 
not the case ; such an impression is entirely erroneous. That it is 
an important and essential part of every examination of the urine 
is beyond question, but it should not be relied upon absolutely. 
Almost invariably the indications of the chemic tests require veri- 
fication and elaboration by means of the microscope. Neither 
means should be relied upon to the exclusion of the other and the 
mind should be disabused of any impression that with an appeal 
to the various chemic tests our duties in this connection are dis- 
charged. 
The importance of the chemic examination is much detracted 
from by the use of the old and faulty methods so much in vogue. 
From the analysis as generally practiced one would conclude that 
there has been no advancement of late years in urinary chemistry. 
Such is not the case however. This branch of medicine has kept 
pace with the progress in other departments. The old heat test 
for albumin and Trommer's and Fehling's tests for sugar are in 
almost general use to-day, and that notwithstanding great improve- 
ment in methods and in our knowledge of the subject. Such a 
state of affairs is indicative of either indifference or culpable con- 
servatism. Adherence to the narrow limits of a cursory examina- 
tion, such as the one described in cases where an exact knowledge 
of the condition of the kidneys is desired, as in the class of cases 
under consideration, cannot result in accurate knowledge and may 3 
expose the patient to grave risk. It is not sufficient that a few 
chemic tests be applied in a cursory manner, but they should be 
systematic and the methods employed should be those which have 
been proved to be the most reliable. In addition a microscopic 
examination of the urinary sediment should invariably be made, for 
the valuable indications such may render as well as to act as a con- 
trol to the possible fallacies of the chemic tests. It cannot be urged 
as an excuse that this requires the expenditure of too much time. 
By means of methods recently introduced the analysis can be com- 
pleted in a few minutes and the results are of too much value in 
these cases not to repay the trouble. 
In every examination the precaution should always be ob- 
served of having a sample of the mixed twenty-four' hours product 
for analysis. The urine varies so greatly in its composition at 
different times of the day that the analysis of any other than a 
mixed sample cannot give representative results. In women, mi- 
croscopic examination should be made of urine drawn by catheter 
or passed after a vaginal douche. Otherwise abundant vaginal 
elements in the urine may obscure the results. 
I should urge that the following points be always ascertained: 
The chemic reaction, specific gravity, total solids, total excretion 
of urea, and the presence or absence of albumin and sugar, and if 
present their respective amounts. In addition microscopic inspec- 
tion of the sediment for casts should be made. 
In my experience the urinometers in common use are very 
unreliable, frequently a number of them giving with the same 
urine a difference of several points in specific gravity. With the 
older instruments the temperature standard was 60° F. Such fre- 
quently required temperature corrections, a precaution rarely prac- 
ticed. Urinometers are now standardized at 77° F. and thus any 
such necessity is obviated. It is well from time to time to test 
the instrument in distilled water and if any variation is found from 
the zero mark, due allowance must be made in the estimation. 
The estimation of the excretion of urea is one of the most impor- 
tant urinary considerations in these cases. More than any other 
urinary solid it is an index of the functional activity of the kidneys 
and any discrepancy between the amount of its excretion and the 
state of the body nutrition should excite suspicion of retention and 
inspire careful investigation. Constituting as it does more than 
90 per cent of the organic output of the kidneys it is a guide to 
the condition of the proteid metabolism. Chronic interstitial ne- 
phritis is early evidenced by a diminution of total urea excretion 4 
and that frequently at a time when no albuminuria exists. Its es- 
timation is readily accomplished by means of the hypobromite 
process with the employment of Doremus' ureometer. 
A most imporant part of the analysis is the detection of albu- 
min. We will not enter here into a discussion upon the relative mer- 
its of the different tests employed for this purpose. What is desired 
is a simple method, one easily applied and always reliable. Such 
a one I have found the potassic ferrocyanide test to be and I much 
prefer it to any of the other methods. It possesses the advantages 
of simplicity, accuracy and ready adaptability, and moreover it is 
selective in its action. When properly applied it reacts to no 
form of albumin in the urine but serum-albumin and as this is the 
albumin of organic kidney disease, this fact renders it peculiarly 
well adapted for use in the class of cases under consideration. It 
gives no reaction with peptones globulin, the albumoses mucin 
vegetable alkaloids and oleo-resins, the causes of inaccuracy with 
other tests. The test reagent consists of a 10 per cent solution of 
potassic ferrocyanide in distilled water. In its application pro- 
ceed as follows : To 10 c.c. of urine in a test tube add 5 c.c. of 
the reagent and then 1 c.c. of acetic acid. Mix, and if albumin is 
present a distinct cloudiness appears throughout the mixture. 
Precipitation does not occur until after the addition of the acid. 
As the reaction deepens upon standing, it is well to set the tube 
aside for three or four minutes and then reexamine. The contact 
method may be employed, but I prefer the method by mixture. 
The ferrocyanide solution must always be added to the urine first, 
and the mixture then acidulated. Otherwise mucin if present in 
excess may be precipitated. Applied in this manner the test 
reacts to serum-albumin and that alone. When present, albumin 
may be estimated either in bulk percentage by means of centrif- 
ugal sedimentation or by the employment of Esbach's albu- 
minometer. 
For the detection of sugar in urine, my own method will be 
found convenient, sensitive and reliable. The test reagents con- 
sist of a cupric oxide solution and a saturated solution of tartaric 
acid in distilled water. The formula for the preparation of the 
cupric oxide solution is as follows : 
Cupric sulphate, C. P 27 grains. 
Glycerin, pure 3 drachms. 
Caustic potash in sticks 130 grains. 
Distilled water to 4 ounces. 
In applying the test, pour into a test tube a drachm of the 5 
copper solution and gently boil over a spirit lamp. Then 
add two or three drops, never more, of the tartaric acid solu- 
tion and continue boiling. The suspected urine is now added 
slowly, drop by drop, boiling and shaking the test between each 
drop until 8 drops of the urine have been added. If sugar be 
present a copious reddish yellow precipitate of cuprous oxide is 
thrown down. If no change takes place, sugar is absent. 
The estimation of sugar may be accomplished in a few minutes 
with accuracy by the employment of my test solutions as follows: 
Take 133 minims of the cupric oxide solution and add thereto six 
drops of tartaric acid solution and three drachms of liquor ammo- 
nia, U. S. P. Bring the total volume of the mixture up to two 
ounces by adding distilled water, and boil the whole in a glass 
flask over a spirit flame. The urine is slowly added to the boiling 
test from a burette or minim pipette until complete decoloration 
i. e., entire disappearance of the blue color has taken place. This 
amount of test solution is reduced and decolorized by exactly one- 
fourth grain of grape sugar. The number of minims of urine re- 
quired to accomplish this is noted on the burette and from that, 
which represents one-fourth grain of sugar the number of grains 
per ounce of urine is estimated by dividing 480, number of minims 
in an ounce, by the number of minims so required and dividing the 
quotient by four. 
In obtaining urinary sediments for microscopic examination 
two methods are available. These are centrifugal sedimentation and 
sedimentation by gravity. The former method is much to be pre- 
ferred. By means of the electric centrifuge a sediment can be ob- 
tained in a few minutes instead of twenty-four hours, the time re- 
quired by the older method of gravitation. In addition to the gain 
in time there is a great gain in reliability by this means. With a 
speed of 1,500 revolutions per minute continued for four minutes all 
solid matter in the urine.is thrown to the bottom of the tube and may 
be drawn off with a pipette and mounted upon a slide for inspec- 
tion. This method possesses the advantage of affording a sedi- 
ment in freshly voided urine without the necessity of waiting a 
number of hours at the expiration of which various crystalline 
products have had time to form and bacterial action and prolonged 
contact with water have probably altered the character of the 
organized sediment. Moreover a sediment collected by means of 
gravity does not always represent the microscopic constituents of 
the urine. When the specific gravity is high, fine hyaline casts, 
being of light atomic weight,frequently fail to settle because of the 6 
density of the medium. Such an accident is not possible with the 
centrifuge, the force exerted being over 2,000 times that of gravity. 
Urine should never be set aside for sedimentation by gravity with- 
out the precaution of first adding some preservative, such as resor- 
cin, being taken, otherwise bacterial decomposition will ensue to 
some extent, resulting perhaps in disintegration of the organized 
elements and greatly detracting from the value of the examination. 
If the urine be one of high density it should be first diluted with 
distilled water before being set aside, for reasons already men- 
tioned. If alkaline fermentation has taken place the urine is unfit 
for microscopic examination, since it has been proved that casts 
become dissolved in alkaline urine. For this reason urine which 
is alkaline from fixed alkali should first be acidulated before sedi- 
mentation is started. The mistake is frequently made of using a 
lensof too high power for the microscopic examination of urine. This 
narrows the field and makes the operation long and tedious. A 
higher power than a one-fourth or one-sixth inch objective should 
never be used. I prefer to first scan the slide through a one-half 
inch lens. With this power the coarser crystalline elements and 
epithelium are readily observed and distinguished and casts can 
be detected. If the latter or any other morbid elements are pres- 
ent they should then be closely inspected through the higher 
power. In examining for casts a shaded light to illuminate the 
microscopic field is always desirable. A condenser should not be 
used. The proper illumination can be obtained by manipulation 
of the mirror or by means of an iris diaphragm. If the light be too 
intense the delicate outlines of hyaline casts are not discernible, 
their light structure rendering them so transparent that they may 
escape detection. 
A rule that should always'be adopted in examining the urine 
of cases prior to operation is never to trust to a single analysis. 
The great variation in the urine from day to day is notorious. A 
solitary examination may be entirely misleading. The output of 
urea one day may be normal, whereas the average excretion is 
much reduced. In certain cases of glycosuria the presence of 
sugar is intermittent, being absent at certain times of the day or 
even for whole days. In like manner the urine of chronic inter- 
stitial nephritis differs greatly at different times. The albuminuria 
of this affection is often irregular, as also is the urea excretion and 
the presence of casts. Hence a single examination may fail ut- 
terly to reveal the disease. An adoption of the methods and sug- 
gestions just detailed cannot fail to render the analysis reliable. 7 
Before leaving this part of my subject I wish to again impress the 
importance of always making a microscopic examination of the 
urinary sediment. Otherwise a positive diagnosis cannot be con- 
structed. But why all this care in urinary analysis in these cases ? 
What the great necessity of diagnosticating lesions of the kidneys 
before operation? It is because such cases bear anesthetization 
and operation very badly and frequently develop fatal complica- 
tions. It is imperative that renal lesions and diabetes when pres- 
ent should be recognized, and understood, as their presence neces- 
sitates either abandoning operation entirely or the adoption of 
preparatory treatment. The causes of danger in operating upon 
such subjects are twofold and may be summarized as being the 
effects of anesthetics and of collapse and disturbance incident 
upon major surgical operations. 
An investigation into the effects upon the kidneys of the two 
most commonly used anesthetics, ether and chloroform, de- 
velops the fact that both these drugs when inhaled or otherwise 
introduced into the circulation result in irritation of the renal 
structure depending in severity upon the nature and amount of the 
agent used. After the inhalation of ether it is found to exist in 
the free state in the blood. A priori it would seem that the kid- 
neys as well as the lungs would assist in its elimination and it was 
generally believed that such was the case. The observations of 
Dr. George B. Wood prove that this is not true however. He 
conducted a series of experiments upon dogs to discover if ether 
was excreted in the urine. In not a single instance was he able to 
demonstrate its presence there after inhalation, although it could 
be readily detected in a free state in the blood. If the kidneys 
take no part in the elimination of ether from the body then how 
are we to account for the nephritis and uremia which sometimes 
follow its administration ? The following are the most recent 
opinions upon the effects of ether in causing nephritis. 
The observations of Fueter, Roux and Kappeler seem to point 
to the conclusion that ether is comparatively harmless in its effects 
upon the kidneys unless organic disease of these organs existed 
before its administration. Nothnagel considers that this agent 
does not produce organic changes in the healthy kidneys. The 
conclusions of Wunderlich, after extensive observations, are that a 
preexisting albuminuria, nephritis would be a better term, is 
often increased by ether narcosis. That it does not produce al- 
buminuria as frequently as does chloroform. That renal casts are 
more frequently present in the urine after ether than after chloro- 8 
form, and if already present will be increased by this agent. Dr. 
Koerte concludes that it has no injurious effect upon the healthy 
organ. 
Although ether has not been demonstrated to any appreciable 
extent in the urine, its irritant effects upon the kidneys are appar- 
ent in cloudy swelling and sometimes even desquamation of the 
epithelium of the renal tubules. Its effects would thus prove de- 
cidedly deleterious to an already diseased organ. Where uremia 
was present to any extent ether would be dangerous in still further 
inhibiting the kidneys. 
These facts and conclusions representing the latest opinions 
upon the subject go to show that ether is a harmless anesthetic in 
its effects upon the kidneys, provided no organic disease already 
exists. In the latter event it would prove decidedly harmful. The 
nephritis and uremia occasionally following its administration 
are undoubtedly aggravation of a preexising condition and not a 
true primary lesion. In rare instances where the inhalation is 
greatly prolonged, or often repeated the intense continued irrita- 
tion may result in organic changes. Such a sequel is rare indeed, 
however. 
The effects of the inhalation of chloroform upon the kidneys, 
while much resembling those of ether, differ in a few important re- 
spects. Wunderlich found albumin in the urine in per cent 
of his cases after chloroform, as against 7 per cent after ether. 
He observed casts in 35 per cent after its administration when the 
urine had been free from albumin before narcosis. Sironi and 
Alessandri found albumin in 68 per cent of patients submitted to 
the influence of chloroform. The amount present seemed to vary in 
direct ratio to the duration of anesthesia. It was greatest on the 
day following the administration, and gradually passed off in four 
or five days. Other urinary disturbances were noted as follows : 
biliary acids and pigments in 21 per cent; sugar in 6 per cent; 
casts and epithelium in 18 per cent. Ferrier and Patin conducted 
observations in ten cases, the urine being tested before and after 
operation. In six cases albumin was found after, though not before 
chloroformization. In one other case the albumin was increased 
sevenfold, death resulting. Bouchard records the occurrence of 
albumin in the urine of hares after inhalation of chloroform. Dr. 
Koerte calls attention to the albuminuria and fatty degenerative 
changes in the kidneys in animals after the prolonged use of this 
agent in experiments. Kast and Mester have shown that chloro- 
form anesthesia sometimes results in the presence of a peculiar 9 
urinary toxin somewhat similar to cystin. Disturbances of tissue 
metabolism, especially in oxidation of proteid substances, accord- 
ing to these writers, may persist for a number of days after its in- 
halation much as in cases of severe poisoning as by phosphorus. 
Finally Eisendrath finds that chloroform is more apt to cause 
albuminuria de novo than ether, but an albuminuria that already 
exists is less frequently increased by this agent than by ether. 
These observations demonstrate the fact that chloroform is an 
irritant to the renal structure, and when its use is prolonged it may 
produce a profound impression upon the body nutrition. It does 
not however exert as harmful an influence upon kidneys already 
the seat of degenerative changes as does ether. 
Apart from other considerations, in the light of the effects upon 
the kidneys of these agents, the conclusion, that must result from the 
study of their action clinically and experimentally is in favor of 
ether as an anesthetic when the kidneys display no evidence of or- 
ganic disease and of chloroform when signs of degenerative lesions 
exist. Of all the conditions contraindicating the exhibition of 
either of these agents, diabetes and the various forms of Bright's 
disease are deserving of the most serious consideration. While 
Bright's disease does not constitute an absolute bar to anestheti- 
zation and operation, it increases the risk of such many-fold. 
When any such condition exists the preference should be given to 
chloroform, provided no cardiac or other contraindications are 
present. In addition to the fact that it is less liable to cause ag- 
gravation of the kidney disease, it is not so prone to increase the 
cardio-vascular changes of chronic interstitial nephritis, and the 
risk of cerebral hemorrhage is not so great. 
Diabetes must be considered almost an absolute contra- 
indication to anesthetization and operation. In this affection the 
tissues have low power of resistance and tend to necrosis. This, 
the direct result of the disease, renders such subjects very prone 
to inflammatory, septic and gangrenous complications, and makes 
them unfit for surgical operations except in carefully selected 
cases. Moreover, they bear anesthetics badly; even in mild 
cases the effects of such are often fatal. Indifference, stupor, con- 
fusion, coma and death often follow their administration. Baxer 
reports three cases of death from anesthesia in diabetes occurring 
in his own practice, and collects nine similar ones from medical 
literatature, coma being the invariable cause of death. This did 
not develop until narcosis had passed off, usually twenty-four hours 
after, in some cases not until forty-eight hours had elapsed. This 10 
is sufficient to show the extreme risk of anesthetizing diabetics. 
It is quite impossible to predict what the outcome will be, the 
severity of the glycosuria not being always a reliable criterion of 
the risk attendant. Baxer does not specify what anesthetic was 
used in the cases reported. Chloroform, it has been found, results 
in the appearance of sugar in the urine much more frequently than 
does ether. This is brought about it is thought by vaso-motor 
disturbance in the liver. In diabetes complications have been 
found to follow chloroform more frequently than ether, no doubt 
because of its more profound effect upon the nutritive processes. 
Reynier calls attention to the different reactive powers shown by 
the tissues of diabetics to traumatism, infection or surgical inter- 
vention. In some cases operation is safe, in others the least sur- 
gical interference results fatally. According to this authority, 
diabetes attended by extensive atheroma is the safest form for the 
surgeon. The nervous or pancreatic is the most dangerous. As 
the disease progresses tissue resistance is lessened, consequently 
the earlier operation is undertaken the safer it is. Gangrene is 
always threatening, and any form of irritation may precipitate it. 
For this reason carbolic acid and all irritating dressings are contra- 
indicated. The slightest germ infection may result seriously, 
therefore the strictest asepsis should be practiced. Antisepsis, 
because of the irritating quality of the drugs employed, is contra- 
indicated. This writer recommends a rigorous course of prepara- 
tory treatment. Of 40 diabetics operated upon by him 15 died 
from gangrene and secondary inflammatory processes ; 3 others 
also died. Of the 40 only 22 recovered. 
Regarding the advisability of operating in diabetes, Verneuil 
says : ''From a surgical point of view the presence of glucose in 
the urine, whatever the amount, is always a serious fact." Tuffier 
supports this opinion, and considers the simple presence of sugar 
in the urine as sufficient to provoke grave complications. He lays 
down the following axiom. " If preparatory treatment, carefully 
carried out reduces the amount of sugar and especially if it causes 
it to disappear, operate ; if medical treatment is inefficacious, one 
ought not to operate." 
Smith and Durham, after extensive observations upon the 
subject, differ somewhat from this opinion of Tuffier in so far as 
they consider the mere presence of sugar in the urine not always 
an absolute bar to surgical operation. A brief synopsis of their 
interesting reports and conclusions will prove instructive. Of 
eight cases in which sugar disappeared as the result of preparatory 11 
treatment or was absent at the time of operation, three died. Of 
thirteen cases in which treatment was adopted beforehand, three 
died, and two of these were severe operations. In certain other 
cases in which sugar persisted in spite of treatment, recovery took 
place without complication. Six cases they report in which no 
preparatory treatment was instituted. Of these, three died ; two 
from coma, one from gangrene, and of the three that recovered 
one narrowly escaped death from severe inflammatory and gan- 
grenous complications. 
Their conclusions are as follows : The benefit of preparatory 
treatment is unquestionable. This probably produces its effect by 
lessening the liability to coma. Although as a result of such 
measures the sugar may entirely disappear, the liability to septic 
processes may remain, and in a few cases coma may supervene. 
On the other hand if sugar persists under certain circumstances 
the patients condition may expose him to greater danger if the 
operation be postponed than is attached to operating, and we are 
then not justified in holding back. 
The facts and conclusions cited lead us to conclude: 
1. That sugar in the urine is a serious fact from a surgical as 
well as a medical standpoint, and except under urgent neces- 
sity should act as a contraindication to anesthetization and opera- 
tion. 
2. Preparatory treatment should always be undertaken if 
possible. 
3. In cases where preparatory measures cause the disappear- 
ance of sugar from the urine, although the danger is not entirely 
obviated operation is admissible. 
4. Circumstances may render an operation advisable in cer- 
tain cases where sugar persists in spite of treatment, or where pre- 
paratory treatment is not practicable. In the selection of such 
cases the condition of the patient, his disease, and the nature of 
the operation must be taken into account. The operation under 
such circumstances should be the one that involves the least dis- 
turbance of parts and causes least shock. 
5. Certain operations of urgency and necessity such as for 
strangulated hernia, hemorrhage and injuries, must be undertaken 
irrespective of the diabetes. 
6. Finally, in every case ether should be by preference the 
anesthetic used. 
The various forms of Bright's disease upon the whole do not 12 
constitute as strict a contraindication to operation as does dia- 
betes. Much depends upon the form and stage of the affection. 
In amyloid degeneration of the kidneys the outlook for opera- 
tion is not bright. This is more a constitutional vice than a 
purely renal lesion, and when present is hardly ever limited to 
these organs, indeed the kidneys are often the least involved, the 
liver, spleen and intestines being more profoundly affected. This 
condition usually appears as a manifestation of constitutional dis- 
ease, especially of affections leading to cachexia of which tubercu- 
losis, chronic suppurative processes, syphilis and malaria are the 
most common examples. Being a product of impaired nutrition, 
such cases must of necessity be poor subjects for severe opera- 
tions, possessing little vitality to withstand shock and for repair of 
tissue. Medical treatment will oftentimes accomplish much for 
their improvement and in bringing them into condition where 
operation is admissible. Each case must be judged upon its own 
merits. No fixed rules can be laid down for their surgical manage- 
ment, except the general one that when the disease is advanced no 
surgical interference should be undertaken. 
Chronic parenchymatous nephritis when present seriously 
jeopardizes the success of an operation. Such cases are usually 
anemic and poorly nourished, and present a high grade of albu- 
minuria, dropsy, diminution of urine and urinary solids with abun- 
dant morphological elements. They are very prone to secondary 
inflammatory complications. When well developed, this disease 
contraindicates anesthetization and operation. In mild cases not 
attended by prominent symptoms, preparatory treatment, consisting 
of rest, tonics, appropriate diet and stimulation of the emunctories 
may bring the patient into condition where surgical measures may 
be undertaken with comparative safety. It is, however, to chronic 
interstitial nephritis the so-called granular or contracting kidney, the 
most frequent form of Bright's disease with which we have to deal, 
that the greatest interest is attached. In the other forms of 
Bright's disease, the urinary signs are pronounced and easily 
recognized, and consequently are seldom overlooked, but the diffi- 
culty of diagnosis of the interstitial form causes it to be frequently 
neglected and often with disastrous results. The physical symp- 
toms while characteristic are usually obscure and the urinary signs 
are hardly ever pronounced. For this reason the latter are fre- 
quently not recognized by the urinary methods in common use. 
In the majority of cases careful examination will elicit a character- 
istic train of symptoms. There is commonly a gouty history pres- 13 
ent. Inquiry will reveal the fact that polyuria exists, evinced 
by a habit of rising once or more during the night to urinate. The 
quantity of urine passed is usually double, even treble the normal 
amount. There may be present an obstinate dyspepsia, headache, 
especially unilateral and occipital, hemorrhages, giddiness, short- 
ness of breath, palpitation, dimness of vision, etc. Dropsy is 
never a symptom except during the late stages of the disease. 
The pulse is found to be full, hard and of high tension, sometimes 
so much so as to roll under the finger like a cord or piece of wire. 
Sphygmographic pulse-tracing shows a well-marked wave of ten- 
sion. There may be some increase of cardiac dullness to the 
left and the second heart sound is commonly accentuated. The 
urine is transparent, pale, increased in quantity, of low specific 
gravity, usually ranging from 1.005 to 1.010 rarely rising even 
with diminution in quantity above 1.012. The quantity of 
urea is constantly diminished both relatively and absolutely, 
seldom more than 7 or 8 grains to the ounce being present. 
The phosphates are diminished early in the disease. The grade 
of albuminuria is very light. Indeed albumin may be absent 
even when the lesion is well advanced. The absolute quantity 
excreted is very limited. The urinary sediment is usually very 
small and contains sparse numbers of narrow hyaline casts and 
occasionally broad hyaline casts. Renal epithelial cells and 
blood corpuscles may also be present. 
The relative value of these symptoms may be given in the 
following order: Rising at night to urinate. If prostatic, blad- 
der and urethral causes can be excluded and the habit is an 
acquired one, not having always existed, this may be regarded as a 
significant sign. The cardio-vascular changes are also character- 
istic. Polyuria, diminution of urea, a trace of albumin and hy- 
aline casts are the special urinary signs of the affection. Every 
patient submitted to operation, should be examined relative to 
these symptoms. 
There is greater danger of uremic complications in intersti- 
tial nephritis than in any other form of organic kidney mischief. A 
general rule may be given, that when the disease has advanced be- 
yond the earlier stages operation is contraindicated, more especially 
if dropsy exists or uremic symptoms are present to any extent, sur- 
gical measures must not be undertaken. Cases should be selected 
with the greatest caution and preparatory measures invariably 
practiced. When the nutrition is good and the heart and arterial 
changes not advanced, with a urine normal in quantity and contain- 14 
ing habitually 7 grains or more of urea to the ounce, and having a 
specific gravity of 1.012 to 1.014 operation is admissible if proper 
preparatory treatment can be carried out. On the contrary if the 
quantity of urine, specific gravity and urea are persistently much 
lowered and fail to be favorably influenced by preparatory measures, 
and especially if the heart changes be advanced and obscure uremic 
symptoms present, surgical measures should not be undertaken. 
The preparatory measures best suited to these cases are rest, ap- 
propriate diet and clothing, diureties and tonics, and measures to 
control the circulatory high tension. These should be continued 
until the urine has for several consecutive days reached a volume 
of eighty ounces or more, the albumin is lessened and the excre- 
tion of urea improved; when this point is reached the patient is 
ready for operation. 
The annals of every surgeon's practice no doubt show many 
cases of organic kidney disease and diabetes that have undergone 
surgical operations without detriment or complication. That these 
lesions greatly increase the risk of such measures however cannot 
be denied. Too great care cannot be taken in the selection of 
cases when evidence of such lesions exist. How are we to be 
guided in doing this? Only by careful consideration of all the facts 
of the case, and the manner in which the patient's condition is in- 
fluenced by preparatory treatment, together with a careful examina- 
tion of the urine with a view to the estimation of the exact con- 
dition of the kidneys. 
Auditorium Hotel.