mmm WJ^, NLM 05110751 NATIONAL LIBRARY OF MEDICINE NLM051107595 A CLI N ICAL STUDY OF o \J F THE KIDN INCLUDING Systematic Chemical Examination of Urine, for Clinical Pltrposks. Systematic Microscopical Examinxa.tion of Urinary Sediments. Systematic Appli- cation of Urinary Analysis to Diagnosis and Prognosis. Treatment. ft* BY Clifford .Mitchell, A. M„ M. D. SECOND EDITION. CHICAGO W. T. KEENER, 96 WASHINGTON ST. 189I. ;!NEX \N3 • M.6, COPYRIGHT, CLIFFORD MITCHELL, 1SS9. PREFACE. Harley has well said that the state of the urine is a key to the condition of the body. While some diseases may not affect the urine, morbid urine indicates disease. Chemical and microscopical examination of the urine enables the practitioner to determine the diagnosis in a large number of disorders and, oftentimes, to save the lives of patients. The object of my work is to show the prac- tical bearing of thorough examination of the urine on the diagnosis, prognosis, and treatment not only of diseases of the kidneys themselves, but of many other disorders. The relation of urinary analysis to diet I have endeavored to explain at considerable length It is by careful observation of the condition of the urine that we often differentiate among various therapeutic agents, mineral waters, and adjuvants of many kinds. iii PREFACE. I have devoted one hundred pages of this book to a consideration of the treatment of Bright's disease. The modern treatment of albuminuria consists in carefully observing many particulars. I have discussed with as much minuteness as possible circumstances of diet, air and exercise, care of the skin, place of residence, psychical influences, etc., etc., which, if observed in connection with proper remedial treatment, will often keep the patient with chronic Bright's disease alive for many years, in some cases, possibly, to the natural limit of life. I have endeavored so far as possible to write thp book for American patients and from an American standpoint as regards diet and mode of life. The influence of English writers On diet and hygiene has been too strongly felt in this country. We should accept with some reserve the dietetic regulations of those who are more familiar with the Hogarth type of eater and his needs, than with the sufferings of the American stomach in general or the Missis- sippi Valley liver in particular. Should any American novelist make his characters disport themselves out-of-doors during an Illinois PREFACE. V winter, or in a Xew York blizzard, as do those of Dickens in the comparatively balmy English holiday week, he would be justly held up to ridicule. Yet many of our own medical writers do not hesitate to advise American "featherweights " to pursue that mode of living which our gigantic Saxon kinsmen in their English climate may find salutary. In order to make the book useful for the gene- ral practitioner, I have inserted numerous tables by study of which diagnosis is made easier. A large number of clinical notes from the experience of well-known physicians will explain the action of various remedies which I have found useful. 1 have paid some attention to the details of management of cases during such emergencies and complications as arise in the course of Bright's disease. I think it necessary in considering renal diseases to pay attention also to those of the entire urinary tract. The authors of many works on diseases of the kidneys ignore dis- eases of the kidney-pelvis, ureters, bladder, and urethra. But inasmuch as the kidney soon feels the effects of any hindrance to the flow of urine in the lower urinary tract, the practitioner VI PREFACE. should become familiar with those disorders on which the renal lesion may depend. In quoting from the works of others, I have, as a rule, named my authority on the spot. The drawings for the cuts of microscopical objects were made by Dr. J. A. Hemsteger of Chicago. 70 State Steeet, Chicago. PREFACE TO SECOND THOUSAND. I have inserted in the plates of the second thousand, on pp. 41 and 42, directions for the use of chemicals, and hints in chemical ma- nipulations, which I hope will prove serviceable to the inexperienced. I have also added to my list of tables in the appendix, and given arithmetical examples for reference in calcu- lating the quantity of albumin, sugar, and urea in the urine. The reader will also find in the appendix of each new edition a summary of therapeutic progress since the last edition. TABLE OF CONTENTS. CHAPTER I. CHEMICAL EXAMINATION OF URINE FOR CLINICAL PURPOSES. How to detect Albumin, Peptones, Bile, Sugar; how to estimate the quantity of Albumin and Sugar ; how to examine a Urinary Sediment for Urates, Phosphates, Uric Acid, Blood, Pus, Cal- cium Oxalate, Mucus; how to estimate the quantity of Urea, Chlorides, Phosphates, Urates, Sulphates, etc.; List of Beagents and Chemical Apparatus required, with five illustrations. Apparatus used by the author .................... Pages 5-42 CHAPTER II. MICROSCOPICAL EXAMINATION OF URINE FOR CLINICAL PURPOSES. How to Select a Specimen of Urine for Examination ; how to col- lect a Urinary Sediment; how to remove a Drop of the Sedi- ment by means of a Pipette ; how to use the Microscope ; how to use Chemicals in Microscopical Work; hoAv to identify, with the Microscope, Uric Acid crystals, Blood, Pus, Mucus cor- puscles, Calcium Oxalate crystals, Epithelial cells, Triple Phosphate crystals, Calcium Phosphate crystals, Bacteria, Tubercle Bacilli, Tube Casts of all sorts; List of Reagents and Apparatus for Microscopical Work; twelve illustrations. Apparatus used by author........................Pages 43-72 CHAPTER III. SYSTEMATIC APPLICATION OF URINARY ANALYSIS TO DIAGNOSIS. What to do when Albumin is found in the Urine ; how to differen- tiate between Functional and Organic Albuminuria; Classifi- cation of Renal Lesions ; six Tables, showing at a glance the Etiology, Symptoms, Condition of the urine in the various renal lesions, acute and chronic ; Albuminuria according to Lesion ; Acute Exudative Nephritis ; Acute Parenchyma- tous ; Acute Diffuse; Chronic Parenchymatous Change; vii Vlll CONTENTS. Puerperal Nephritis; Parenchymatous Change in Diabetes Mellitus ; Chronic Diffuse Nephritis; Sclerosis; Gouty Kidney; Lardaceous Disease; Acute and Chronic Hyperemia of the Urine in the various Renal Lesions. Acute and Chronic; how to tell whether Nephritis is Acute or Chronic ; two Tables, showing Symptoms of Acute Nepliritis; Table of Differential Diagnosis in Chronic Renal Lesions, parenchymatous, diffuse, sclerotic, etc.....................................l'ages 73"97 CHAPTER IV. THE PROGNOSIS IN DISEASES OF THE KIDNEYS. The Prognosis in Functional Albuminuria; the Prognosis in Organic Albuminuria. Favorable and unfavorable signs. The Prognosis in Chronic Nephritis; the Bearing of Tube-Cants on Prognosis ; Nephritis without Albuminuria; Condition of the Heart; Dr. Tyson's Conclusions for the Life Insurance Examiner ; Summary of Prognosis..............Pages i>8-110 CHAPTER V. THERAPEUTICS OF BRIGHT'S DISEASE. One Hundred Pages on the Treatment of BrightOs Disease : how to cure Functional Albuminuria ; what Cases of Acute Nephritis are Curable, and how to bring about Recovery; Indications for Use of Remedies; Complete Hygienic Details : AVhat the Patient should Eat, what he should Drink, and what he should Wear; how to prevent Post-Scarlatinal Kephritis; how to cure Post-Scarlatinal Nephritis; Table, giving Choice of Lead- ing Remedies in Acute Nephritis ; Treatment of Emergencies, with Remarks on Use of Purgatives, Diuretics, and Dia- phoretics; Cerebral Symptoms and Heart Failure ; Treatment of the Anaemia of Acute Nephritis; how to cure Sub-Acute Nephritis; Climatic Cure of Sub-Acute Nephritis; Diet, Hygiene, and Remedies in Sub-Acute Nephritis. Chronic Nephritis: Diet, Place of Residence, Care of Skin, Air and Exercise, Psychical Influences ; Food and Drinks in Chronic Nephritis; Use of Mineral Waters; Alcoholic Drinks; the Milk Treatment, and just how to use it. Climatic Cure of Bright's Disease: Relative Advantages of Egypt, (ape Town, Southern California, New Mexico; Winter Resorts in Europe and America for the Nephritic Patient; Summer Resorts in the United States, England, Switzerland, etc. The Value of Rest in the Treatment of Bright's Disease; the Effect of Psychical Influences; Clothing and Baths for the Albumin- uric; Value of Fresh Air and Exercise; Use of Oxygen Gas, Passive Exercise, etc. How to follow the Course of a Case by Examination of the Urine ; the Author's Method of Classifying Cases Clinically by ascertaining the Quality of the Urine. CONTENTS. IX Remedies in Chronic Nephritis; Table, giving Choice of Lead- ing Remedies in Chronic Renal Degeneration, dependent upon Hepatic Disorders ; what Mineral Waters to use; Clin- ical Notes; Remarks on Treatment of Dropsy; Remedies in Chronic Diffuse Nephritis due to Syphilis, Gout, or Malaria; the Treatment of Syphilitic Cases; the Treatment of Gouty Cases: Remedies and Waters; the Treatment of Malarial Cases; Treatment of Anaemia ; Remedies in Sclerosis, both according to Cause and Symptomatically; Treatment of Sclerosis prior to Cardiac Hypertrophy and subsequent to it; Treatment during Stage of Heart Failure ; Signs of Death in Sclerosis; Remedies in Lardaceous Disease ; Remedies in Acute Hyperaemia; how to cure Acute Hypersemia of the Kid- neys ; Causes of Chronic Hyperaemia, with Treatment; New Remedies used as Heart Stimulants. The Heart in Renal Diseases. Apex Beat ; how to tell when the Heart is Hypertrophied and Dilated; Weak Heart; Cardiac Failure; Mitral Diseases : Differential Diagnosis ; Atheroma; High Arterial Tension ; Low Arterial Tension ; Treatment of Renal Disease with reference to the Heart. The Albuminurias of Pregnancy : How to tell whether a Pregnant Woman is in Danger of Uraemia ; Choice of Remedies in Puerperal Cases; Clinical Notes : Treatment of Convulsions; Induction of Labor. Complications of Renal Diseases: Treatment of Ascites, Apo- plexy, Asthma, Bronchitis, Cardiac Lesions, Epistaxis, Erysip- elas, Gangrene, Gastric Disorders, Headache, Hydrothorax, Hydropericardium, Jaundice, Nervous Derangements, (Edema, Palpitation of the Heart, Pericarditis, Peritoneal Effusion, Pleuritis, Pneumonia, Retinal Lesions, Septicaemia. Uraturia: Landois's Theory ; R61e of the Liver ; Acute Uraemia ; Symp- toms, Diagnosis, and Treatment; Treatment of Ursemic Con- vulsions; Uraemia during Pregnancy; Chronic Ur;emia more prevalent than generally known ; Treatment. Syphilis of the Kidney. Summaey : General Indications for the Use of Fifty Remedies in Bright's disease, with sixty-five Clinical Notes from the Experience of noted Practitioners in this country and abroad, illustrating the effect of medicinal agents.......Pages 111-216 CHAPTER VI. PYURIA AND HEMATURIA. Examination of the Urine in Diagnosis of Diseases of the Kidney- Pelvis, Bladder, etc.; how to tell where Pus in the Urine comes from ; how to tell where Blood in the Urine comes from ; Use of the Spectroscope ; Diagnosis by Instrumental Exploration; Examination of the Saliva after Injection into the Bladder of Potassium Iodide Solution ; Ratio of Albumin to Haemoglobin. Newman's apparatus............................Pages 217-225 X CONTENTS. CHAPTER VII. RENAL TUMORS. Hydronephrosis ; Cystic Degeneration ; Hydatid Cysts ; Table of Differential Diagnosis in cases of Renal Tumors; Differential Diagnosis between Renal and Non-Renal Tumors; Etiology, Diagnosis, Prognosis, and Treatment of Hydronephrosis, Cys- tic Degeneration, and Hydatid Cysts............Pages 226-233 CHAPTER VIII. SUPPURATIVE DISEASES OF THE KIDNEYS, RENAL PELVIS, AND URETERS. Etiology, Pathology, Diagnosis, and Treatment of Suppurative Nephritis, Pyelo-Nephritis, Pyonephrosis, and Pyelitis ; Micro- organisms in the Urine, and Infective Processes ; Precautions in the Use of Instruments; Administration of Boracic Acid; Dietetic Rules ; Directions for Cupping of the Loins ; twenty Remedies of Value, with Clinical Notes ; Perinephritic Abscess: Causes, Diagnosis, Prognosis, and Treatment... .Pages 234-255 CHAPTER IX. RENAL CALCULUS. Forty Pages on an Important Subject; Frequency of Calculous Disorders in the West; the Uric Acid Diathesis : Diagnosis ; what to do when Renal Calculus is suspected ; the Urine in Oxaluria and Phosphaturia; how to tell in what Part of the Urinary Tract a Calculus is Lodged; Analyses of Urine in cases of Renal Calculus; Treatment of Uricaemia (Uric Acid Dia- thesis) ; Details in regard to Food and Drinks; what Food to Avoid ; what Mineral Waters to Drink; Solvent Treatment of Calculus ; Remedies in Uric;emia ; Palliative Measures ; Oxa- luria : Diagnosis, Diet, and Treatment; Phosphaturia : Causes, Diagnosis, Treatment; when there is Flatulent Dyspepsia. Treatment of Renal Colic : Remedies, Manipulation, Baths, etc ; Treatment of the Haematuria of Renal Calculus; when to Operate for Renal Calculus; Nephro-Lithotomy and miscel- laneous Surgical Measures ; Renal Colic in Children: how to detect Uricaemia in children....................Pages 256-296 CHAPTER X. CHRONIC RENAL TUBERCULOSIS. CARCINOMA, AND OTHER TUMORS. FLOATING KIDNEY. How to Find Tubercle Bacilli in Urine ; the Urine in Genito- urinary Tuberculosis ; Symptoms of Genito-Urinary Tubercu- losis ; Table of Differential Diagnosis in Tubercular Pyelitis, CONTENTS, Calculous Pyelitis, and Renal Cancer; Treatment of Renal Tuberculosis. Cancer of the Kidney: How to Detect its Presence; Symptoms and General Treatment. Other Tumors. Diagnosis and Treat- ment of Floating Kidney ; " Strangulation of the Kidney ;" General Treatment of Renal Haematuria.........Pages <:97-311 CHAPTER XI. SUPPURATIVE DISEASES OF THE URETERS, BLADDER, PROSTATE, AND URETHRA. Diagnosis of Ureteritis and Renal Tenesmus; Differential Diag- nosis between Renal Tenesmus and Renal Colic; Prognosis and Treatment of Ureteritis , Cystitis : Diagnosis ; the Urine in Cystitis; Extraordinary Progress in Diagnosis from use of the Cystoscope ; the Urine in new Growths of the Bladder, and in Stone in the Bladder ; Hemorrhage from the Bladder ; Prog- nosis in Cystitis; Treatment of Cystitis. Diet and Hygiene, Mineral Waters, Remedies, and Clinical Notes ; Solutions used in washing out the Bladder. Cystitis in the Female : Diagnosis and Treatment; how to use the Catheter ; how to wash out the Bladder; Catheter Fever ; Treatment of Hemorrhage from the Bladder ; Suppuration in the Neck of the Bladder : Differential Diagnosis from Pyelitis, Treatment. Fissure in the Neck of the Bladder in Females ; Hemorrhages from Neck of the Blad- der and Prostate. Prostatic Disorders : Hypertrophy ; Congestion ; Chronic Prosta- titis ; Prostatic Irritability ; Treatment. Urethritis : how to find the Gonococci ; " Clap-threads" in the Urine. Summary : How to Examine a Patient when Pus is found in the Urine, with hints for the diagnosis.................... Pages 312-356 CHAPTER XII. OLIGURIA AND ANURIA. INCONTINENCE OF URINE, MOTOR-NEUROSES. Oliguria and Anuria; Diagnosis and Treatment; Retention and Suppression; Treatment. Incontinence of Urine: Causes; what to do in cases of Urinary Incontinence; Diet and Treat- ment, Medical and Surgical, of Incontinence. Motor-Neuroses of the Urinary System : Spasm of the External Sphincter; Spasm of the Detrusors ; Treatment. Paresis of the Bladder : Diagnosis and Treatment. Enuresis : Treatment and Clinical Notes ; Examination of the Patient in Motor-Neuroses, with hints for the diagnosis.........................Pages 357-368 XII CONTENTS. CHAPTER XIII. DIABETES MELLITUS AND INSIPIDUS. How to Test for Sugar in the Urine ; Haines's Test; Brucke's Test; when to Test for Sugar ; Differential Diagnosis between Gly- cosuria and true Diabetes; Early Recognition of Diabetes; Diabetes Decipiens; Analyses of Urine ; what to do in cases of Diabetes; how to Estimate the Quantity of Sugar in the Urine ; Fehling's Solution, how made; Relation of Uricaemia to Diabetes; the Prognosis in Diabetes ; Unfavorable Signs ; the Urine in Diabetic Coma; Early Recognition of Diabetic Coma ; hoAv to Test the Urine in cases of Diabetic Coma. The Cure of Diabetes Mellitus, when possible ; Systematic Method for the Cure; Bill-of-Fare in Diabetes; Drinks; Effect of Diet, Rest, and Exercise ; Baths , Residence ; Climates to be sought; Massage and Electricity ; Respirations; Care of the Mouth and Teeth ; Removal of drops of Urine ; Protection of the Skin ; Occupations ; Accidents ; Oxygen ; Mineral Waters; Remedies; Clinical Notes; Empirical Treatment; Complica- tions. Diabetes Insipidus the two Forms ; Symptoms, Diet, and Treat- ment...........................................Pages 369-398 CHAPTER XIV. MISCELLANEOUS. Disorders in which Peptone is found in the Urine ; Biuret Test; Tests for the various Peptones; the Urine in Diseases of the Liver : Jaundice, Acute Yellow Atrophy, Functional Disorders of the Liver, Carcinoma, Amyloid Disease, Cirrhosis, Hepatic Tumors ; the Urine in Pernicious Anaemia ; the Urine in Neu- rasthenia; the Urine in Insanity and Epilepsy; Ehrlich's Typhoid Fever Reaction : its use in Pneumonia, Phthisis, Puerperal Fever ; Aromatic Compounds in the Urine ; Indican in the Urine; the Urine in Diseases of the Upper Air Passages: Uricaemia and Congestion of the Larynx and Pharynx ; Sum- mary of the Urine in Cancer, especially Cancer of the Stomach. Tests for certain Poisons in the Urine: Iodoform, Carbolic Acid, Morphine..............................Pages 399 to 410 Appendix.—Tables, showing at a glance how to tell what percent- age of the normal average a given quantity of Urine Urea or Phosphoric Acid is............................Pages 411 to'416 Index Pages 417 to 431 CHAPTER I. Systematic Chemical Examination of Urine for Clinical Purposes. Before entering upon the study of urinary pathology it is necessary to become familiar with the physical characteristics of normal urine, its chemical constituents, and the microscopic appearance of the sediment. Attention should also be paid to the changes taking place in normal urine as it becomes old. It is often the case that patients will collect their urine and set it aside for a day or two before giving it to a physician for examination. It is always advisable to inquire into the age of a specimen of urine about to be examined, so as to waste no time on urine several days old. For quantitative chemical analysis the urine of twenty- four hours is necessary. The best day for collecting is 2 DISEASES OF THE KIDNEYS. Sunday. To collect the urine of twenty-four hours the patient should begin Sunday morning after breakfast. He should save the first urine voided after breakfast and all voided during the day, including that which is voided on going to bed at night, pour it all into a bottle and label "Day Urine." He should also save all the urine voided during the night and that which is voided on rising the next morning, pour into a second bottle and label "Night Urine." These two bottles contain the total urine for twenty-four hours. The day urine should be two or three times as much in quantity as the night urine, provided the patient is in health. In addition to the urine of twenty-four hours, the patient should furnish for microscopical examination a sample of freshly voided urine passed after the twenty-four hours' urine has been collected. Moreover, in special cases where it is desirable to detect traces of albumin and of sugar, exam- inations of the urine should be made at different hours of the day. A complete examination of urine, therefore, to be satisfac- tory, should include the following: CHEMICAL EXAMINATION OF URINE. 3 I. Quantitative chemical analysis of the twenty-four hours' urine, with also qualitative tests for abnormal constituents and estimation of the quantity of such as are found. II. Microscopical examination of the sediment of the twenty-four hours' urine and of the sediment of a freshly voided sample of urine passed about noon. III. Tests for albumin and sugar at different hours of the day. Test for albumin at whatever hour the patient is most fatigued, or after the most active exercise of the day. Test for sugar in the urine voided about three hours after the heartiest meal of the day. I have found sugar in urine voided between three and four o'clock in the afternoon when I could not find it at any other time. It is not necessary for clinical purposes to make what chem- ists would call a thorough quantitative analysis, since the sig- nificance of many of the urinary solids is either unknown or of little importance. Estimation, approximately, of the total solids according to a method given in Table III should be made, and also quantitative estimates of urea, phosphoric acid and, in certain cases, uric acid; if albumin and sugar are found, 4 DISEASES OF THE KIDNEYS. the quantity should be estimated. Indican should be tested for and the result compared with normal urine. I have ar- ranged a series of tables which will be found in the Appendix, giving comparisons with normal averages, taking as standards the analyses of Yvon-Berlioz and Parkes, respectively. These tables will be found serviceable to those making numerous quantitative analyses, as comparison of the results of any analysis with normal averages can be made at once without the trouble of figuring. In cases where it is impossible to obtain the total urine of twenty-four hours, microscopical examination of any freshly voided specimen may be made and chemical tests applied to urine voided on rising in the morning. Reliance should not, however, be placed on the results of a few tests of single specimens. Moreover, patients should be taught to furnish as much urine as possible for analysis. Many patients seem to feel that it is indelicate to supply the physician with a large quantity of urine, and give him but an ounce or two, or pos- sibly but a few fluidrachms. Urinary examinations have been much more valuable in their teachings since the collection of CHEMICAL EXAMINATION OF URINE. 5 twenty-four hours' urine has been insisted on. Patients are usually willing, and among the more intelligent classes even anxious to supply the full quantity for the twenty-four hours if they understand that it is wanted, and the suggestion be made that Sunday be taken for the day of collection. TABLE I. Constituents of Normal Urine. Constituent. Average amount in 24. hours. Water, . . 40 to 50 fluid ounces, or 1,200 to 1,500 C. c. Urea, . . 308.6 to 617.2 grains, or 20 to 40 grams Urates, . . . 6.17 to 12.34 grains, or 0.4 to 0.8 gram Kreatinine, . . 7.7 to 20 grains, or 0.5 to 1.3 gram Hippuric acid, . . 7.7 to 15.4 grains, or 0.5 to 1 gram Chlorides,. . J54-3 to 246.8 grains, or 10 to 16 grams Earthy phosphates, I5-43 to 23.14 grains, or 1 to 1.5 gram Alkaline phosphates, 30.86 to 61.72 grains, or 2 to 4 grains Sulphates, . . 46.29 to 61.72 grains, or 3 to 4 grams. TABLE II. Physical Characteristics of Normal Urine. 1. Quantity in 24. hours: Average^S fluid ounces; 3 pints; 1500 Cubic centimetres* Possible normal range: Men, 30 to 60 fluid ounces; Chil- dren, 17 to 50 fl. oz.; Women, 26 to 45 fl. oz. 2. Color: Yellow to amber; after drinking, pale; on rising, dark amber. In young children, but little color. 6 diseases of the kidneys. 3. Specific gravity: Of the 24 hours'urine, 1015 to 1025; after a full meal,, high as 1030; on rising, 1015 to 1025. 4. Solids: 55 to 75 grams, or 850 to 1155 grains, in 24 hours. 5. Reaction: Of the 24 hours' urine, slightly acid; after drinking, neu- tral ; after full meal, neutral or slightly alkaline. 6. Odor: Of the 24 hours' urine, faintly aromatic. 7. Transparency: Usually clear when freshly voided; faintly visible cloud after standing a few hours; sometimes partially opaque when first voided, but later clear, above, with flocculent mass beneath ;* sometimes turbid on cooling.f 8. Consistence: Perfectly fluid like water. TABLE III. How to Examine Urine as to Chemical and Physical Characters. Characteristic. Method of Examination. 1. Quantity in 24 hours: Cause patient to collect all urine voided in 24 hours, be- ginning and ending with an empty bladder. Measure in Cubic centimetres or fluid ounces and compare re- sults with Table II. 1. (Quantity). 2. Color: Let ten or fifteen fluid ounces of the 24 hours' urine settle . *A slight sediment of earthy phosphates, cleared by a few drops ol nitric acid can hardly be regarded as abnormal. tCaused by deposition of urates, which clear on application of heat. chemical examination of urine. 7 and note color of the urine, in the middle and upper parts of the glass; or filter, and note color of filtered urine. If colorless to straw yellow, it is pale; if yellow to amber, is normal; if reddish-yellow to brown, is highly colored. Note any unusual color, as green^ dirty-blue, blood-red, intense yellow, brown, or black. 3. Specific gravity. Take the specific gravity of the 24 hours' sample with a good urinometer, standardized for a temperature of 770 F., and use a fluted glass jar;* read the figure on the scale from above the fluid. 4. Total amount of Solids: Estimate the quantity of solids from the specific gravity: multiply the last two figures of the sp. gr. by Haeser's coefficient, 2.33, and the product will be approximately the number of grams of solid matters in every 1,000 C. c. of the urine; multiply this product by 151^ and the new product will be the number of grains in every 33.8 fluid ounces of urine. [Another and more rapid method is to measure the quantity of urine of 24 hours in fluid ounces and multiply the number found by the last two figures of the sp. gr. The product represents approxi- mately the number of grains of solids in the whole urine of 24 hours]. Consult Table II., 4. ( Solids ). 5. Reaction: The urine being: in a beaker or vessel with a wide mouth dip into it a piece of neutral litmus paper. Hold the paper in the urine until it is saturated; if it turns red, the urine is said to be acid; if it turns blue, alkaline; if it does not change color, it is neutral. In case the neu- tral litmus paper cannot be obtained, the ordinary red and blue papers may be used. Dip into the urine a slip *A long stemmed urinometer standardized at GO' and provided with a thermom- eter is also valuable. 8 diseases ok the kidneys. of red litmus paper, and also, using the other hand, a slip of blue. Hold the papers in the urine until they are saturated; if the blue paper is reddened, the urine is acid; if neither is changed in color, it is neutral. If the urine is found to be alkaline, allow the litmus paper used to dry, and notice whether the blue color remains, or whether the red has returned. If the blue color remains, the urine is alkaline from fixed alkali; if the red returns, the urine is alkaline from volatile alkali. If a piece of bright blue litmus paper is very quickly turned a marked red in freshly voided urine, there is hyper-acidity of the urine. Odor: Notice whether the odor be (i) normal (faintly aromatic), (2) strongly urinous, as in that of fevers, or (3) fetid and ammoniacal, as in stale urine. Transparency : Notice whether the urine deposits a sediment on standing. If the. sediment is plainly visible, the urine is abnormal except perhaps in cases of females, and possibly when the deposit consists of earthy phosphates or urates. (See Table II., 7, foot note.) A slight turbidity or "mucus cloud," barely percepti- ble, is noticed in all normal urine on standing for a short time; after the urine has been voided for some hours, a turbidity may normally be present. The urine of children four or five days old is some- what turbid. The turbidity seen in urine is due to the presence of substances, which the Water of the urine cannot dis- solve or keep dissolved, and which, after long standing, form what is known as a sediment, that is, " something which settles to the bottom." Urine which is transparent is not necessarily normal. chemical examination of urine. 9 Urine which is very turbid when freshly voided is ab- normal. 8. Consistency: Observe whether the urine is (a) perfectly fluid like water, readily flowing through a tube of very small diameter and dropping easily from it, in which case its consist- ence is normal; or, whether (6) it is thick, " ropy," and viscid; or, (c) creamy, forming a jelly-like mass after being voided. Notice whether the froth on the surface of the urine is (a) temporary, in which case it is normal, or (<5) per- manent. I. Notes on Manipulation. 1. Quantity: To collect the urine of young children place a clean sponge over the genitals and fasten the diaper over it. To measure the urine of 24 hours, use a 64 fluidounce graduated jar, or two smaller ones. To convert fluid ounces into Cubic centimetres multiply by 29*. 2. Color: To determine the color of turbid urine, have recourse to filtration. In order to filter urine there is need of a fun- nel, filter paper, and a receiving vessel of some kind, such as a salt-mouthed bottle or a beaker. A filter-ring and stand are also very useful. Funnels for this purpose are of glass, and those three or four inches in diameter across the top are of convenient size. IO diseases of the kidneys. Filter paper is unsized paper, and the best is called Swedish, and may be bought already cut in circular form; filters seven and a half inches in diameter fit well into the funnels above de- scribed. In order to fold a filter so as to fit it into a funnel, first fold it in two, then turn the right half over on the left. In this way a fun- nel shape is given to the paper. Now fit it into the funnel and it is ready for use. When the paper thus folded has been fitted into the funnel three 'pockets1' can be seen; the liquid may be poured into any one of these three wu pockets " except the middle one. It is often well to wet the paper slightly so as to fit it better to the funnel, and, for quick filtrations where the fil- tered urine only is wanted the filter paper may be ribbed. At the bedside, use small filters one to two inches in diameter folded as above, and inserted without a funnel into a wide mouthed test-tube. Observe the color of the urine after it has come through the filter paper. 3. Specific Gravity: Be careful to note as to whether your urinometer is standardized for 60° F., or for 77°. Take the temperature of the urine, using a chemical thermometer, and warm or cool it to the temperature to which the urinom- eter is standardized. (Or consult Table of Cor- rections for temperature. See "Practitioner's Guide in Urinary Analysis.") Squibb's urinom- eter, recommended by Prof. Tyson, is standard- CHEMICAL examination OF URINE. II ized at 77° F., and is free from many objections. A urinometer with a long stem and provided with a thermometer is also useful. 4. Solid*: In taking the specific gravity with a view to estimation of urea or solids, the urine should first be boiled, filtered while hot, then cooled to standard temperature, 77° F., with a Squibb urinometer, or 60° F., if a common instru- ment is used. 5. Reaction: Litmus-paper may be procured in the form of little books, which should be kept protected from the air. Blue litmus can be turned red by exposing to action of acid fumes or by immersing in vinegar and water; in the latter case dry before using. Remember that urine on standing may grow more acid, and finally may change to alkaline reaction. II. Tests for Albumin, Peptone, Bile, Sugar. In general, examine a specimen of the 24 hours' urine. In doubtful cases, examine the urine of each micturition during some one peri- od of 24 hours; if albumin is sought for, cause the patient to take as vigorous exercise as is prudent before voiding urine for examination; women should take a cleansing injection before voiding urine for examination, especially if they are troubled with leucorrhoea. A. Albumin: If the amount of albumin is 12 DISEASES OF THE KIDNEYS. small, or there is doubt as to its presence, as there might be in cirrhosis, lardaceous degene- ration, and congested kidney, especially in early stages; or, if it be desired to test for small quan- tities of albumin in the urine of a patient recov- ering from acute nephritis, recourse should be had to a careful and systematic search as fol- lows: (1). Get the urine perfectly clear; filter through several papers folded together, and if it comes through turbid, warm with one-fourth its bulk of Liquor Potassse and filter again. If the filtered urine is still turbid, warm it with a few drops of magnesian fluid (magnesi- um sulphate one part, pure ammonium chloride one part, pure Liquor Ammonise one part, dis- tilled water eight parts, all by weight) and filter. (2). Fill a test-tube, preferably a short one, to the depth of half an inch with the clear fil- tered urine; hold it somewhat inclined in the left hand, and with the right, take up by means of a pipette, preferably roughened at the upper end, pure colorless nitric acid and allow the lat- ter to flow down the side of the inclined test- tube into the urine. If there is any difficulty in causing the acid to flow steadily from the pipette, rotate the lat- ter, covered by the index finger, between the middle finger and the thumb, as suggested by Dr. Tyson. AVait a few moments until the acid CHEMICAL EXAMINATION OF URINE. 13 has slowly sunk through the urine, then bring the tube from the inclined position to the verti- cal. If a whitish zone is seen at the juncture of the urine and acid, albumin is probably present. Set the tube aside while the next test is being made. (3). Pour three fluidrachms of the clear fil- tered urine into a perfectly clean test-tube pre- ferably a long, narrow one, and add two drops of acetic acid to it. Shake well so that the acetic acid may be well diffused throughout the urine. Take the reaction by pouring a drop or two on a piece of blue litmus-paper. If the lat- ter is not turned slightly red, add another drop of acetic acid, and try again with the litmus - paper. See that the urine turns blue litmus- paper slightly red, then holding the tube by the bottom between the thumb and forefinger, heat the upper part gradually to boiling. If a whit- ish turbidity appear where the urine has been heated, and if moreover a whitish zone was seen resulting from the cold nitric acid test (2), albu- min is present, and nothing further need be done. (4). When albumin is abundant, tests two and three will be noticeably successful; if there is any doubt read the following: . Remarks. 1. If a turbidity be obtained with the nitric acid test, but nothing at all with the heat test 14 DISEASES OF THE KIDNEYS. applied to the clear acidified urine, the urine being allowed to stand six hours after the heat test has been performed before a decision is made, albumin is absent. 2. If with the nitric acid test we are unable to see any zone or turbidity, but with the heat test a turbidity is plainly visible, add a few drops of nitric acid to the urine which has been boiled, and if the turbidity disappear, albumin is absent. If it does not disappear, add up to 15 or 30 drops of nitric acid, and if the turbidity persists, albu- min is present. [_Go back to the test-tube in which the cold nitric acid test has been per- formed, and after it has stood for a time you will probably in a good light be able to see a few flakes of albumin. Even if you do not, however, the heat test now indicates a very small amount of albumin]. 3. Whether the nitric acid test shows a zone or not, if the heat test shows nothing at the time it is performed, but, if after six hours, a turbid- ity is noticed, apply heat again and if the tur- bidity disappear, albumin is absent: if it does not disappear, on boiling, albumin is present. [Go back as in (2) to the test-tube in which the cold nitric acid test has been performed]. 4. If, before making the heat test, upon add- ing acetic acid the urine becomes turbid (as com- pared with a specimen of the clear filtered urine to which nothing has been added) and if, after CHEMICAL EXAMINATION OF URINE. l5 heating, this turbidity is not increased (seen by comparing with the same bulk of clear filtered urine to which the same amount of acetic acid has been added, but which has not been boiled), albumin is absent. If the turbidity is increased, albumin is pvcaent. The conditions described in 2, 3, and 4 will not usually cause any trouble. I lay great stress on the importance of compar- ing results, and have seen dozens of students detect albumin in this way who were unable to see any change before comparison was made. Moreover, comparison does away to a great de- gree with the necessity of a good light, dark back-ground, etc., and thus saves time. 5. If the urine has been boiled with an alkali to make it clear, it should be carefully neutral- ized, by addition of acetic acid, drop by drop, before the heat test is tried. Add the acetic acid, drop by drop, taking the reaction by pour- ing a drop of urine on red litmus-paper. When the urine turns neither red litmus-paper blue, nor blue litmus-paper red, it is neutralized. Enough should be added so that a faint tinge of red may be seen on the blue paper, then pro- ceed with the heat test. Freshly voided urine can generally be filtered clear through several thicknesses of filter paper, and effort, in this direction should always be made first. 6. Instead of a pipette, my own device, a small glass syringe, may be used, to which l6 DISEASES OF THE KIDNEYS. a glass tube, slightly tapering, is connected by rubber tubing. I have found this superior t<; the pipette in point of ease of manipulation. Fill the syringe with the acid, then inserting the tip of the small glass tube inside the test-tube held inclined in the left hand, with the right fore- finger gently press on the piston. The acid will flow out very regularly and slowly, and a clear- cut, well defined zone is seen, if albumin be pre- sent. The syringe should, of course, be well packed and in good order. III.—Estimation of Quantity of Albumin. Rough Method of Estimation of Albumin:— Set the second test-tube—namely, that one in which the acidified urine has been boiled—aside. and then note the amount of albumin which has settled. If the amount is insignificant, the loss of albumin in 24 hours is under 2 grams (31 grains); if moderate, from 6 to 8 grams (93 to 124 grains); if considerable, 10 to 12 grams (155 to 186 grains); if very large, about 20 grams (310 grains). Boil daily, using test-tubes of the same size, the same amount, of urine passed at about the same hour of day, adding 3 drops of acetic acid. Set the tube aside, and compare results with those of a preceding day. Rough Method of Estimation of Percentage of Albumin: Fill a test-tube two-thirds full of CHEMICAL EXAMINATION OF URINE. 17 clear, filtered urine and add 20 drops of nitric acid; let settle. If the entire fluid is coagulated, 2 to 3 per cent of albumin, hj weight, is present; if the coagulated albumin reaches half-way up the column of urine, 1 per cent of albumin is present; if one-third the way up, 0.5 per cent; if one-quarter the way up, 0.25 per cent; if one- tenth, 0.1 per cent; if the curved part of the tube is barely filled with coagulum, 0.05 per cent; slight cloudiness merely, less than 0.01 per cent. It is well to perform the operations in a grad- uated test-tube, as the comparisons can then be made more accurately, and a record of results jotted down in a note book from day to day. Esbach's Method:—Dissolve 10 grams (155 grains) of picric acid and 20grams (310 grains) of pure citric acid (dried in the air) in 800 or 9(H) Cubic centimetres (about 0.8 or 0.9 of a quart) of cold, distilled water. After the substances have dissolved, add distilled water enough to make a litre (1.05 quart). Obtain the specially constructed tube which has an upper mark, R, a second mark below it, U, and the figures 7, G, 5. etc., one above the other, beginning just below U, and going down to nearly the bottom of the tube. Fill the tube with urine, which has been shown to be albuminous, as far as the mark U. Then add the picric acid solution up to the mark R. Close the mouth of the tube with the thumb, and invert a dozen times without shak- l8 DISEASES OF THE KIDNEYS. ing. Then close with a rubber cork, and let it settle for 24 hours. Read the height of the deposited albumin in figures on the tube. If, for example, the sediment is as high as the fig- ure 5, it means that this particular specimen of urine you are examining contains 5 grams (77 grains) of albumin to the litre. The graduation of the instrument, therefore, represents in grams the quantity of albumin contained in a litre of the urine under examination. Reckon a gram 15i grains, and a litre a quart. See how many litres of urine the patient passes in 24 hours, and multiply this number by the number of grams in one litre, found by estimating, and the result is the total amount of albumin the patient is voiding in 24 hours. The urine in all cases should be acid. Hence, if it does not redden blue paper, add a few drops of acetic acid. Urine loaded with albumin may better be diluted with water, so that the sedi- ment does not rise above the figure 4. If this is done by adding an equal amount of water, then double the result found; if by adding two parts of water to one of urine, multiply the number of grams (figure on the tube) by three and so on. For clinical purposes this method gives at the end of 24 -hours sufficiently accurate data. All estimates should be made from a specimen of the mixed urine of 24 hours, and in cases where there is no great hurry it is well to let the preci- CHEMICAL EXAMINATION OF URINE. IO, pitate settle 30 hours instead of 24. To find the per coda ge of albumin move the decimal point one place to the left. Thus, if a specimen is found to contain 4 grams to the litre, the per cent of albumin is 0.4 that, is four-tenths of one per cent. The total quantity of albumin voided in 24 hours is, however, what I prefer to record. B. Detection of Bile. (a) Coloring Matter:—I. Drop into a test- tube containing nitric acid to an inch in depth a splinter of wood and boil. The acid turns yel- low. Proceed now as in testing for albumin. If bile coloring matter be present, there will be seen after the acid is caused to flow down the side of the tube into the urine a series of colors at the juncture. The colors from above down- wards will be green, blue, violet-red, and yellow. Green is the most constant and first color in order; the violet, shading into red and yellow, is most always seen. Criticism:—The above test is not always suc- cessful. The urine tested should be that freshly voided. If the test fails, dip a piece of white filter paper into the urine and let it dry. Brown coloration on the paper indicates bile. Try also the following: 2. Float afe/r drops of urine on some tinct- ure of iodine in a test-tube. Green color at juncture indicates presence of bile-pigment. 20 DISEASES OF THE KIDNEYS. Bile Acid Salts: Approximate Estimation:— To 20 minims of clear filtered urine reduced to 1008 in sp. gr. add 60 minims of test-fluid pre- pared as follows:— Pulverized peptone - gr. xxx; Salicylic acid - gr. iv; Acetic acid (B. P.) - - - m. xxx: Distilled water to - - - fl. oz. viii. To be filtered repeatedly until transparent. If bile salts are present in quantity greater than normal, a distinct milkiness promptly ap- pears, becoming more intense in a moment or so. If the bile salts are in normal or less than nor- mal quantity, there is no immediate turbidity, but in a short time a slight tinge of milkiness is seen. C. Detection of Peptones—Ralfe's Test. Whether or not serum albumin has been found, take cold Fehling's solution* and cause fresh amount of urine to trickle clown the side of the test-tube into it. A rosy-red color at juncture indicates presence of peptones; a violet coloration may be noticed when serum albumin is present, in which case try the test on urine freed from albumin by boiling and filtering. D. Sugar. In testing for sugar obtain urine voided two or three hours after the principal meal. In *See Sugar. CHEMICAL EXAMINATION OF URINE. 21 estimating the quantity, collect and measure the urine of twenty-four hours. To test urine for sugar in routine manner use the caustic potash test. 1. Liquor Potass 03 test:—Add an equal amount of freshly-made solution of potassium hydrate (sp. gr. of solution, 1060) to the urine, mix well, boil upper part of' column of fluid, and, if sugar be present, the heated portion will be colored, first yellow, then brown-red, while the non- heated part does not change color. Nitric acid destroys the color and the fluid gives off an odor of molasses. This test is useful for its simplicity, but it is not very delicate.* If it gives no marked coloration, recourse should be had to the following: 2. Copper test for Sugar:—Grind up in a glass mortar five grains of pure crystallized cop- per sulphate and ten grains of pure neutral potassium tartrate. Dissolve the whole in two fluidrachms of liquor potassse. A blue liquid results. Take a little of this, say, 15 minims or about 1 C.c, dilute with four times its bulk of dis- tilled water and boil for a few seconds. If 'clear,f proceed as follows:—remove any albumin from the urine by cautiously acidulating with acetic acid, boiling well, and filtering; then add to the *To test for small quantities of sugar requires much judgment and experience. t If the solution is not clear on boiling make a new solution or add a little more liquor potassse and filter. 22 DISEASES OF THE KIDNEYS. hot, clear, blue liquid a few drops of the urine and raise to the boiling point, if in the mean time the blue liquid has cooled. A yellow pre- cipitate indicates sugar in abundance. If no precipitate is obtained on adding a few drops of the urine, add more, drop by drop, bringing to the boiling point occasionally, until finally a volume of urine equal to that of the blue liquid has been added. If now there is no. yellow pre- cipitate, sugar is absent, clinically speaking." It will be found convenient to procure Haines's sugar-test liquid for routine work in sugar- testing. It is a blue liquid containing sulphate of copper, alkali, and glycerine. Quantitative Estimation of Sugar. 1. Rough Metliod/—Collect urine of 24 hours. Take specific gravity. Multiply last two figures of the sp. gr. by 2, and this result by the number of litres of urine passed in 24 hours. Subtract 50 and the result is the amount of sugar in grams. Multiply by 15* to get it to grains. Suppose total amount of urine in 24 hours be four litres; sp. gr. 1036: (36x2x4)-50 — 238 grams of sugar in the 24 hours urine. 2. Approximate Method / — Collect the urine of 24 hours, measure carefully, pour four fluid ounces into an eight ounce bottle and add a *The author hardly thinks it worth while to discuss the interminable suDieot of traces of sugar, in a work of this kind. CHEMICAL EXAMINATION OF URINE. 23 small piece of yeast, then pour four fluidounces into another eight ounce bottle, adding no yeast. Set aside the two bottles in a warm place for 24 hours, then take specific gravity of the urine in each. It will be found that the one containing the yeast is of lower specific gravity than the one without the yeast. Each degree of sp. gr. lost means one grain of sugar to the fluidounce of urine, or 0.2196 gram of sugar to the 100 C. c. of urine. For example, suppose the patient voids 150 fluidounces of urine in 24 hours; suppose sp. gr. of the urine in the bottle with yeast to be 1035, in that of the bottle without yeast 1045, then this specimen of urine contains ten grains to the fluidounce, and in 150 fluidounces there will be 150x10 grains or 1,500 grains of sugar passed in the 24 hours. This method of estima- tion should be made from time to time in order to ascertain whether the patient is voiding more and more sugar or less and less. The same urinometer should always be used and, prefer- ably, one with a long index, so that the variation in degrees can be easily read off and closely observed. N. B. In making the fermentation estimate be sure that the bottle containing urine without yeast be tightly corked; the urine containing yeast may be poured into a bottle provided with a nicked cork to permit escape of the carbonic acid gas formed. 24 DISEASES OF THE KIDNEYS. Occasionally it is wise to make an accurate estimation of the percentage of sugar. E. Sediment. Proceed now with the examination of the sediment; go back to the first portion of the urine which has been standing so that the sedi- ment, if any, may settle. Pour off the super- natant urine very carefully down the side of a glass rod; when nearly all the urine has been poured off from the sediment cease pouring; save the urine that has been poured off and let it settle again for microscopic examination, No. 2. Divide the sediment, if abundant, into two portions, reserving one portion for micro- scopical examination, No. 1. [If the sediment is not abundant, proceed at once to the micro- scopical examination]. N. B. It is sometimes necessary, especially when a uric acid sediment is to be looked for, to collect the urine of separate micturitions, let settle and observe carefully in how many hours or minutes the sediment is perceptible. I. Chemical Examination of the Sediment. (a) Warm a little of the sediment in a test- tube, taking care not to boil; pass the tube to and fro in the flame of the alcohol lamp; if the sediment clears noticeably (shown by compar- ison with sediment in another tube not heated) CHEMICAL EXAMINATION OF URINE. 2^ urates are present. Sediment often reddish. (b) Whether urates have been found or not, examine the sediment with the naked eye for uric acid crystals. These appear as reddish, or reddish-brown specks, like red-pepper grains. They may be seen either along the sides of the glass in which the urine is contained, or on the bottom of it. Hold the glass up at arm's length and look at it from below. If the urine is in a bottle, the uric acid crystals may possibly be collected in the lowest corners of the curving bottom. (c) If the sediment is reddish in color, or dark, test for blood: take equal parts of spirits of turpentine and tincture of guaiac, shake well, and cause an equal volume of sediment to flow down the side of the tube into the mixture; a blue coloration at the juncture indicates pres- ence of blood. [If blood is present, the phos- phates in urine when precipitated by caustic potash and gentle heat will appear blood-red in color]. The tests should be made on freshly voided urine if possible and, if unsuccessful, the microscope should by all means be used; it is in general, moreover, advisable to use the mic- roscope in order to make the differential diag- nosis between hematuria and hemoglobinuria. In performing the turpentine and guaiac test pay no attention to a whitish turbidity, which 26 DISEASES OF THE KIDNEYS. appears in the lowest part of the liquid after the urine is added. (d) Take a fresh sample of the sediment, add four or five drops of U. S. P. acetic acid to it, shake well, and compare with the same bulk of sediment to which just as much distilled water has been added as was acetic acid. If the sedi- ment is noticeably cleared by the acetic acid, earthy phosphates are present. Take a fresh amount of the sediment to which nothing has been added, and dip into it a piece of red litmus- paper; it should be turned blue, if the phosphatic sediment is in any abundance. Allow the paper to dry, and if the blue color persist, calcium phosphide is probably the chief constituent of the sediment, the urine being alkaline, from fixed alkali as it is called. If the blue color disappear when the paper dries, triple (ammo- nio-magnesian) phosphate is the one. (In all cases the microscope should be used to confirm results). (e) If the sediment is not wholly urates nor phosphates, nor both, but there is evidently something else present, pour some more of it into a test-tube and add a few drops of Liquor Potassse. If the sediment be originally of a whitish color, and on addition of the caustic potash become greenish and glassy, first stringy, then thicker, till it forms a lump,^.s is present. The stringiness maybe perceived by pouring the CHEMICAL EXAMINATION OF URINE. 27 mixture from one tube to another, or by trying to remove by means of the pipette. If the sed- iment is dissolved by the caustic alkali, but has not been by heat, mucus is the constituent. [Uric acid is soluble in Liquor Potassse but is not light colored]. The above directions apply to testing well- marked and characteristic sediments examined within a few hours after the urine has been voided, and before any changes have taken place. In other words, before the urine becomes stale. In many cases chemical identification of a sedi- ment is not easy, and recourse to the microscope must be had. Note, however, the following:— Practical Hints. 1. The urine on standing deposits some little sediment, but remains generally turbid, the tur- bidity not settling, not even if the urine stand for days; the sediment removed by the pipette does not respond to tests (a) to (e); bacteria are present and the sediment needs use of the mic- roscope for recognition. [Such urine if tested for albumin needs magnesian fluid and warming before filtration, otherwise it will not filter clear]. Held up to the light in a test-tube the urine will be seen, especially when shaded with the hand, to be traversed by fine, silky, interlac- ing waves. 28 DISEASES OF THE KIDNEYS. 2. No sediment is noticeable at the end of a few hours, but a very slight one after twelve to twenty hours, the urine not being alkaline. Ex- amine with microscope for calcium oxalate. [If enough of the sediment can be collected, and no albumin is present, divide into two parts, add acetic acid to one and nitric to the other. If acetic acid have no effect but nitric acid dissolve, it is possibly calcium oxalate. Verification by means of microscope not only desirable, but ab- solutely necessary, as certain forms of the ox- alate are of great clinical significance]. Keep the sediment in a cool place, or in a well-stopped bottle. Urine containing calcium oxalate sedi- ment will often deposit it on the sides of the glass, forming numerous fine lines running in bands. It is often the case that the sediment is either caught in the mucous cloud, or according to Tyson, the whole of the cloud-like mass so much resembling mucus is made up of the oxa- late of lime (chemical term, calcium oxalate). When it has settled there will often be noticed two parts to the sediment:—a soft, grayish layer on the bottom, and, over this a whiter, denser layer with a wavy, but well-marked surface. 3. The sediment is abundant enough for chemical tests and settles within a few hours. It clears partly with heat, but does not respond to any other tests. In this case, after warming, add a drop or two of Liquor Potassa>, and, if it CHEMICAL EXAMINATION OF URINE. 29 clears noticeably, urates and uric acid both may be present. Verify with the microscope. 4. If the sediment clear wholly on application of heat, so as to be as clear as the urine itself, decanted or filtered from the sediment, it is com- posed of urates and no further chemical tests need be made. 5. If the sediment with heat has not cleared, or only partly cleared, and, moreover, on addi- tion of acetic acid has cleared only in part, and, further, if it respond to no other of the tests thus far given, recourse should certainly be had to the microscope. 6. If the test for pus given in (e) be not suc- cessful, pus is not necessarily absent. This test is of value only (a) when the urine is acid in reaction, and (b) when also the amount of pus is considerable. When the amount of pus is inconsiderable even though the urine be acid in reaction, the test applied as in (e) will not give a cohesive lump, but the sediment disappears, and the fluid becomes vitreous and stringy. Use as much sediment and as little supernatant urine as possible. The chemical test in such cases not being marked in results, many prefer Day's test; pour a little tincture of guaiac not freshly made into a test-tube and let some of the sediment trickle doAvn into it. If a blue color appear, in course of a few minutes, pus is present. This test, 3° DISEASES OF THE KIDNEYS. however, should be confirmed, if possible, by microscopic identification of pus corpuscles. 7. The test for pus given in (e) fails in alka- line urine: pus is not necessarily absent; if urine is turbid when freshly voided, clears consider- ably on standing, and the sediment is greenish, stringy, tenacious, and clings to the side of the glass, the ropy strings being soluble in acid, it is pus. Mucus alone does not form a similar cohering mass. For verification, test the urine itself as follows:—fill a test-tube half full wTith the filtered urine to be tested, and heat gradu- ally the upper part of the column of the fluid to boiling. An increase of the opacity in the por- tion so heated, as compared with the lower por- tion not boiled [seen against dark background] indicates presence of pus, if fins increased opacity remains after addition of one or two drops of acetic acid. 8. The sediment does not respond to the various tests, and, it has been noticed, that the urine filters very slowly: excess of mucus is present, and the sediment becomes a thin liquid with flakes on addition of Liquor Potassa?. If pus is present at the same time, this test will not be successful. In which case take a solution of iodine dis- solved in potassium iodide solution and add a little of it to acetic acid; pour the mixture into the urine and a turbidity will be seen, due to CHEMICAL EXAMINATION OF URINE. 31 presence of mucus. This test distinguishes mucus from pus. Filter urine suspected to con- tain much mucus and allow the filter paper to dry; if it appear coated, as if with glistening varnish, much mucus is present. 9. If the urine is albuminous and of acid re- action: the sediment may be very slow in settl- ing; do not wait for it to settle, but shake well in a test-tube, boil, and filter. If the filtered urine on cooling throws down a sediment which in turn is cleared by application of heat, the sediment consists of urates, at least in part. Table IV. Important Constituents of Urinary Sediments.* Test. Heat dissolves. Recognized by naked eye. Blue with turp. & guaiac. Acetic acid dissolves. Caustic potash makes stringy. Caustic potash makes flaky Soluble in nitric acid and in acid sodium phosphate. *For all constituents not mentioned here, consult "Practitioner's Guide in Urinary Analysis," second edition. Constituent. Urates Uric acid. . Blood..... Phosphates. Pus.......... Mucus(Epithelia) Color of Sediment. Reddish or fawn colored. Reddish crystals Reddish...... Whitish..... Whitish Whitish Calcium oxalate. Whitish Reaction of Urine. Acid........ Acid........ Any reaction. Alkaline or neutral. Any reaction. Any reaction. Any reaction. ■22 DISEASES OF THE KIDNEYS. II. For identification of epithelia, oil glob- ules, tube-casts, fungi, and spermatozoa, see Chapter II. Consult Chapter II. also for closer identification of substances just mentioned in Table IV. F. Normal Constituents. Urea, Chlorides, Phosphates, Sulphates, Urates, etc. Estimation of the quantity of the normal con- stituents is of importance. Mere qualitative testing is of no moment, for all normal urine contains them. Estimation of urea is of the greatest importance as an aid to prognosis and diagnosis. See Chapter IV. (a) Estimate first the urea: use the hypo- bromite process with, for example, (1) Doremus's instrument. 100 grammes (1543 troy grains) of caustic soda dissolved in 250 C. c. (8.5 fluidounces) of distilled water. Of this solution take 10 C. c. (2.7 fluidrachms) and add 1 C. c. (16 minims) of bromine. Shake the mixture well, until the bromine is dissolved and the whole becomes yellow in color. Dilute with 10 C. c. of distilled water. Pour the whole into the cup of Doremus's ureometer and care- fully fill limb with it. Then by means of a curved pipette introduce 1 C. c. of urine into the soda solution. Effervescence takes place CHEMICAL EXAMINATION OF URINE. 33 and the soda solution is displaced by the gas formed. Every division on the scale of the instrument indicates 0.001 gramme of urea in 1 C. c. of urine. (2) As bromine is unpleasant to use, try the hypochlorite method, with, for example, the instrument devised by Lyons or Squibb, or the apparatus of Fowler. In using the Lyons in- strument proceed as follows : Have ready two solutions: one of potassium bromide, 90 grains to the fluidounce in strength, the other Liquor Sodse Chloratse, preferably Squibb's. Do not use a stale sample of the soda solution. Mix 5 C. c. of the bromide solu- tion with 25 C. c. of the chlorinated soda, let stand a few minutes, then pour into the ureo- meter. Now fill the graduated test tube exactly to the mark with the urine to be examined, and lower it into the bottle by means of a thread, or by the aid of a pair of dressing forceps, taking care that none of its contents are spilled in the operation. Fill the graduated jar with water, which must be of the same temperature as the air of the room, to a point a little above the 0 of the scale, supporting the extremity of the overflow tube so that no water can escape. Remove the rubber cap from the vent tube and connect the apparatus, pressing in the rubber corks firmly so as to make the joints air-tight. 34 DISEASES OF THE KIDNEYS. Finally put on the rubber cap, drawing it down so as to force a little water out of the overflow tube, and bring the level of the water remaining exactly to the 0 mark, the orifice of the over-. flow tube being on the same level. A little practice will make this easy. To make sure that the connections are all perfectly air-tight, lower the end of the over- flow tube a few inches ; a few drops of water will escape from diminished pressure, but if the joints are perfect there will be no further drop- ping. If there is any leakage, the defective joint must be found, and the difficulty corrected before proceeding further with the experiment. Having made sure that the connections are perfect, catch the curved end of the overflow tube over the edge of a measuring graduate, (an ordinary bottle or any other receiver may be used in place of the graduate). Now, by canting the bottle, cause the urine to flow out of the test tube and mix with the hypobromite solution. Effervescence is at once produced, and the gas evolved forces a corresponding volume of water out of the overflow tube. Shake the bottle occasionally, but not too violently, to promote the escape of the gas. When the action appears to be at an end, pour into the measuring graduate water enough to reach above the opening of the overflow tube, in order that cooling of the gas evolved, which is at first CHEMICAL EXAMINATION OF URINE. 35 quite warm, may not draw air into the appara- tus. Let the apparatus stand 15 or 20 minutes to cool, then shake the bottle containing the urine once more and proceed to read off the result. To do this, it is necessary to bring the opening at the end of the overflow tube just to the same level as that of the fluid remain- ing in the graduated cylinder, since raising or lowering the tube slightly affects the volume of the gas to be measured. The percentage of urea is read off without need of any calcu- lation from the scale of the instrument. Fio. 1. Lyons's Urea Instrument. To calculate approximately the total urea of 24 hours, multiply the quantity of urine ex- pressed in Cubic centimeters by the percentage of urea obtained. Thus, suppose quantity of 36 DISEASES OF THE KIDNEYS. urine in 24 hours is 1500 C. c. Suppose per- centage of urea is 2*. Then 1500 x .025 = 37.5 grammes of urea, approximately, in the whole urine for 24 hours. [To reduce to troy grains multiply by 15i]. If the urine is of specific gravity above 1025, dilute urine with equal parts water before es- timating, and multiply percentage figure ob- tained by 2. (b) Estimate the sodium chloride in an ap- proximate way : Decrease or absence of common salt from the urine is alone of importance. Hence it is not necessary to pursue any complicated quan- titative process. Make a solution of silver nitrate containing one gramme to eight Cubic centimetres of dis- tilled water. Obtain a specimen of the 24 hours' urine, remove albumin, if there is an abundance of it, by boiling and filtering, fill a test tube half full of the filtered urine, add two or three drops of nitric acid, shake, then add just one drop of the silver nitrate. If the urine contains a normal amount of chlorides, a precipitate is formed in the shape of cheesy lumps which do not further divide, nor make the urine more milky, by moving the glass about. If the chlorides are so diminished as to be of clinical significance, no lumps will form, but a CHEMICAL EXAMINATION OF URINE. 37 turbidity only, and the entire fluid becomes milky. (Tyson). If no chlorides are present, there will be no turbidity at all. In cases where the physician may be unable to prepare a weighed amount of the silver nitrate, let him dissolve some of the crystals in distilled water and proceed as fol- lows : Procure half a dozen test tubes of the same size; make a mark with a file half way up each one of them; make another mark an inch, say, above this one, being careful that the marks on all the tubes are the same distance from the end of the tube. Fill the tube half full of urine, then add a drop or two of the nitric acid, and then solution of silver nitrate pouring it in up to second mark. Shake well and let precipitate settle. Set tube aside and next day repeat the operation in a second tube and compare results, noting height of precipitate. If the precipitate grows less and less in amount, it is an unfavor- able sign; if more and more, favorable. It is important in each examination to have the urine of twenty-four hours from which to examine a specimen. (c) Phosphates—Earthy Phosphates : These may be approximately estimated as follows : Get a test tube 16 centimetres (6.299 inches) long and 2 centimetres (.787 inch) wide. Make 3§ DISEASES OF THE KIDNEYS. a mark on it one centimetre from the bottom (.399 inch). Fill one-third full with clear or filtered urine, add a few drops of Aqua Am- monise or Liquor Potassa3, warm over a lamp until a precipitate is plainly seen. Lay aside for 10 or 15 minutes. If the sediment is notice- ably above the mark, the earthy phosphates are increased ; if noticeably below, decreased. (Ploffmamr Ultzmann). Alkaline Phosphates: Add to clear, filtered urine one-third its bulk of magnesian fluid (page 12). A snow white deposit takes place. If the entire fluid present a milky cloudiness, the amount is normal; if the cloudiness is denser and creamy, the amount is too great; if but slightly cloudy and transmit- ting light distinctly, the phosphates are dimin- ished. (Tyson). id) Sulphates. Prepare solution of barium chloride (1 gramme in 8 Cubic centimetres of distilled water and one-half of one Cubic cen- timetre of hydrochloric acid). To clear urine in beaker, add one-third its bulk of the barium chloride solution. Opaque milky cloudiness normal. Intense opacity, con- sistency of cream, too much. Slight cloudiness, too little. (Tyson). Compare with normal specimen to which the same amount of chemical solution has been added. ( phi-litic taint. 98 CHAPTER IY. The Prognosis in Diseases of the Kidneys. A. Functional Albuminuria. If the albu- minuria is indeed functional,1 the prognosis is favorable except that repeated functional dis- order paves the way for organic renal disease. Grainger Stewart holds that the gravity of mere albuminuria as a symptom has been over- rated. Nevertheless I regard every persistent albuminuria in a patient over 40 as incipient Bright's disease, provided, of course, the albu- min is not due to presence of pus, blood, etc. B. Organic albuminuria: The prognosis de- pends upon the kind of. renal lesion. I. In acute nephritis the prognosis is, as a rule, favor- able, but depends somewhat on the form. In (a) acute exudative nephritis (See Table YI.c/) which is essentially a transitory lesion, if the patient does not die from the immediate effects of the disease the kidneys return to their nat- ural condition, hence the prognosis is favor- able so far as they are concerned, and rests upon the nature and severity of that disease of which the nephritis is a complication. l Carefully distinguish between functional albuminuria and the intermittent albuminuria of certain renal lesions. [ See Chapter III, Chronic Diffuse Neph- ritis (Large Kidney) and also Sclerosis]. THE PROGNOSIS IN DISEASES OF THE KIDNEYS. 99 In (b) acute parenchymatous degeneration on the other hand, the prognosis is grave. If the lesion is due (a) "to mineral poisoning, death is not always immediate but may take place in a few years from chronic nephritis. If the lesion exists (b) as a complication of an acute disease, the termination is usually fatal. For example, in scarlet fever, as is well known, if convulsions occur, the patient seldom lives. Similarly in typhoid fever and other acute dis- eases, the advent of the parenchymatous lesion is an unwelcome one. It is, therefore, of great importance that the physician be able to re- cognize this form of acute Bright's disease. (See Chapter III., Table VI. a). In (c) acute diffuse nephritis, it is important to note whether the lesion is a sequela or com- plication of some acute disorder : if either, the prognosis is favorable if the disease is recog- nized early and is mild in its onset. In some few cases death takes place within a day or two, following very rapidly on uramic symp- toms. If, on the other hand, the lesion is idio- pathic, not a sequela or complication of an acute disorder, the prognosis while it may be immediately favorable should be guarded as to the ultimate result, since inflammations with production of new connective tissue are likely to persist, become chronic, and eventually prove fatal. But it is possible by proper treatment IOO DISEASES OF THE KIDNEYS. to bring about recovery and to prevent the disorder becoming chronic. It is readily seen how closely prognosis and treatment are linked to diagnosis in cases of acute nephritis, and that the life itself of a patient rests upon an intelligent understand- ing of the pathological condition in the begin- ning. Certainly no field is more attractive to the student of medical science than the one through which we are now wending our way over paths to which the author hopes these pages may serve as a guide. Favorable signs in acute nephritis are the following: urine less dark colored and less scanty before end of the first week. At end of two weeks, quantity of urine nearly normal and albumin but one or two tenths of one per cent. At end of four weeks, urine nearly nor- mal ; may contain small amount of albumin. If there has been much dropsy, the quantity of urine may become very large. Steady in- crease in total solids with disappearance of casts a favorable sign. Unfavorable signs in acute nephritis: Severe symptoms in the earliest stages ; sudden fall in the quantity of urea1; complete suppression2 of urine. If the urine continues to be scanty 1 If the urea falls much below 16 grammes in 24 hours, it is usually unfavor- able. 2 Cases are, nevertheless, on record of complete recovery after suppression of more than two days. (Ralfe). THE PROGNOSIS IN DISEASES OF THE KIDNEYS. and with much blood, acute ursemia may super- vene at any time ; or the patient succumb to various- complications in the second or third week or before. If the urine increases in quan- tity, the blood disappears, the albumin dimin- ishes, but yet casts persist and are of the granular and fatty variety after six or eight weeks, the disorder is to be regarded as chronic. II. Chronic nephritis: the prognosis in chron- ic nephritis depends on the form of renal les- ion present. In (a) chronic parenchymatous metamorphosis early death is, as a rule, to be predicted. The patient may live one or two years at most. Death oftener takes place in a few weeks or a few months. Recovery sometinies seems to have taken place but, after a time, all the symp- toms will return. When the patient is finally so ill as to be confined to his bed, recovery is very unusual. In (b) puerperal nephritis the matter of prog- nosis is a nice one and deserves careful con- sideration. In general, if the patient escape eclampsia, and if she has had no previous re- nal disease, the prognosis is favorable.1 So long as the severest symptoms are merely nervous- ness and anxiety, the amount of albumin mod- 1 Reliance can not be placed on an assumption or statement that a patient has had no previous renal disease, unless the urine has been carefully examined during ail pregnancies. 102 DISEASES OF THE KIDNEYS. erate, and the quantity of urine in 24 hours not greatly diminished, the total solids and urea in particular not too low (urea not below sixteen grammes) the prognosis is favorable.1 Suppose now the patient has convulsions, what is the prognosis? Serious, if convulsions occur before or during labor. But the case may not terminate fatally even if convulsions occur dur- ing labor. If the convulsions are violent, fre- quent, long-lasting, and associated with notice- able coma, the prognosis is unfavorable ; if they are not severe, shorter, and if the inter- vals between attacks grow longer and the pa- tient is conscious throughout, the chances are better. As a rule the earlier in the course of ges- tation nephritis arises, the more unfavorable the prognosis, unless abortion occurs.2 When nephritis occurs in several pregnan- cies, the tendency is to the development of chronic nephritis. [ Many authors think the latter to be chronic interstitial nephritis, but, so far as my experience goes, I find the urine in some cases like that of chronic parenchy- matous change, sometimes like that of chronic diffuse nephritis, seldom like that of sclerosis proper]. l Nevertheless the patient should be watched and collections of urine made constantly. 2 Purdy. THE PROGNOSIS IN DISEASES OF THE KIDNEYS. IO3 The immediate prognosis in puerperal neph- ritis is unfavorable when the quantity of urine in 24 hours is reduced with total solids much below normal figure. When, however, the quantity of urine and solids is not far from normal, eclampsia seldom takes place.1 (c) Parenchymatous change associated with diabetes mellitus : the cases which I have seen, terminated fatally, as a rule, within a short time after albumin and casts appeared in abund- ance. An increase in amount of albumin and in number of casts, coupled with decrease in quantity of urine and of sugar, is a highly un- favorable sign, and coma may soon be expected. The usual length of time within which death takes place is from six to twelve months after the albuminuria appears, but, according to Rob- erts,2 some patients live many years. The care and attention which a patient receives has much to do with the prolonging of life, but, so far as is known, the case will always termin- ate fatally eventually. In (d) chronic diffuse nephritis (large white kidney) the immediate prognosis is fairly fa- vorable and, while recovery can not be pre- dicted with certainty, patients willing to live like sensible beings may be assured of from ten to twenty years of comparative comfort. 1 Purdy, Bright's Disease, 1386. 2 Urinary and Renal Diseases. 104 DISEASES OF THE KIDNEYS. The prognosis should be based on a knowledge of the patienVs character : if he is a man who goes to excess in any direction, over-eats, drinks to excess, or over-works, exacerbations will occur at any time, and the prognosis is then unfavorable. If the patient suffering from the disorder be stricken with pneumonia, the prognosis is unfavorable. Signs of an exacerbation are decrease in quantity of urine, decrease in urea, presence of blood in abundance, increase in albumin, in- crease in quantity of casts. Death may take place with awful suddenness after one of these exacerbations. In chronic diffuse nephritis of the second form, viz.: small kidney with vascular thicken- ing, the prognosis is as favorable or more fa- vorable than in the first form.1 In chronic diffuse nephritis, third form, viz. small kidney without vascular thickening, the prognosis is unfavorable after the symptoms have become pronounced. This is undoubted- ly the most fatal form of the diffuse group.1 In (e) clironic interstitial nephritis (sclerosis) and in gouty kidney the prognosis is unfavor- able and the disorders essentially incurable, but the time a patient may live is from ten to twenty years, if the disorder is recognized early. Sudden death, following excesses or 1 Porter, Renal Diseases, 1887. * THE PROGNOSIS IN DISEASES OF THE KIDNEYS. IO*C strains of any kind, is common. Death may be due to paralysis of the heart or follow con- vulsions or coma. In (f) lardaceous disease of the kidneys the prognosis depends on the primary disease,1 which, as a rule, is fatal. If the primary dis- ease can be treated successfully, the patient will not die from lardaceous disease. Patients have been known to live eight or ten years. xVdvanced stage of the disease is indicated by decreased urine, increased albumin, and abund- ance of casts. Ursemia is not so common in this disorder as in some other forms of Bright's disease.2 Cases—or at least one case—are on record in which lardaceous disease following constitutional syphilis was cured. When lar- daceous disease complicates chronic parenchy- matous nephritis, the case is usually hopeless.3 Chronic diarrhoea is an unfavorable sign, as is also general dropsy. In (g) acute hypericinia the prognosis is, as a rule, favorable. In cases of malarial poison- ing or by some irritating diuretic, suppression and ursemia may take place4 and death follow, unless the patient be relieved. In (h) chronic liypercemia (cyanotic indura- tion) death from this condition alone is un- 1 Phthisis, caries, suppurative processes with syphilitic taint. 2 According to Saundby lardaceous disease is not properly a form of Bright's- 3 Ralfe. 4 Porter. io6 DISEASES OF THE KIDNEYS. usual. But the prognosis is unfavorable, inas- much as the diseases on which the disordei depends are, as a rule, incurable. So long as the compensatory enlargement of the ventricle1 is adequate to overcome the mitral defect and to maintain a proper balance between the arte- rial and the venous circulation, the case will continue in a favorable condition without the appearance of urgent or marked symptoms. Such improved state may last for several months and in some cases possibly two or three years, with but slight fluctuations.2 Nevertheless in some cases exacerbations occur,3 one after an- other, till finally the patient succumbs to urse- mic attacks. Or death may result from exhaus- tion, extreme dropsy, pulmonary apoplexy, or heart failure after the hypertrophy of the ven- tricle passes into fatty degeneration or dilata- tion. Reduction in the quantity of urine with in- crease of the dropsy is,then, an unfavorable sign. Complicatienis of renal lesions: there are many unwelcome complications in the course of renal diseases, rendering the prognosis unfavorable. The most serious are the following in alpha- betical order : Apoplexy. Asthma (uraemic). 1 Do not mistake dilatation of the heart for compensatory hypertrophy. 2 Purdy. 3 A help in the diagnosis is the age of the patient; if young, the case is more likely one of acute nephritis than an exacerbation of a clironic disorder. THE PROGNOSIS IN DISEASES OF THE KIDNEYS. IOf Cellulitis. Dropsy, abdominal, when excessive. Dyspnoea. Eczema. Endocarditis. Erysipelas. Fractures. Gangrene. Hydropericardium. Hydrothorax. Jaundice. CEdema of lungs or of glottis. Pericarditis. Peritonitis. Phthisis. Pleuritis. Pneumonia. Uraemia. In gouty patients the chronic nephritis is slowly evolved and generally runs a prolonged course, provided indiscretions in diet, etc., can be guarded against. When syphilis, struma, or general cirrhosis is associated with sclerosis of the kidney, death takes place more rapidly. The most fatal complication is that of gout with chronic lead poisoning and sclerosis of the kidney. Persistence of ursemic symptoms1 after treat- ment is more unfavorable than a decided at- tack of severe convulsions.2 l Headache, twitchings, morning vomiting. 2 Ralfe, on. cit. IOS DISEASES OF THE KIDNEYS. In general, extensive and obstinate dropsy, valvular disease of the heart or any cardiac complication, retinal disease, dyspnoea, acute cedema of lung, and all acute inflammatory conditions as pneumonia, pericarditis, and cel- lulitis are very serious, the last probably always fatal. Ursemic attacks are not always neces- sarily fatal, if promptly treated. Acute inter- current nephritic attacks are unfavorable ac- cording to the amount of dropsy and presence of cardiac complications. When the urine falls below normal in quan- tity, the pulse grows weak and fluttering, and the respirations quicken on slightest exertion, the end is near, the heart being then dilated and usually fatty. Note that the age of the patient has much to do with prognosis. For example : when chronic parenchymatous nephritis occurs in comparatively young subjects and is the result of some morbid condition of the blood, as scar- let fever, syphilis, etc., recovery has been known after albuminuria of a year. This is especi- ally true of cases which survive the first six months. Miscellaneous. Bearing of tube casts on prognosis:—Mucous casts are not of unfavorable significance. A few, small, hyaline casts occasionally found, es- THE PROGNOSIS IN DISEASES OF THE KIDNEYS. IO9 pecially after violent exercise, are not ominous. Waxy casts, the large, transparent casts, more solid in appearance than hyaline casts and resembling molten wax, are an unfavorable sign. Granular and fatty casts, found during recovery from acute nephritis, are not neces- sarily unfavorable unless they persist for some weeks or months. If found in the urine of adults who have not recently had acute neph- ritis, they should render the prognosis guarded. But the prognosis is highly unfavorable if long, large, straight, dark, highly granular or fatty casts are found. They are the worst possible sign in the course of chronic nephritis. Albumin and casts with decreased urine and deficiency of solids may coexist with heart disease and weakened circulation. If there are signs of the latter, the prognosis should be deferred, until regulation of the heart and supply of fluids show whether the evidences of renal impairment persist or not. Sometimes both albumin and casts may disappear under treatment. Nephritis ivithout albuminuria: In some cases, well-pronounced renal lesions have been found post-mortem where during life the urine con- tained neither albumin nor casts. Obstinate vomiting, continuous and persistent, should render the prognosis unfavorable, even if nei- ther albumin nor casts can be found. no DISEASES OF THE KIDNEYS. Condition of the Heart: In cases of small kidney the condition of the heart, in many in- stances, is of more prognostic value than infor- mation obtained from examination of the urine. In a case which I saw eighteen months before death, there were no tube casts in the urine and but a minute amount of albumin, yet the diagnosis and prognosis were readily made from the history of the case, condition of the heart, etc., etc. Dr. Tyson's conclusions for the life insurance examiner : Given that albumin is found in the urine of a person applying for life insurance, he should not be rejected, according to Dr. Tyson, provided: 1. In all other respects he presents signs of good health. 2. The albuminuria is unaccompanied by tube casts. 3. The albumin is not large in amount, not habitually over one-fifth by bulk.1 4. There is no albumin in the urine voided on rising. 5. The specific gravity of the 24 hours' urine is 1020 or upwards. 6. There are no signs of hypertrophy of the left ventricle, or of high vascular tension shown by sphygmograph. l I regard the amount of albumin as large when the reading on the Esbach tube shows one gramme to the litre or more. THE PROGNOSIS IN DISEASES OF THE KIDNEYS. Ill 7. The patient is under forty. S. There is no true gout. 9. There are no retinal symptoms common- ly associated with Bright's disease. To these I add the following : 10. There is no hereditary predisposition to renal disease. Summary of Prognosis. Acute nephritis : Exudative, favorable ; pa- renchymatous, unfavorable; diffuse (sequela or complication), favorable; diffuse (idiopathic), immediately favorable, ultimately unfavorable. Chronic (parenchymatous) nephritis: Unfa- vorable; (puerperal), favorable or unfavorable, see page 101; (diabetic), unfavorable. Chronic, diffuse : large white kidney; chance of life, fifteen years or more; small kidney with vascular thickening, chance of life bet- ter still ; small kidney without vascular thick- ening, most fatal of the diffuse group, chance of life doubtful. Chronic, interstitial (sclerosis) : chance of life, at best, fifteen or twenty years. Lardaceous disease: not of itself fatal but primary disorder usually so. Acute hypereemia: favorable. Clironic hypereemia: not of itself fatal but prognosis unfavorable, if primary disorder se- vere and exacerbations frequent and severe. 112 CHAPTER V. Therapeutics of Renal Diseases. The modern treatment of albuminuria con- sists in close observance of many particulars. A. Functional albuminuria : I. Hygienic treatment. The patient is to cut down hours of work, or rest entirely; avoid stimulants ; take change of air if possible1; try saline douches of tepid water (85°) daily; eat as lit- tle meat as possible; avoid over-eating; wear woollens2 next to skin. If the patient is a boy, see that he does not masturbate. In the case of corpulent elderly patients with scanty urine, free use of water, as Londonderry Lithia Water. II. Medical treatment: In albuminuria due to gastric or hepatic disorders, the principal remedies are Nux Vomica, Podophyllum, Bry- onia. If the patient is constipated, sallow, irrit- able, and the urine of high color, high specific gravity, with high percentage of urea, and con- taining sediments of calcium oxalate, the al- bumin being noticeably increased after meals, l A summer at Saratoga with judicious use of Congress water is often all tha is necessary, provided the case is not real Bright's disease. 2 Jaeger or Jaros wear. THERAPEUTICS OF RENAL DISEASES 112 Nux Vomica second or third decimal, will be found useful. Sometimes Podophyllum, if gen- erally indicated, may be given during the day with a dose of Nux Vomica at night, before re- tiring. In some cases of slight febrile disturb- ance and hepatic symptoms, I have used Bry- onia in the beginning and followed with Nux Vomica later.1 The phosphate of strychnine has been used successfully in some cases. Elt- on y mine has cured cases in the South, some of which seem like genuine nephritis, but may possibly have been functional albuminuria de- pendent on hepatic derangement, with nausea, headache, etc., etc. Other remedies may be suggested by the symptoms : Mercurius, (B., II., 2) Iris, Acid urn Nitromuriaticum should be remembered. [Those who advocate vigorous measures rely on nux vomica, and nitromuriatic acid, with saline purgatives every other morning21. B. Organic albuminuria. I. Acute exudative nephritis: Subsides usually when the pyrexial stage of the disorder on which it depends is over. See hygienic treatment below. II. Acute parenchymatous change: 1. Hygien- ic: patient to bo put to bed, wearing woollen night dress and wrapped in blankets. Jseger night-clothing and bedding desirable. Patient 1 Both Nux and Bryonia include scanty red urine among their symptoms. 2 See Ralfe, Kidney Dis-'ases, 1885, p. 541. I 14 DISEASES OF THE KIDNEYS. to be sponged daily with tepid water contain- ing a little alcohol; each part of the body to be rubbed dry, after sponging, before another part is wet. Room to be about 70° F. in tem- perature. Thorough ventilation to be secured. Diet: if urine suppressed or nearly so, arrow- root gruel for two days ; then if urine more abundant, milk in small quantity mixed with the gruel, rice in thin broth, plain rice pud- ding. In severe cases, no meat or fish for two weeks, and milk only in preparation of foods. Grapes, oranges, strawberries allowable. After the first day or two give pure spring water freely. Such waters as Poland, Bethesda, Clys- mic desirable. Potatoes, especially sweet, al- lowable. When severe symptoms subside, ex- clusive milk diet. Try the entire milk, or if not borne, skimmed milk, a few ounces every two or three hours, limewater and milk, milk of magnesia and milk. Or, if constipation, milk and Yichy, milk and carbonic water. Bear in mind also, peptonized milk, peptonized gruel and milk, peptonized milk toast. 2. Medical: patient's bowels moved daily by enemata, except in typhoid, yellow fever, and cholera. If ursemia threatens (shown by head- ache, nausea, twitchings, scanty urine), try hot air bath: patient on chair with perforated seat, wrapped in several thicknesses of blankets, which inclose the chair also ; under chair, alco- THERAPEUTICS OF RENAL DISEASES. II5 hol lamp, its flame inclosed with piece of sheet iron. [If patient confined to bed, use curved metallic tube leading from heat reservoir of metal1 ]. In moderate cases, give the hot air bath every other day, and for twenty minutes. Hot drinks, as hot lemonade (without sugar), to be given during the hot air bath. In case of faintness give a little brandy or aromatic spirit of ammonia. In severe cases, hot air bath daily, and, if necessary, free diaphoresis to be maintained for an hour, with hot drinks, and hot flax-seed meal poultices to the lumbar re- gion. Inasmuch as this lesion occurs in the course of severe febrile disorders as typhoid fever, diphtheria, etc., the urine should be examined constantly during those maladies and the pa- tient watched as closely as possible. If the urine is found to be as described, page cS2, in Table VI., a, (Acute Parenchy- matous Change) give Belladonna when cerebral symptoms appear quickly and at the beginning of the disorder, as in Table VIII., Group I., page 95. AYhen gastro-intestinal symptoms are prominent at the beginning of the disorder, the remedies are Mercurius, Arsenicum, Argentum Nitrieum, Acidum Nitricum, Cuprum, etc.2 These 1 These, ready-made, may be purchased of instrument makers. 2 A number of drugs may be thought of according to the prominence of the various symptoms. I mention the names of a few often indicated. I l6 DISEASES OF THE KIDNEYS. remedies are suited to the symptoms of Group IL, in Table YIIL, page 95, and to those of Group III., when not the result of actual min- eral poisoning. When gastro-intestinal symp- toms precede the cerebral symptoms, Mercurius is often of service: Mercurius Corrosivus when there is pain in the back and febrile disturb- ance is marked; [Mercurius Solubilis when feb- rile disturbance is not prominent, hence seldom of value in acute parenchymatous degenera- tion]. [Arsenicum is recommended when gastro-in- testinal symptoms are found in the beginning of the disorder, and when there is great pros- tration with remittent type of fever and especi- ally if hydrothorax be present and if there is tendency to coma]. Argentina Nitricwn, when there is no marked prostration and no severe pain in the back but early in the disease obstinate vomiting or diarrhoea, with pallor, oedema, violent headache, and, later, cerebral symptoms as delirium, co- ma, or stupor. It is possible that there is a field of useful- ness for such remedies as Euonymine, Podo- phyllum, etc., in this disorder ; Mercurius Dul- cis is also to be thought of. In the treatment of nephritis from poisoning, the essential points are rest, warmth, attention to the skin and diet; elimination of the poison- THERAPEUTICS OF RENAL DISEASES. I 17 ous substance is to be favored by judicious administration of diluents, the bowels to be opened by enemata, and the skin kept active and moist. | There are those who advocate vigorous measures in the treatment of acute parenchy- matous degeneration, occurring in febrile dis- orders : for example, in the early stages, one drachm of digitalis infusion every six hours. For prompt diaphoresis, pilocarpine, hypoder- matically, in doses of one tenth to a sixth or fifth of a grain.1 For the liver, inspissated ox- bile in two to three grain doses. When ursemic symptoms are severe, dry cups to the loins, followed by warm poultices]. III. Acute diffuse nephritis. The subject will be discussed as arranged in Table YIIL, Groups IV., V., VI., VII. and VIII., page 95. [For distinction between acute parenchyma- tous degeneration and acute diffuse nephritis, see Table VI., a, page 82]. Acute diffuse nephritis not following scarlet fever but idiopathic and due to exposure to cold and wet, or from unknown cause, (bacte- rial ? ) is to be treated as follows: 1. Hygienic treatment: rest, warmth, non- Jiitrogenous diet: as fruits, vegetables, cereals; ■oysters, light animal broths usually allowable. 1 I believe that pilocarpine should not be used in this particular renal lesion* occurring as it does in connection with severe disorders already mentioned. nS DISEASES OF THE KIDNEYS. Often fish, fowl, and game. Milk may be given freely. Also pure spring water. Woollens next to skin. When the urine is very scanty or completely suppressed, the diet should be rig- idly non-nitrogenous, and carried out as de- scribed, page 114. 2. Remedial measures : the patient's bowels are to be kept open daily. If ursemia threatens, hot air baths, with hot drinks, and hot fomen- tations to the loins. In critical cases when no time is to be lost pilocarpine, hypodermatically, one tenth to possibly one quarter of a grain1 according to age of patient. Give first some stimulant as aromatic spirit of ammonia (thirty drops in water), or gin and water. No piloc- arpine when the respirations are abnormal, for fear of oedema of the lungs. The remedies of value are as follows : in Groups IV. and V. of symptoms in Table YIIL page 95, Mercurius Corrosivus takes first rank when the nephritis has been preceded by coated tongue, sluggish bowels, thirst, sallow complex- ion, pain in the back, followed by chill or fe- ver, and albuminous urine, etc. In other words, when gastric and hepatic symptoms are first noticed, followed by fever and albuminous urine. Icrebinthina is to be given when at the out- set gastric and intestinal irritation is extreme l One sixth of a grain is usually sufficient at most. THERAPEUTICS OF ACUTE NEPHRITIS. II9 (vomiting, diarrhoea,) and dyspnoea is marked. Headache. Cerebral symptoms rapidly in- creasing in severity: coma, delirium. Argentum Nitricum: Gastric symptoms also, but oedema greater than when Terebinthina is indicated, cerebral symptoms not so 'severe. [When prostration is a marked feature, Mer- curius will usually be found useful; Merc. Cor. when there is marked febrile disturbance; Merc. Sol. when febrile disturbance is not marked]. See Table X. Ferritin1 is indicated when gastro-intestinal symptoms are prominent, with oedema, prostra- tion, and remittent type of fever. Rhus Tox. is indicated when there is chill, tearing pain in the region of the kidneys, fever, and later, cerebral symptoms. Rhus is useful usually when the nephritis is due to exposure to wet; there is usually general oedema. Aconite is to be thought of in early stages of cases due to exposure to cold and rapidly fol- lowed by dropsy. Solania is advised in cases due to cold and wet. Sub-acute Nephritis (Groups VL, VII., p. 95) will be discussed after post-scarlatinal nephri- tis. iFerrum lias been found superior to Arsenicum by Dr. Woodward in both forms of acute nephritis, when the symptoms pointed to these remedies. 120 DISEASES OF THE KIDNEYS. Acute post-scarlatinal nephritis. The treat- ment is as follows: 1. Preventive: it has been held that a milk diet throughout, in scarlet fever, with avoidance of exertion, and of taking cold, in the third week, is sufficient to prevent the onset of acute nephritis. If, however, at that time the temper- ature again rises and the urine begins to dimin- ish, with headache, oedema, etc.: 2. Hygienic: rest, warmth, milk diet, pure water. Woollens. Entire skin washed in tepid water daily, or in milk and water. 3. General: patient's bowels to be opened daily. For cerebral symptoms, when there is high arterial tension, hot air bath, hot applica- tions to lumbar region. 4. Radical: The remedies to be employed are these: Mere. Cor. should be given, even before albu- min appeals in the urine, provided there are the usual indications for its use. (See Table X). The patient may complain of frequency of mic- turition and of scalding urine, before albumin can be detected. Terebinthina, indications already given. Use- ful sometimes as soon as blood appears in the urine, and to be continued for some days, the second decimal dilution preferred. I s probably of more service in idiopathic than in post-scar- latinal cases. THERAPEUTICS OF ACUTE NEPHRITIS. 121 Ferrum is often of great value in post-scarla- tinal and diptheritic nephritis. Ferrum Plios. is often used. Ferrum Iod. has proved wonderfully curative in some cases1 of post-scarlatinal nephritis. Digitalis is useful where there are cardiac complications. The oedema and dropsy occur early, are very noticeable, and followed by signs of heart failure; gastric symptoms later and not so severe as when Terebinthina is indicated; prostration not marked. Digitaline is often used, but complaints are made that it is uncertain in action. [When prompt action is desired, infusion of digitalis is the most reliable. The latter should not be given persistently after the flow of urine has been re-established. Amy! nitrite is useful when the patient has been drugged with digitalis]. Apis is indicated when headache is severe and early, with generally oedematous condition of the whole body, especially of the face and limbs; dyspnoea is distressing. Gastro-intesti- nal symptoms and backache not severe. Urine high colored, containing much albumin and blood, together with heavy sediment of urates. Frequent urgings to urinate. Apium virus is conveniently administered in tablet triturates. "■See North American Journal of Homoeopathy, 1889, p. 122. 122 DISEASES OF THE KIDNEYS. Miscellaneous remedies: There are those who in the beginning of acute nephritis (post-scarla- tinal) give Aconite before albumin shows itself. [Dr. Mahomed detects traces of hemoglobin in the urine, before albumin shows itself in scarla- tinal nephritis, by use of the ozonized ether and tincture of guaiacum test, which, modified by Stevenson, is as follows: To a drop or two of urine in a small test tube, add one drop of freshly prepared tincture of guaiac and a few drops of freshly prepared ozonized ether. Shake, and let ether rise. If the ether is colored blue, hemoglobin is present, provided the urine be free from saliva, nasal mucus, or compounds of iodine, all of which strike a blue color with guaiac]. When blood appears, Terebinth, is the remedy for several days. When serous effusions are evident, Arsenicum, Bryonia, Senega. Others give Acielum Carbolicum and Kali Bichromicum in the early stages, following with Mercurius Corrosivus, or Cyanatus, and using Apis in the later stages. Rheum has been recommended in post-diph- theritic nephritis, as has also Apis. When micturition is frequent with scalding urine and bronchial, laryngeal, or intestinal symptoms, Cautharis is advised. Other remedies for which success is claimed THERAPEUTICS OF ACUTE NEPHRITIS. 123 are Crotalus, Lachesis, Secale, Phosphorus, Ni- tric Acid, Coccus Cacti, Cuprum Aceticum, Scilla. Most cases of acute nephritis need merely at- tention to diet, hygiene, etc.; in some cases remedies are needed, but vigorous measures and active treatment {diuretics, etc.), tend to precipi- tate convulsions. Some one of the remedies named in Table X will often be all that is necessary. Merc. Cor. is now-days prescribed in a routine way, and often where another remedy should be used. Study the characteristics of the drugs in Table X., and in prescribing make careful selection. When the albuminuria has been preceded by marked signs of disturbance of digestion, loss of strength, and backache, Merc. Cor. is in- deed to be preferred to such remedies as Apis or Digitalis. When together with the gastro- intestinal symptoms there is marked dyspnoea, Terebinth, is preferable to Merc. Cor. When the gastro-intestinal symptoms are soon followed by oedema, Ferrum is to be thought of. When high temperature is noticed early.with oedema and dyspnoea, and without history of gastro-intestinal disorders in the start, the choice is between Apis and Digitalis, the former being especially indicated if from the beginning of the case headache is severe, the latter when cardiac disturbances are present. TABLE X.—Choice of Leading Remedies in Acute Nephritis.1 Mercurius Cor. Terebinth. Ferrum. Digitalis. Apis. Gastro-intestinal symptoms prominent early. As In case of Merc. Cor. As in case of Merc. ('or. Not prominent and later. Like Digitalis. Prostration and backache prominent early. Not marked and not early. Considerable pain and prostration. Of little prominence till late. Moderate only. Chills or fever following gastric and hepatic symptcms. High temperatures. Fever a prominent symptom. Remittent type of fever following gastro-intes-tinal symptoms. High temperatures and marked cirdiac disturbances. Chills and feververy prominent symptoms. (Edema not early nor prominent. As in case of Merc. Cor. (Edema following gastro-intestinal symptoms. (Edema early and very prominent. (Edema, especially of face.early and prominent. Dyspmra not early nor prominent Dyspnien marked and a prominent symptom. Dyspnoea not marked. Dyspna'a early and severe. Dyspnoea distressing. Cerebral symptoms not marked. Headache marked. Cere-bral symptoms increas-ing rapidly in severity. Coma, delirium. Cerebral symptoms not marked. Cerebral symptoms not marked. Headache severe and e rly. (1) Based on suggestions from Prof. A. W, Woodward, M.I). THERAPEUTICS OF acute nephritis. l25 5. General palliative treatment in Acute Nephritis :—In some few cases where emergencies arise, more vigorous meas- ures may possibly be necessary:— Purgatives:—Elaterium, one-twelfth of a grain, repeated if necessary; or elaterin, one-twentieth to one-eighth grain every four hours, till free watery stools are produced; sulphate of magnesium, on the first two days, 60 grain doses every hour till 480 grains have been taken, or the bowels have moved (Delafield). As enema, glycerine and water. Diuretics:—In the early stages, digitalis; dose of the infu- sion, 40 to 60 minims; of the tincture, 1 to 4 minims, every six hours; discontinued after it ceases to increase the flow of urine. Dr. Hale recommends syrup of wild cherry as a vehicle for tincture of digitalis. Diaphoretics:—Pilocarpine muriate, hypodermatically, in one-tenth to one-fifth grain doses. To reduce oedema, alcohol sweats may be required. A method is as follows: flannels saturated with fifty per cent alcohol are wrapped round a jug of hot water, and also round hot bricks. The water-jug is placed under the patient's flexed limbs and the bricks at his sides, not near enough to burn. All, including the patient, are wrapped in blankets. Miscellaneous :—In severe cases, leeches to the lumbar re- gion; in lingering cases, counter-irritation to the lumbar re- gion, by means of a mixture of one part croton oil to three or four parts of olive oil. If counter-irritation is used, it is more humane to apply to the sides in the concavities above the crests of the iliac bones, as suggested by Purdy. Cerebralsymptoms :—In acute exudative nephritis and acute diffuse nephritis Delafield advises that, in treating cerebral symptoms, attention should be paid to the condition of the heart and arteries:—for example, if the heart is laboring and the arteries contracted, drugs should be used which dilate the 126 DISEASES OF THE KIDNEYS. arteries, as chloral hydrate, opium, amyl nitrite, and nitro-glyc- erine; or the quantity of blood is to be diminished by venesec- tion, sweating, or purging. With feeble heart and relaxed arteries, use digitalis, cafFein, convallaria, or strophanthus. Heart-failure:—In acute renal dropsy, when the pulse-beat is short and easily arrested, temporary dilatation and weakness of the left ventricle is indicated (Broadbent). Low tension is certainly occasionally observed, and some writers insist on rec- ognition of the dangers of this condition. Broadbent recom- mends iron, sulphate of magnesia, nux vomica, and digitalis. Maguire, nux vomica and iron, in low tension. For aneemia, one meal daily of solid food, meat with bread and butter; during the rest of the twenty-four hours, milk. Bowels to be opened daily by enema or simple laxative. Oxygen gas to be given for 10 or 15 minutes twice a day. Internally, Ferrum Sulphuricum. [Delafield advises six to twenty-four of Blaud's pills daily. The late Dr. X. F. Cooke had great confidence in Boudreau's pills]. Patient to rest and not attempt work. Acute Exudative Nephritis. Weinbaum has called our attention to an acute nephritis in which there is exudation of blood serum, and consequently large quantities of albumin in the urine. Delafield distinguishes four forms of exudative nephritis, (1) a mild form; (2) a severe form; (3) a form in which there is much pus; (4) a protracted form. It is often difficult clinically, to distinguish an exudative nephritis from a diffuse lesion (Tyson). Nevertheless, therapeutics of acute nephritis. 127 the form in which there is an excessive pro- duction of pus deserves mention, as the prog- nosis in this case is, as a rule, unfavorable. According to Delafield, such cases occur both in childhood and in adult life. The nephritis may be primary, or follow scarlatina, diphtheria, or measles. The invasion is sudden. Symp- toms are marked fever and prostration, restless- ness, sleeplessness, delirium, headache, stupor. The patients lose flesh and strength, and pass into the typhoid state. Dropsy is absent alto- gether, or is very slight. The entire clinical picture resembles that of acute meningitis. The urine is not much diminished in quantity; its specific gravity is not decreased; albumin, casts and blood may be present, but sometimes not until late in the disease, and sometimes they are entirely absent. The remedies in this disorder would be, among others, Glonoin, Belladonna, Hepjar Sul- phur, Mercurius Corrosivus, Rhus Tox. Pallia- tive measures, if necessary, as before. SUB-ACUTE NEPHRITIS. This disorder may be either idiopathic or a sequela of scarlatina and diphtheria. Whereas the duration of acute nephritis is about four weeks, that of sub-acute may be for months or even years. The symptoms are chiefly anaemia, I2S DISEASES OF THE KIDNEYS. dropsy, loss of strength, nausea, vomiting, diarrhoea. The urine is not likely to be greatly diminished; it may even be increased, but the amount of solids as compared with that of the water is deficient; i. e., the quality of the urine is poor. The arteries are usually relaxed, but sometimes contracted; there may be inflamma- tion of the retina. (Delafield). 1. Hygienic treatment. Removal of patient to suitable warm climate, where out-of-door life is possible, as Southern California, the Bermudas, the Arkansas springs, Thomasville in Georgia, Tallahassee in Florida. High alti- tudes, rough ocean voyages and long railway journeys to be avoided: if the patient goes to California, he should do so by easy stages, and take vestibuled trains when possible. If Ber- muda be chosen, the voyage should be arranged, so far as possible, in calm weather, as this par- ticular trip is a very rough one, and uraemia from seasickness is to be thought of and guarded against. If the patient reside in a cold climate, he must be kept in-doors in stormy weather and observe every precaution about catching cold; wear woolens, etc.; diet need not necessarily be limited to liquids, except in acute exacerba- tions. Patient may take as much solid food (of a non-nitrogenous character) and fats as he THERAPEUTICS OF SUB-ACUTE NEPHRITIS. I2t) can digest. Excessive use of mineral waters of doubtful utility. The patient should void enough urine daily to excrete the normal amount of urea (32 grammes, or 500 grains); and when dropsy is to be overcome, the amount of fluids taken by the patient should not exceed the amount of urine voided.1 The same general hygienic treatment per- tains to protracted forms of acute nephritis. The patient may have to be kept in bed for a time, but should be given fresh air as soon as it is prudent. 2. General treatment. The patient's bowels should be kept in order and the skin moist and active. Massage is helpful, also inhalations of oxygen gas, when there is anaemia. See "Anaemia" under "Acute Nephritis.'1 3. Radical treatment. The remedies espe- cially adapted to the sub-acute form are Apis, Digitalis, Ferritin, Mercurius Cor. Where Apis is indicated, headache is particularly noticeable. (See indications already given in Table X). Digitalis is useful when oedema and dropsy, to- gether with cardiac failure, are prominent early in the case. There is some nausea, but the pain in the back is but slight. Indications for Ferrum have already been given, as have those for Merc. Cor. (See Table X.). i Delafield, Med. Record, March 23, 1889. 130 DISEASES OF THE KIDNEYS. I have found in some cases where malarial history was obtainable, that Fer. et Chin. Citr. in the third decimal did good work, after Merc. Cor. had failed. In one case thus helped, the amount of albumen was indeed a mere trace, but the sediment contained blood corpuscles and numerous yellow casts. Chin. Arseii. is undoubt- edly of service in malarial districts. Care should be taken not to give it too low when urea is deficient. Other remedies which have been ad- vised are Kali Hyd., Kalmia, Picric Acid. I. Palliative 7reatment. In extreme cases of dropsy, purgatives, diaphoretics, as already mentioned under acute nephritis, palliative treatment. Puncturing the skin and tap- ping serous cavities may be necessary; in such cases there is usually but little hope. For high arterial tension,* nitro-glycerine, chloral hydrate. For coma, without increased tension, strophanthus, sparteine, etc. According to Delafield, some patients with sub-acute nephritis continue to get worse every way, and die within one or two years; some get better after a few months, then become ill again, and so go on for years. Very few recover per- manently. CHRONIC NEPHRITIS. 1. Hygienic^ Treatment. The chief points *Some practitioners are in the habit of giviug small doses of calomel, in connection with free use of saline cathartics, to reduce high tension. fAs the hygienic treatment applies in general to all forms of chronic nephritis, I shall not discuss each form separately, but note exceptions as they occur. THERAPEUTICS OF CHRONIC NEPHRITIS. 1X1 are in regard to diet,place of residence, care of the skin, air and exercise, waft, psychical influences. Diet.—The patient may take the following: 1. What he does take frequently, but little at a time. Soups: Vegetable, sago, or vermicelli. 2. Oysters (raw only) and fresh fish, which should not be fried. 3. Meats: Tender beefsteak and mutton chops once a day, but not in very severe chronic cases. The fat portions of steaks and chops to be preferred. White meat of poultry. I. Vegetables: Green vegetables, except beans and peas; vegetable salads. 5. Farinaceous food: In general, properly cooked farinaceous foods are allowed. Well- risen bread, well-cooked rice, tapioca, arrow- root, etc.; bread and milk. 6. Desserts: Rice pudding, milk pudding, tapioca pudding. Fruits: Those which are laxative and those not too acid, as ripe peaches, pears, grapes. In some cases where the symptoms are not urgent, fruit, as, for example, an orange first at breakfast, followed by oatmeal and cream, are advisable. At the noon meal, tender steak or chops; at night, skim milk and "zwieback.'1 7. Drinks: Distilled water, flavored with lemon juice; such mineral waters as are free 132 DISEASES OF THE KIDNEYS. from organic matter and do not contain a large amount of solids; Salutaris; Poland water; Bethesda water; Buffalo lithia water. Distilled water is more valuable as a solvent of the waste products in the organism. Londonderry lithia water is serviceable in cases where much uric acid is found in the sedi- ment soon after the urine is voided. In gen- eral terms, however, the patient should not take any more liquid than is necessary to cause him to void his 33 grammes (500 grains) of urea in 24 hours. In interstitial nephritis, in the later stages, it is not advisable to pour cold water into the patient, or waters rich in carbonic acid gas, for fear of apoplexy, after marked changes in the blood vessels have taken place. The question of alcohol requires more than passing comment. Those to whom it is no great struggle to give up liquors should certainly do so, and especially in chronic parenchymatous change. To a man who has been an inveterate drinker, a little brandy and water or good whisky, well diluted with Salutaris or imported Vichy, may be allowed. Fothergill holds that moderate quantities of light wines, claret and light French and German wines, and of cider do no harm. [Alcoholic stimulants, brandy and whisky, are sometimes imperatively called for in the course of chronic nephritis when there THERAPEUTICS OF CHRONIC NEPHRITIS. *33 is exhaustion, or in uramia when there is pro- found cerebral anaemia, when the heart is beat- ing rapidly and feebly]. Beer, ale, and porter are strictly tabooed; also Moselle, Madeira, and Champagne. Oxygenated water1 is sometimes greatly relished by patients, and on that account serviceable in cases where the patient dislikes to drink or- dinary water. It should be thought of in cases where the urine is below normal in quantity, as in chronic parenchymatous metamorphosis.1 Pulque is highly recommended by A. W. Par- sons, of Mexico, and R. N. Foster, of Chicago. Milk may be given freely to those with whom it agrees. It will often be borne better if skimmed, boiled, or pentonized. If milk be given freely, other albuminous foods should be discontinued. In obstinate cases milk diet to the exclusion of other food has certainly done great good in many cases, though I am aware that certain authorities are opposed to it. The umilk treat- ment" of the late Dr. T. A. McBride, of New York, was as follows: The patient is to use skimmed milk, and skimmed milk alone; no other kind of nourish- ment. JIt is very gratefully taken by children with post-scarlatinal nephritis. 134 DISEASES OF THE KIDNEYS. The patient is to take three or four times dai- ly, and at regularly observed intervals, from two to six ounces of skimmed milk. This must be taken slowly, and in small quan- tities, so that the saliva may be well mixed with it. The reaction of the milk to test paper must be neutral or alkaline. The first week is the most difficult to get over, unless the patient has a strong will. During the second week two ordinary quarts may be consumed during the day. The milk must be drunk four times daily; at 8 a. m., at noon, at 4 and 8 p. m. The hours may be changed, but regular intervals must be main- tained. If the patient comply with these directions, he will complain neither of hunger or thirst, al- though the first doses appear so very small. The daily quantity may be increased to eighty or more ounces. If after having attained this quantity or more, the patient gets worse, diminish the amount to the quantity used the first week, and increase more slowly. Constipation at the beginning is a good sign. This may be remedied by warm water injections, or by the use of castor oil, rhubarb, addition of sugar of milk to the milk, or by taking some bi- carbonate of soda at bed-time. If the constipa- THERAPEUTICS OF CHRONIC NEPHRITIS. I35 tion be obstinate, a little coffee may be added to the morning dose of milk, or towards 4 p. m., stewed prunes or a roasted apple. If, on the other hand, diarrhoea results, and rumbling of the bowels is frequent, the milk is too rich or is being taken in too large doses. Feverishness is no contra-indication to its use. If the patient be thirsty, he may drink Clysmic, Bethesda, Poland, or Vichy water. If he have a strong desire for solid food at the end of the second or third week, he may have a little stale white bread or toasted bread with salt in the morning, and again at 4 p. m. Once a day he may have some soup made of milk and oat- meal. After continuing this treatment for five or six weeks it may be modified, by allowing the milk only thrice daily, and once a day steak or a chop. Raw meat digests most easily, and should be used in preference to the cooked when possible. It may be necessary to add a little salt to the milk in some cases, and in others to have the milk drunk when very hot. If the patient be- come flatulent, buttermilk is often beneficial in small quantities.1 There is no doubt in my own mind but that in some cases, usually when there is or has been marked lithaemic tendency, milk will do more 1 Journal of Reconstructives. I36 DISEASES OF THE KIDNEYS. harm than good, the urine becoming intensely acid. If it cause obstinate constipation, it is certainly harmful. In such cases the milk should be given as suggested by Saundby with bread or farinaceous food or with puddings. Sometinies alternation of milk diet with mixed diet does well, using milk for two or three months, then mixed diet for three or four weeks. Exclusive milk diet, in general, is to be aban- doned when too great an excretion of urine is observed, or symptoms of anaemia and exhaus- tion; particularly is this the case if, in addition, the quantity of albumin is but a small fraction of one per cent by weight. In such cases it is allowable and desirable for the patient to take farinaceous and vegetable food. If the patient still loses strength, a small amount of broiled or roasted meat, once daily, at an early dinner must be allowed (Robinson). When great irritability of the stomach is present, small quantities of cold, skimmed milk at short intervals are best given. Sometimes the only way in which milk can be borne is iced, in small quantity, in which case other articles of diet should be given. When there is incessant vomiting, the patient's strength must be kept up by nutritive enemata, until the vomiting subsides. The various mixtures of milk described under "Acute Nephritis" must not be forgotten. THERAPEUTICS OF CHRONIC NEPHRITIS. *37 In the diffuse forms of nephritis which border on the sclerotic, and in sclerosis itself, the diet should consist of milk, cream, vegetables, and a very small quantity of meat except in advanced cases when the exclusive milk diet may be preferable, the milk being diluted with Vichy. But the patient should avoid taking large quantities of cold waters charged with carbonic acid gas. In sclerotic cases during stage of heart fail- ure the diet should be more liberal than during the stage of cardiac hypertrophy. (See "Scle- rosis.'7) In lardaceous disease the diet should be suited to the cause of the disorder. For example, if phthisis be the cause, milk, cream, meat, and good wine1 are desirable. But when the disease at the bottom of the renal change has disap- peared, the diet should then be that of chronic nephritis in general. In regard to what the patient must avoid in diet, the following may serve as a guide : The patient should avoid the following : 1. Overloading the stomach; all animal soups. 2. Cooked oysters and fried fish. 3. Meats : all smoked and seasoned meats ; ham, tongue, corned beef, sausages, pork ; all hashes and stews; turkey, lamb, gravies, eggs. 1 Beverly Kobinson, Med. Record, 1889. i33 DISEASES OF THE KIDNEYS. 4. Vegetables: beans and peas. 5. Farinaceous food : heavy, soggy bread ; batter-cakes. 6. Dessert: pies, cake, ice cream. 7. Beer, ale, porter, coffee, ice water. Hard waters not to be taken, if purer waters can be obtained; the solvent power of hard water is not as great as that of soft. In general it may be stated that starchy, sac- charine, and oleaginous articles of food are to be preferred to nitrogenous ones, and, if the patient can do without meat, it is advisable for him to drop it, or, if he craves it greatly, to eat fat meat only. It must be admitted that there are some patients who do not do well on any one-sided diet, but for whom ordinary mixed diet is the best thing. Schreiber actually recommends that patients, under ordinary mixed diet, eat in addition eggs, either raw or boiled, and meat. Some physicians report success from the use of raw eggs and milk. The fundamental principle underlying all diet should be, it seems to me, to keep up the patienfs strength, while at the same time the excretion of urea and daily quantity of urine are not allowed to diminish. Place of Residence:—The desideratum is dryness accompanied by ivarmth or, at any rate, THERAPEUTICS OF CHRONIC NEPHRITIS. 139 evenness of temperature. Dry soil is necessarily included. Upper Egypt is probably the best locality. Next to it, the dry plateau north of Cape Town in South Africa. In this country, Southern California and portions of New Mex- ico and Texas, when the altitude is not too great, possess climatic advantages. I believe that New Mexico will eventually be shown to combine the requisites. Continuous residence in some one of these localities is better than mere tem- porary sojourn. In this country the following towns are often visited by subjects of chronic . nephritis during the no liter: Arkansas: Eureka Springs. Florida: Tallahassee. South Caro- lina: Aiken. Georgia: Thomasville. Mexico: Saltillo. California: between Los Angeles and San Bernardino. Texas: San Antonio. Abroad the following are recommended as winter resorts: France: Pau, Cannes. Italy: Rome, Naples. Besides these Malta, Malaga, and the Madeira Islands are highly spoken of. During the summer the patient may visit in this country such places as Saratoga, Nantucket, Newport, Block Island. Nantucket is often very dry in July and August. I have seen six weeks pass by there without rain other than very light showers. Fogs are not usually cold or long continued. The soil is exceedingly dry. East- erly storms may appear after the middle of 140 DISEASES OF THE KIDNEYS. August. If the patient be in the North during the summer, he should find out the character of the season at the various health resorts and govern himself accordingly. For example, it is sometimes very dry in Nantucket and wet with- in 100 miles of it, and vice versa. I deem Nan- tucket an advantageous place to visit when the patient lives far inland, especially if he re- side in the Mississippi Valley and suffer from malarious affections. Many of the cases of Bright's disease which I see in Chicago are un- doubtedly of malarial origin, acquired in the country about the Western rivers. In England, the desirable summer resorts are Folkestone, Bournemouth, Torquay, St. Leon- ards, and the south of the Isle of Wight; in Scotland, the higher part of the Highlands as Braemar in Aberdeenshire ; in Switzerland, the Engadine. A patient after spending the sum- mer in these resorts may, as winter approaches, take the sea voyage to Cape Town and find summer there also, thus avoiding winter alto- gether. It is probable, however, that a climatic cure is effected only by continuous residence in a farorable spot, the patient removing from the unfavorable climate before the disease has made great headway. Holland, Denmark, Scandinavia, and the shores of the Baltic are to be avoided, as is also THERAPEUTICS OF CHRONIC NEPHRITIS. I41 Great Britain, except as mentioned above dur- ing the summer. In this country the patient should avoid even in summer the New England coast north of Boston, and the White Mountains; the country about the Great Lakes, particularly the west shore of the Lakes; also all localities where malaria is rife, inasmuch as places may be found where without malaria there are the advan- tages of warmth and evenness of temperature. Shun, therefore, the valleys of rivers, especially where the latter empty into the sea. It is doubtful whether anything is gained as a rule by visiting most of the Southern States owing to the unfortunate location and surroundings of the towns, and the lack of first-class accommo- dations in any save very few localities. Aiken, South Carolina, has a first-class hotel. South Georgia and the table lands of Texas are prob- ably the best localities. If the patient is to take a sea voyage, the month least likely to be stormy in the North Atlantic is July. To go to the Bermudas, January is usually (not always) the best winter month. September, November, De- cember, February, and March are likely to be bad months on the Atlantic Ocean. The voy- age to the Bermudas is often exceedingly rough and should not be attempted by those who have shown uraemic symptoms or, in general, when 142 DISEASES OF THE KIDNEYS. the amount of urea voided is less than thirteen grammes in 24 hours. Violent sea sickness has been known to cause death from uraemia. If the patient go to Saratoga, he should avoid promiscuous drinking both at hotel bars and mineral springs. Altitudes higher than 5000 feet are to be shunned and in general those not over 3000 feet are desirable. In changing from lower to higher level, patient to be careful about exerting himself at first. Localities where "mountain fever" abounds should be avoided. Those not desperately ill and to whom sea air is known to be beneficial, may take a long sea voyage,1 provided it be on board a first-class steamer, where it is possible to regulate diet. The trip from San Francisco to Australia and return has often been recommended. In all traveling by rail, fatigue must be carefully guarded against. Deaths immediately due to the fatigues of travel have been known to take place in cases of albuminuria. (This applies more particularly, also, to cases of diabetes). Those afflicted with albuminuria should, where- ever it is possible, travel in what are known as "vestibuled" trains. 1 Particularly desirable in case of patients in the Mississippi Valley. THERAPEUTICS OF CHRONIC NEPHRITIS. I43 Those who are obliged to attend to their business, and cannot afford to leave it per- manently, must observe certain precautions as to residence, which should be as near as possi- ble to their place of business. Long rides in vehicles of any description are to be avoided— especially cold ones. Running for trains abso- lutely forbidden. Observation of Sunday as a day of complete rest a necessity, wherever the residence may be. An intelligent physician will direct his patient to live in such a part of town as is easiest to reach from the place of the patient's business. I doubt whether the fresh air of suburban towns makes up for the worry of catching trains and the fatigue of the twice daily rides, though this depends largely on the nervous system of the patient and the business in which he is engaged. Whenever possible, the patient should remain at home during cold north-east storms, whether of rain or snow, and rest in a recumbent fiosition. It is well known that those suffering from diseases of the kidneys are worse in cold, damp weather. Psychical influences:—Too little attention is paid to what are called, for want of a better term, "psychical influences." But I will guar- antee that your patient will not improve if he is harassed and worried by business or social cares. It is needless to say that "powerful I44 DISEASES OF THE KIDNEYS. emotions" will increase the albumin in the urine. Freedom from worry in Americans is as essential as anything else in the hygienic treatment. Obstinate cases, where all precau- tions are observed and no improvement noted, are sometimes unexpectedly relieved by a change in the psychical conditions. The physi- cian must make it a business to see that his patient is not worried by the thousand and one annoyances of modern life. Uncongenial friends or even relatives must be cleverly got rid of and sent to visit some one else. One of my cases showed diminution in albumin of nearly one-half, in two days after a tiresome person left the patient's house. Care must be taken that nurses and attendants generally are to the patient's liking. These precautions are of course not always necessary, but in nervous, "cranky" patients they must not be forgotten. Care of the skin :—It has been said with truth that it is of the greatest importance to promote uniform activity of the skin in all forms of albuminuria. The albuminuric patient should shun cold applications to the skin, whether of air or water. He should avoid draughts as he would contagion. All authorities which I have seen, whatever be their theories, unite in advis- ing the use of woollen garments for albuminuric patients. This is especially advisable for those THERAPEUTICS OF CHRONIC NEPHRITIS. H5 compelled to live in the northern states. Beau- metz advises, in addition, that the patient wear wild-eat skin (with the fur) over the region of the kidneys. Semmola believes in keeping patients in a warm, well ventilated room, all winter long. Purdy points out that confine- ment in bed for a time often produces marked improvement. Some care must be observed in regard to baths, as the least negligence may do much harm to the patient. But warm baths followed by frictions, and great precautions against chilling afterwards, may prove bene- ficial. It is generally admitted that the dry hot-air bath is best of all, but may in some cases weaken the patient if taken too often. Fresh air and exercise:—It is universally agreed that fresh air is a positive necessity in chronic nephritis. Attention should be paid, therefore, to ventilation. Numerous appliances are now to be had which favor ventilation with- out chilling the patient. Inhalations of oxygen I deem of positive value to any albuminuric, and especially to the housed patient. [It is well known that in desperate cases almost moribund, life has been prolonged for weeks by the administration of oxygen. While it is not a "specific," oxygen is at least a valuable adju- vant if methodically and persistently given. See Medical Treatment]. 146 DISEASES OF THE KIDNEYS. The patient's exercise should be carefully looked after. Fatigue of any kind must posi- tively ,be avoided. On sunny days, short walks on a level may be taken unless the patient's business requires walking or much movement, in which case these will be sufficient for him. To housed patients, passive exercise is to be recommended. In mild cases, where the amount of albumin is a small fraction of one per cent and the urea not much below normal, I have found gentle exercise beneficial. In one case where previously no regular exercise had been taken a diminution in the albumin followed, which I attributed to the general improvement in the patient's health. But I could always detect albumin in the urine voided after exer- cising, while it gradually disappeared from the urine voided at other times. I hold that frequent quantitative examina- tions of the urine are of more importance than procedure according to any set theory. The quantity of urine in 24 hours, the quantity of urea, and the quantity of albumin are what the physician needs most to know, and particu- larly what the quality of the urine is, /. e., the ratio of the solids to the water, of the urea to the salts, etc. THERAPEUTICS OF CHRONIC NEPHRITIS. 147 THE QUALITY OF THE URINE. Call the average specific gravity of urine 1020 and the average quantity in 24 hours 1450 cubic centimeters. By Trapp's formula ^ x 20 x 2 we have 58 grammes of solids in 24 hours. (Haeser's formula, page 7 (4), would give 68 grammes as the average; but I regard this figure as too high. Haeser's form- ula is probably more correct in urines of high specific gravity). If 58 grammes is the average in 1450 c. c. of urine, there should be in 1 c. c. of urine 58^-1450 gramme of solids or 0.04 gramme. To ascertain the quality of the urine as to total solids, therefore, divide the total solids by the total amount of urine and compare result with 0.04 the normal average. To ascertain the quality of urine as regards urea in particular, divide the total urea by the total urine of 24 hours. In normal urine the quantity of urea in 24 hours is about 33.5 grammes, 33.5-^-1450 equals .023 gramme. The normal ratio of urea to the salts is about H to 1. The total solids in urine being 58 grammes and the total urea 33.5 grammes, the difference between them represents approximately the quantity of salts (phosphates, chlorides, sul- phates, urates, etc.), in 24 hours—58 minus 33.5 equals 24.5. Urea then is to salts as 33.5 is to I48 DISEASES OF THE KIDNEYS. 24.5 or as 1.36 is to 1. In regard to phosphoric acid in particular, it is probable that about 3 grammes of this substance are found on an av- erage in the 24 hours' urine. If in 1450 c. c. there are 3 grammes, in 1 c. c. there should be 3^-1450 gramme or 0.207 nearly. The more recent analyses of Yvon-Berlioz show the following: Male. Female. Quantity in 24 hours................ 1360 c.cm. 1100 Sp. Gr.........-------......______ 1022,5 1021.5 Urea, per litre----------.........._ 21.50 gm. 19.0 Urea, per 24 hours_________________ 26.50 20.5 Uric acid, per litre_________________ 0.50 0.55 Uric acid, per 24 hours_____......... 0.60 0.57 Phosphoric acid, per litre.........._. 2.50 2.40 Phosphoric acid, per 24 hours_______ 3.20 2.60 Ratio of uric acid to urea.....___....._......_.....1:40 Ratio of urea to phosphoric acid......._______________8:1 [Merz states that the average quantity of urine for children of eight years is in boys 700 c.c, in girls, 600c.c. At ten years, for boys, 750 c.c, for girls, 700 c.c. At 12 years, for boys, 1000 c.c. for girls, 800 c.c] Taking the tables of Yvon-Berlioz as a min- imum standard, and those of Parkes as a max- imum, I have devised a method of indicating for clinical purposes results of analyses com- pared with normal standards. These tables were published in part in the Hahnemannian QUALITY OF THE URINE. I49 for March, 1890, and more fully in the Era of April and May. Suppose a male patient is voiding 15 grammes of urea daily. By comparison with the stand- ard (Yvon-Berlioz) we see that his urea is about 55 per cent, of normal. It is more con- venient to represent the amount of urea by 55, assuming 100 as normal, than to say that it is 15 grammes, since the former figure shows at once the falling off from the normal average, while the figure 15 grammes must be compared with the average, and if the reader is unfamil- iar with French measures must be expressed in English. In my tables, which are suited to both French and English measures, the comparisons with normal have been made for all cases, and will be found exceedingly useful for reference in keeping record of a case. For example, call normal average 100; a number of analyses yield figures which by reference to my tables express the quantity of urea for five successive days as follows: 40, 35, 20, 15, 5. It needs no knowl- edge of anything but the simplest arithmetic to see what the condition of the patient is with reference to the excretion of urea. The following analyses are those of urine of poor character. The patient was a man suffer- ing from sclerosis of the kidney: l5° DISEASES OF THE KIDNEYS. ORDINARY METHOD. First analysis. Second. Third. Quantity in 24 hours.......1980 c.c. 1530 2130 Specific gravity___________1012 1012 1012 Total solids (Trapp'scoeff.). 48 grammes 37 51 Urea, per litre____________ 9 9 9 Urea,total_______________ 18 14 19 Phosphoric acid, per litre.. 0.8 0.54 0.4? Phosphoric acid, total. .. 1.58 0.80 1.00 Ratio of urea to phosphoric acid, 11 to 1 17 to 1 19 to 1 Comparing the urea and phosphoric acid with the averages of Yvon-Berlioz, and express- ing them on the scale of normal =100, we have the following: NEW METHOD. First analysis. Second Third. Urea,per litre...............________40 40 40 Urea,total___________________________70 50 70 Phosphoric acid, per litre____......___30 20 20 Phosphoric acid, total_________________50 25 30 Ratio of urea to phosphoric acid......130 210 235 The second table shows at a glance the defi- ciency of the urine in phosphoric acid, and the general poor quality, as regards both urea and phosphoric acid. (Results are given in the nearest multiple of 5.) The results may further be classified roughly as follows: any percentage from 100 to 75 may be classified as A, any from 75 to 50 as B, from 50 to 25 C, and from 25 down, D. In this way we should obtain the following from the last figures given: THERAPEUTICS OF CHRONIC NEPHRITIS. !5! First. Second Third. Urea, per litre...................____C C C Urea, total______________.........._B B B Phosphoric acid, per litre_____________C D D Phosphoric acid, total........________C C C The urine should be collected and measured frequently, and its quality carefully watched. The patient should not be worried with the de- tails of his case, but the physician should make observations of the condition of the urine with as much care as the captain of a vessel takes soundings when approaching a dangerous coast. 2. REMEDIES IN CHRONIC NEPHRITIS. Recoveries from chronic nephritis have cer- tainly taken place, or, at any rate, patients have lived for many years and succumbed to other disorders than those usually recognized as fol- lowing in the wake of renal lesions. It will be convenient to discuss the field of usefulness of remedial agents in each lesion separately. REMEDIES IN CHRONIC PARENCHYMATOUS CHANGE. The three great causes of this lesion are: I. Previous acute attacks. II. Alcohol and other poisons. III. Associated hepatic disorders. Treatment should, therefore, in the first place be hygienic, to prevent further acute exacerba- tions ; next, alcohol and all substances interfer- l52 DISEASES OF THE KIDNEYS. ing with hepatic function should be avoided; all forms of rich, greasy food and pastry, all highly seasoned food to be strictly forbidden. Great care should be taken that the patient does not overeat, or over-work. If the lesion is the result of poisoning, systematic treatment to counteract the general effects of the poison should be undertaken. This form of chronic nephritis is the one most commonly observed as a result of acute poison- ing by salts of the metals, and corrosive agents in general. Effort should be made in any case where there is history of poisoning, to ascertain the character of the poison, and to suit the treatment accordingly. [The reader will find directions for treatment of poisoning in the author's "Physician's Chemistry." Among the larger works on poisons may be mentioned Wormley's " Micro - Chemistry of Poisons," Woodman and Tidy's " Forensic Medicine and Toxicology." Besides these, the works of Murrell, Taylor, Blyth, Reese, and Tanner, will be found useful.] Lastly, if the disorder be associated with pro- longed disturbance of hepatic functions, as is claimed in some cases, consult the following table for selection of a remedy : TABLE XI.—Choice of Leadinc; Remedies in Chronic Renal Degeneration if Dependent upon Hepatic Disorder. Mercurius Cor. Acidum Nitricum. • Argentum Nitricum. Kali Bichromicum. Iodine. Gaetro-intestinal or hepatic symptoms early and prominent. (See paste 118). Ditto. Ditto. (See page 116). Ditto. Ditto. Pain in the back and pros-tration early and marked. Pain and prostration not prominent. Pain and prostration not marked till late. Pain and prostration moderate. Pain and prostration late. Pallor, oedema, headache not marked at first. Pallor, cedema, head-ache early and marked. Pallor, oedema, head-ache early and marked. Head-ache violent. Pallor, oedema, head-ache not marked at first. Pallor, oedema, head-ache not marked at first. Respiratory or circulatory trouble* not marked till late. Ditto. Respiratory or circu-latory symptoms not promi-nent. Cardiac and respiratory symptoms early and marked, follow-ing gastric, etc. Ditto. Coma, delirium not prominent. Mental symptoms prom-inent after oedema, etc. Ditto. Coma, delirium, etc., not marked. Ditto. (1) Based on snswntionn from Prof. A. W. Woodward, M.D. 154 DISEASES OF THE KIDNEYS. In addition to the remedies mentioned in Table XI., there are others which may prove of value. Ruonymine is a remedy to be thought of in this lesion, since by its use a " restoration of the integrity of the functions of the liver'' may be brought about. It must be given in appreciable doses, from a quarter to half a grain, care being taken that the elimination of urea is not checked in any way. Ammonium Chloride may be tried in torpid conditions of the liver, jaundice, etc. It is given for these conditions in doses of from two to five or ten grains. Dr. Hale suggests Carduus and 7hlaspi. Dr. Woodward thinks 7huja of possible value. Inasmuch as oedema is often early and marked, Apis and Digitalis should not be forgotten. Mineral waters :—In this lesion Buffalo Lithia water, when there is torpidity of the liver, acid dyspepsia, etc.; Vichy, when debility is not great, but urine is acid and the functions of the liver are disturbed to a marked degree. Carlsbad, when there is fatty liver, enlarged liver, gall-stones, etc. Carlsbad and Buffalo waters are useful in anaemic cases, since they contain iron. It is possible that there are two stages in this lesion, viz.: first, chronic degeneration proper; and, second, chronic nephritis following the degeneration. If the patient be tided over the early stage of chronic degeneration (while the albumin and casts are yet present in but small quantities), THERAPEUTICS OF CHRONIC NEPHRITIS. 155 he may recover, or at any rate live for a consid- erable period of time. But after the amount of albumin and casts has become large, treatment can only be directed toward prolonging life and warding off acute exacerbations. Recovery, however, in the case of young patients has sometimes been noted when least expected. There is clinical testimony in favor of the following: Ferrum Sulph. for the anaemia with exhaus- tion and lassitude. It will be found useful in the remissions after acute exacerbations. China, also for exhaustion and lassitude. Nux Vomica, for heaviness and stupor. Helleborus, dropsy with diarrhoea. Cantharis, when, in addition to the scanty urination, and high colored urine, there is scald- ing, irritation of the bladder and urethra, aching in the loins or testicles ; especially when there is history of stricture and prostatic disease. Digitalis, when the quantity of urine is di- minishing to a dangerous degree with cardiac symptoms, etc. Phosphorus, for cases arising during suppura- tion. Agaricus and Nux Vomica, in cases due to alcoholism. Miscellaneous Measures: Hot air baths are particularly useful in this i.tf DISEASES OF THE KIDNEYS. lesion, unless the patient be too weak or arterial pressure too great. In the latter case, Glonoin may be used, especially when albumin is abund- ant and the patient dropsical. It may be given conjointly with Ferrum Muriaticum in the lower dilutions. When the patient becomes very dropsical and the measures previously described have failed, it will be necessary to prolong life so far as possible by more vigorous measures. Palliative treatment:—This consists essentially in produc- ing diaphoresis, catharsis, and diuresis. Diaphoresis : Muriate of pilocarpine, in doses subcutaneously from one- fifth of a grain to one-half a grain (even two-thirds or three- fourths of a grain, if in desperate cases, when the patient is almost " water-logged."—Porter). Stimulants to be given in , advance of the pilocarpine. The hot air bath may be tried, or alcohol sweats, as already described. Catharsis: when there is tendency to uraemia, with ex- cessive and persistent oedema, small and repeated doses of elaterium, or the official triturate of elaterine in sugar of milk (dose sV to \ grain), may be given for the time being [See treatment of Uraemia under head of " Complications."] Diuresis:—Application of dry cups to the loins, followed by warm poultices with digitalis infusion internally (page 117). Free use of mildly alkaline waters. Ordinary coffee. When there are cardiac symptoms try caffeine. [Caffeine in combination with digitalis and strychnine is recom- mended by Porter.] Caffeine should never be used with pilocarpine. THERAPEUTICS OF CHRONIC DIFFUSE NEPHRITIS. 157 Caffeine (citrate) is also given in connection with paral- dehyde, the former in doses of from two to four grains (some- times four to eight grains) three times daily, and the latter in capsules, 30 to 45 drops, in two or three doses at evening. When ascites is a prominent feature, Millard advises Apocy- num Cannabinum. An infusion of a drachm of the root to eight ounces of water may be used, of which the dose is a dessertspoonful two, three, or more times daily, unless it cause nauses and vomiting, or too free action of the bowels and consequent prostration. Miscellaneous:—The number of crude drugs which have been prescribed with claimed success in chronic nephritis is large. Lack of space forbids even an enumeration. Many rely on bichloride of mercury, which is given sometimes in doses of i^th of a grain, three times daily. REMEDIES IN CHRONIC DIFFUSE NEPHRITIS. See pp. 85 and 86 for diagnosis. In treating this and other disorders of the kidneys, bear in mind the three great causes of renal disease:— I. Syphilis. II. Gout. III. Malaria. In lesions which border on the sclerotic type bear syphilis in mind. Gouty conditions show themselves both in the history and in the urine, the latter loaded with urates and uric acid, of intensely acid reaction, etc., etc. Malarial origin often escapes notice. Look carefully for history of chills and fever. Con- I^S DISEASES OF THE KIDNEYS. sider the locality in which the patient lives. In the cities, syphilitic and gouty cases are more common; in river valleys, look for malarial cases. The object to be attained by treatment is to bring the disorder to a stand-still, even when complete cure is impossible. I. In syphilitic cases Mere. Iod. or Kalilod. are beneficial. Merc. Cor. will help many cases and is prescribed in a routine way. It fails, however, in some cases which Merc. Iod. and Kali Iod. will help. In cases where the etiology is obscure, try the two remedies, Mere. Iod. in the first decimal, Kali Iod. in three grain doses of the crude drug, well diluted, three times daily after meals. Dr. Delamater gives Kali Iod. in some cases immediately before a meal, the patient taking a dose of Bismuth after the meal. Or if Kali Iod. prove irritating, the sodium com- pound may be tried. If there is clearly a his- tory of syphilis and the amount of albumin in the urine is large, the patient dropsical, etc., it is advisable to use first the hot air bath, etc., especially if there is indication of uraemia. As soon as the quantity of albumin is reduced and the amount of urine in 24 hours increased, then the iodides may be given steadily for weeks or THERAPEUTICS OF CHRONIC DIFFUSE NEPHRITIS. X59 even months. [Beale advises administration of iodide of potassium for a fortnight and then, for a like period of time, syrup of iodide of iron or Blanchard's pills, one or two at 11 and 4 daily for a fortnight.] II. In gouty cases, when the urine is scan- ty, acid, loaded with urates and uric acid, Lon- donderry Lithia water, by increasing the quan- tity of urine and diminishing the acidity, proves useful. Carlsbad salts, three times weekly, will help matters if there is gastric catarrh. Lithium benzoate may also be tempor- arily employed with benefit. Euonymine should be remembered in cases where the bowels are sluggish. III. In malarial cases, Arsenicum and Fer- rum should be tried. Arsenicum in the second decimal, or Chin. Arsen., provided urea is not too greatly diminished. Ferrum Muriaticum lx when Ferrum is indicated. [There are those who claim that Fowler's solution com- bined with solution of ferrous malate is of service in malarial cases. As large doses as five minims of Fowler's solution and thirty of ferrous malate have been given three times daily in severe cases.] Merc. Cor. has also proved beneficial in ma- larial nephritis. In some cases Arsenicum in alternation with Terebinthina has done good i6o DISEASES OF THE KIDNEYS. service. Ammonium Muriaticum is advised when Arsenicum fails. Euonymtne should not be forgotten. Patients with nephritis due to malarial poisoning have been helped by the waters of La Bourboule, in France, Department of Puy de Dome. These waters contain ar- senic and iron, and are alkaline. La Bourboule has an elevation of 2400 feet.—(Millard.) IV. General treatment. The remedies called for on general princi- ples in diffuse nephritis are most often the fol- lowing:—Apis, Terebinthina, Digitalis, Mere. Cor., Ferrum. Indications for their use have already been given. See Tables X and XL Re- cent experiments tend to show that Cantharis may possibly have a field of usefulness in dif- fuse nephritis. Miscellaneous:—Oxygen gas is sometimes of service, especially if the patient be ansemic. Where there is constant and early formation of uric acid crystals in the urine it is possible that enemata of oxygen gas may do good. Jaccoud gives ten litres of oxygen three times daily in chronic Bright's disease with the simplest pos- sible diet, promoting tissue change with the in- haled gas by systematic application of douches, followed by friction. The Japanese loofah is good material for friction. Cod-liver oil,1 maltine, and hypophos- 1 Some good article as, for example, Moller's. THERAPEUTICS OF CHRONIC SCLEROSIS. l6l phites are often better for the anaemia than the various preparations of iron. Ferrum should not be given too low or too persistently when nervous symptoms are prominent. REMEDIES IN SCLEROSIS. This condition is usually referable to syph- ilis, and, if the etiology is obscure, treatment should be instituted on the theory of syphilitic origin. If, however, there is gouty history, or if lead poisoning is the cause, Mercurius must not be given too low or too persistently. Nor should large quantities of mineral waters be allowed, when the patient is already voiding much more urine than normal. RADICAL TREATMENT OF SCLEROSIS. Plumbum is the stand-by in this disorder, if not due to lead poisoning or to syphilis. Mercu- rius Vivus 3x when due to lead poisoning. Nux Vomica for the disorders of the stom- ach. Nitric acid for gastro-intestinal disorders. Cactus for the over-action of the heart. Aurum J\[uriaticum, when there are nervous symptoms, irritability, hypochondriasis, ver- tigo. Lithium Curb, and Lithium Bcnzoate in gouty kidney. l62 DISEASES OF THE KIDNEYS. Lithium benzoate may now be had in the granular effervescent form, which is a most agreeable preparation. For sclerotic kidney of syphilitic origin, Mercurius Corrosivus is the remedy. It has been given in doses as strong as the one-six- tieth to one-thirty-second of a grain. When Merc. Cor. fails, Merc. Iod. and the tannette oj mercury are sometimes of service. In rheumatic cases, or those due to lead poisoning, persistent use of mercury in appreciable doses is not to be allowed. In the treatment of forms bordering on the sclerotic type, and in sclerosis itself, regard should be paid to the condition of the heart. Before cardiac hypertrophy and signs of high tension:— Diet limited as to nitrogenous foods; general hygienic pre- cautions: if urine below normal, digitalis and salines, if neces- sary, allowable. Bowels to be opened regularly. Lastly, during heart failure, diet should be more liberal and a moderate amount of meat allowed daily. Such drugs as strophanthus, etc., allowable, if necessary; also hot-air baths. Strychnine and iron may be useful.—(Purdy.) The urine should be watched and any sudden reduction in quantity (:oupled with change for the worse in quality) should be noted. Miscellaneous:—Cod-liver oil is often exceed- ingly serviceable in sclerosis. To diminish the nocturnal urination, chloride of gold and sodium, in doses of from one-fiftieth to one-thirtieth of a grain is recommended. Symptoms indicating THERAPEUTICS OF LARDACEOUS DISEASE. 163 an unfavorable termination are scanty urine, heart failure, much oedema, albuminous retinitis, intense constant headache, urinous odor of the skin, and prurigo, coma, or excessive lethargy. -(Millard.) REMEDIES IN LARDACEOUS DISEASE. Many cases occur in the course of tertiary syphilis. The patient's strength should be sup- ported by a liberal and nutritious diet. The iodides are the leading remedies: In syphilitic cases, Kali Jod. has proved useful in appreci- able doses, as suggested before. In cases not due to syphilis, the iodides of iron and of ar- senic are often serviceable. Cod-liver oil and the hypophosphites are sometimes beneficial. If there is dyspepsia, Nux Vomica, Pepsin. Pa- tients may often take a good wine with benefit. Wnie of pepsin may be of help. In tuberculous and strumous conditions, Calcarea Curb, and Phos. must not be forgotten. [Calcium chloride in appreciable doses (5 to 20 grains in milk, largely diluted) has been used where there is enlargement of the lymphatic glands.] Ac id u in Phosphoric um has been a leading remedy in this disorder. Nephritic complications are sometimes no- ticed and will require treatment, as described under the head of the different forms of ne- 164 DISEASES OF THE KIDNEYS. phritis. It is not advisable to give cathartics in lardaceous disease. Diuretics and hot-air baths are the best palliatives in nephritic complica- tions. If, however, lardaceous disease is dependent on suppuration, the latter should be treated. Removal by surgical operation of the exciting cause should be attempted, if the suppuration is at a point where the necessary surgical pro- cedure is not certain to be attended with fatal results, for amyloid change, with its exciting focus of suppuration still present, becomes ab- solutely fatal.—(Loomis.) REMEDIES IN ACUTE HYPEREMIA. This disorder is often overlooked. See pages 90 and 91 for diagnosis. It occurs mostly in the pyrexial stage of acute diseases, but may arise independently of any specific fever, sim- ply from exposure to cold. Since both albumin and blood may be found in the urine, it is some- times difficult to distinguish the condition from acute nephritis or from an acute exacerbation of a chronic disease. It is the catarrhal ne- phritis of Yirchow. In my opinion there is more danger of mistaking a genuine nephritis for acute hypersemia than acute hyperemia for nephritis. If the patient be feverish, complain of pains in the loins, frequent micturition, and THERAPEUTICS OF ACUTE HYPEREMIA. 165 albumin,blood, and casts are present in the urine, but there is no dropsy or anasarca, the disorder may doubtless be merely acute hyperemia, especially if the patient be young. Cases are not very common, and too decided an opinion should not be given at first. Rest in bed should be required of the patient, and, in general, the hygienic precautions described under the head of "Acute Nephritis" (Page 117). Mercurius Corrosirus is an excellent remedy, when gastric and hepatic symptoms, with pain in the back, precede the fever and albuminous urine. In one case which I am quite certain was acute hypersemia and not acute or chronic nephritis, Merc. Cor., third decimal trituration, brought about a speedy recovery. Helonias has also been suggested. Indications for other remedies mentioned under the head of uAcute Nephritis " may be found in cases which come under observation. The disorder usually yields to radical treat- ment; palliatives are not only unnecessary but, as a rule, undesirable. Sometimes if there is obstinate constipation, elaterium may be needed in -fa grain doses every twenty minutes till y± grain has been given or the patient's bowels have moved. [After the tension of the blood has decreased, the acme of the disorder has been reached. Porter advises tincture of digitalis in ten minim doses every three hours until 166 DISEASES OF THE KIDNEYS. the renal secretion is started, and then less frequently. If uraemic convulsius, etc., appear, pilocarpine muriate may be needed as in acute nephritis]. When there is much pain in the back, dry or wet cups followed by warm poultices may afford relief. REMEDIES IN CHRONIC HYPEREMIA. This disorder is always secondary to mechan- ical interference with the circulation of the blood. Delafield declares the usual causes to be the following:—Chronic endocarditis, peri- carditis, dilatation of the ventricles of the heart, aneurism of the aorta, pulmonary emphysema; fluid in the pleural cavity, and tumors. To these I add cirrhosis of the liver, in which dis- order there may be pressure on the inferior vena cava in the groove of the liver which it traverses. I have seen several cases in which I suspected an hepatic cause for chronic hyper- semia, and, in one case, a post-mortem exami- nation confirmed the suspicion. In this partic- ular case, cirrhosis of the kidneys was not shown by the condition of the urine, which from first to last was that characteristic of chronic hyper- semia. The remedies are necessarily those which tend to remove, if possible, the cause of the congestion or to mitigate the sufferings of the patient. Phosphorus may sometimes be indicated. Convallaria majalis when the heart is rapid, THERAPEUTICS OF CHRONIC HYPEREMIA. 167 irregular, and there is anasarca and ascites in mitral insufficiency from cardiac dilatation and hypertrophy. Digitalis will sometimes re- duce the pulse and increase the flow of urine, when other remedies fail. Dr.W. A.Wakely1 prescribed Arnica 3x with most satisfactory results in cardiac dropsy when the patient felt " bruised as if beaten." Copious urination took place and at end of a week great improvement was evident. In cardiac dropsies, Adonis Vernal is in 2 drop doses every 2 to 4 hours is recommended by Dr. T. F. Allen. Purdy gives digitalis in connection with adonis. Adonidin is some- times used. Hale prefers tincture of digitalis with tincture of strophanthus in syrup of wild cherry as a vehicle. Brunton calls our attention to the value of beef tea as a cardiac stimulant. When digitalis fails, caffeine, may be employed to advantage; dose of caffeine citrate, 3 to 5 grains. Used in connection with paraldehyde. In cardiac drop- sies See claims that by use of two ounces of milk sugar in two quarts of water, all other liquids being suppressed, marked diuresis is obtained. Coronillin and pyrutin are two heart stimulants lately employed. lN. A. J. of H., Nov. '89. l68 DISEASES OF THE KIDNEY'S. THE HEART IN RENAL DISEASES. In chronic diffuse nephritis, especially in the forms bordering on sclerosis, regard should al- ways be paid to the condition of the heart. In general, in all cases where renal lesion is sus- pected, not only note the character of the pulse, but examine the heart as well. Apex beat:—This is normally in the fifth left intercostal space, well to the inner side of a line drawn vertically through the nipple. Hypertrophy and Dilatation:—Displacement of the apex beat to the left, when not due to pulmonary disease, spinal deformity, or pres- sure from intra-abdominal structures, is gener- ally indicative of enlargement of the left ventri- cle. The cardiac impulse may then be situated outside the nipple line, an inch or more in ex- treme cases, and in the sixth or even seventh interspace. Commonly, the hypertrophy is what is known as eccentric hypertrophy, or in- creased thickness of the ventricular wall, to- gether with dilatation of the corresponding cav- ity. The character of the apex beat varies ac- cording as either hypertrophy or dilatation pre- dominates. If the former, then the impulse is forcible, heaving, diffused, and the apex beat itself is broad and thrusting. When, on the other hand, dilatation exceeds hypertrophy, the THE HEART IN RENAL DISEASES. 169 cardiac impulse may be wholly absent, or so feeble as to be scarcely perceptible either by eye or hand. When the true apex beat can be made out, it is very localized, feeling more like a gen- tle tap than a strong thrust. In some instances the cardiac impulse gives a faintly diffused sen- sation, as of a soft body tumbling against the chest wall. Percussion generally reveals an in- crease in the area of praecordial dullness cor- responding to the side of the organ enlarged. When it is the right ventricle that is hypertro- phied or dilated, there is, in addition to visible and palpable epigastric pulsation, an increase of dullness on towards or even across the body of the sternum at the level of the fourth costal cartilages. The character of the heart sounds depends upon the state of the cardiac muscle. When hypertrophy is pronounced, the first sound at the apex is of low pitch, prolonged and loud, in a word " booming, " and the second sound in the aortic area is accentuated. When, however, the muscle of the heart is weak and the ventri- cle dilated, the first sound is shorter, weaker, and more valvular in quality. The pulse of hypertrophy is slow, full, and strong, while in the weakness of dilatation it is more or less rapid, weak, and compressible, and in rhythm either regular or extremely inter- 170 DISEASES OF THE KIDNEYS. mittent and variable in both force and volume. In hypertrophy there may be no symptoms referable to the heart, whereas in dilatation there is usually a feeling of bodily weakness and breathlessness on even slight exertion, with or without a subjective sense of palpitation. Signs and symptoms of pulmonary engorge- ment are also present in many cases, as well as evidence of general venous congestion. Sufferers from weak heart, when not associ- ated with valvular disease, are usually past middle age and will be found on careful search to manifest more or less evidence of atheroma. Hence peripheral arteries should be examined with special care. Should there be more or less evidence of arterial degeneration, distinct attacks of angina pectoris, and should the pa- tient's general condition reveal no satisfactory cause for the increasing heart failure, it may be suspected that the cardiac weakness is due to degeneration as a result of sclerosis of the cor- onary arteries.* Cardiac failure from this cause may be acute, subacute, or chronic. Acute cases may appear and end fatally in a few minutes, hours, or days, while chronic forms may last for years. Renal lesions, secondary to cardiac dilatation, * 13 ibcock. Sclerosis of Coronary Arteries, etc. North American Practitioner for Jau. 1889. THE HEART IN RENAL DISEASES. 171 differ. In many, the kidneys give post-mortem evidence of chronic hypersemia, while in long standing cases there may be actual degenera- tion. Marked hypertrophy of the left ventricle is usually produced by renal cirrhosis. When from the age of the individual, as well as from other conditions, the dilatation of the heart is likely to be due to degeneration of its walls, digitalis, so useful in dilatation of valvular dis- ease, should be employed with great caution. Its effect is to increase arterial tension, while at the same time augmenting the force and ef- fectiveness of cardiac contractions; hence it is at once apparent that there is real danger of its occasioning rupture of the degenerated heart muscle, or at least of increasing rather than lessening the dilatation by reason of the periph- eral resistance produced by the drug. Analysis of urine in a case in which there was considerable dilatation of both ventricles, and marked evidence of general venous stasis:— Volume in 24 hours, 720 C. C. Sp. gr., 1022. Solids by Trapp's coefficient, 32 grammes. Urea per litre, 181 grammes. Urea total, 13 grammes. Phosphoric acid per litre, 1.9 gramme. Phos- phoric acid, total, 1.33 gramme. Albumin, plain trace. Sediment: Hyaline and hyalo-epi- thelial casts, though not plenty. Death in six weeks from time of this analysis. 172 DISEASES OF THE KIDNEYS. Mitral Diseases.—Differential diagnosis as follows: MITRAL OBSTRUCTION. (1.) Murmur is presys- tolic, limited to mitral area, not transmitted to the axil- lary region, often accompa- nied by presystolic thrill. (2.) No enlargement of left ventricle. (3 ) Increase of precor- dial dullness to right, epigas- tric pulsation, accentuation of second pulmonary sound and reduplication of second sound at junction of fourth left cos- tal cartilage with sternum. (1.) Pulse small, regular or irregular in time, force, and volume. (5.) Symptoms of pul- monary engorgement, such as breathlessness, and often more or less cough. (6.) Found most com- monly in young subjects. (7.) As a rule not com- plicated by lesions of other valves. (8.) Prognosis as to time often very bad. MITRAL REGURGITATION. (1.) Murmuris systolic, not limited to mitral area, but transmitted to left into axil- lary region, and often to in- ferior angle of left scapula. (2.) More or less enlarge- ment of left ventricle. (3.) Praecordial dullness increased to right, epigastric pulsation and accentuation of second pulmonary sound, but these secondary signs not so marked as in mitral obstruc- tion. (•4.) Pulse regular or ir- regular in time, force, and volume. (5.) Symptoms, too, of pulmonary engorgement, not apt to be so great as in mitral stenosis. (6.) Found in young and in old subjects alike. (7.) Often found in con- nection with aortic disease. (8.) Prognosis as to time often very fair, and better in young adults than youth or age. Mitral obstruction and regurgitation are gen- erally combined, but in differing proportions, and the blending of the murmurs with the sounds, produces a characteristic rolling rhythm. Change of patient's position from erect to re- THE HEART IN RENAL DISEASES. 173 cumbent, and rapid or quiet action of hearts will generally occasion alternation in character, quality, or time of murmur. AORTIC OBSTRUCTION. (1.) Simple hypertrophy of left ventricle, as shown by well defined, thrusting apex beat, situated somewhat to left of normal position. (2.) No epigastric pulsa- tion or other signs of right- sided enlargement. (3.) Pulse small, firm, hard, regular, as a rule. (4.) Rough systolic mur- mur, having maximum inten- sity in aortic area, propagated upward into vessels of neck. (5.) Weakening of sec- ond aortic sound. (6.) Absence of signs and symptoms of pulmonary and general venous engorge- ment, unless complicated by mitral disease. AORTIC REGURGITATION. (1.) Hypertrophy, with dilatation of left ventricle, as shown by powerfully heav- ing and diffused apex beat, situated considerably outside of and below nipple. Often strong pulsation throughout entire praecordia. (2.) No epigastric pulsa- tion or other signs of right- sided enlargement. (3.) Pulse abrupt and jerking or collapsing, ren- dered more pronounced by elevation of arm; in marked cases visible pulsation of per- ipheral arteries, particularly temporals. (4.) A rough or blowing diastolic murmur, with maxi- mum intensity over body of sternum, and propagated downward along sternum, or in some cases towards the apex of the heart, not into ves- sels of neck. (5.) Second aortic sound generally masked by mur- mui. (6.) In uncomplicated cases no signs or symptoms of ven- . ous engorgement. 174 DISEASES OF THE KIDNEYS. Aortic constriction and incompetence are fre- quently combined, in which event a double or uto and fro" murmur is heard in aortic area, and both apex beat and arterial pulse are modified. Mitral regurgitation and aortic stenosis both have a systolic murmur; but in mitral re- gurgitation the murmur has maximum intensity in mitral area and is propagated to the left, it may be to the inferior angle of left scapula, while the murmur of aortic stenosis has maxi- mum intensity in aortic area and is propagated upwards into vessels of neck. The murmurs of mitral stenosis and aortic regurgitation are diastolic, but in mitral stenosis it is praesys- tolic and of maximum intensity at or just within the apex beat; while that of aortic regurgita- tion occurs with second aortic sound, has maxi- mum intensity in aortic area, and is propagated down the sternum or towards apex beat. Tricuspid Incompetence:—Organic tricuspid disease is extremely rare, but, when observed as a congenital defect, presents marked signs and symptoms of general venous hypersemia. Tricuspid regurgitation occurs as a func- tional or relative incompetence from over-dilata- tion of right ventricle in last stages of mitral or certain pulmonary diseases. There is a soft blowing murmur, systolic in time, and limited to lower end of sternum, tricuspid area, and there THE HEART IN RENAL DISEASES. 175 is generally a visible and palpable jugular and hepatic pulsation. Dropsy is a prominent symptom. General Arteriosclerosis, Atheroma:—This condition, common after middle age, is charac- terized by hardening and loss of elasticity of the arterial coats. The affected vessels are resisting to the finger, feeling like a cord, and often so infiltrated with earthy salts as to ap- pear like a row of fine beads. The vessel is tortuous and in early stages of the disease this may be the most marked condition noticed. The heart may or may not be weak from degen- eration. The second aortic sound is accented. The results of this condition are arterial ansemia and general venous hypersemia.—(Bramwell, Fothergill, and others.) • High arterial tension:—The signs of this con- dition are hard, full pulse, sense of fullness in the head, with perhaps vertigo. The compress- ibility or non-compressibility of the pulse can be best estimated by placing the forefingers of both hands side by side upon the artery, grad- ual pressure being made with the proximal finger, while the distal finger notes the effect upon the pulse. The sphygmographic tracing of the high tension is characteristic. 176 DISEASES OF THE KIDNEYS. Dr. Mahomed's method of gauging high ar- terial pressure is as follows:1 Draw a straight line from the apex of the up- stroke of the tracing a, to the bottom of the notch b, preceding the dicrotic wave, and if any part of the tracing rise above this line, then the pulse is one of high pressure. Moreover, the height of the notch may also be taken as an indication of the pressure; the higher it is from the res- piratory line c c, the higher the pressure. The above figure represents a normal pulse tracing; a is the apex of the up-stroke, b the dicrotic notch. The above figure represents a tracing in con- 1Purdy, Op. cit. ALBUMINURIAS OF PREGNANCY. 17 tracting kidney with cardiac hypertrophy and high tension.—(Saundby). Loid arterial tension:—Pulse beat short and easily arrested has been noticed in some cases of acute nephritis. Treatment with reference to the heart. Treatment in cases of renal disease should to a certain ex- tent be regulated by the condition of the heart. If there is not as yet any cardiac hypertrophy, diet may be moderately liberal, and, if absolutely necessary, diuretics like digitalis, salines, etc., administered. On the other hand, during the stage of cardiac hypertrophy diet should be low, patient not allowed to over-eat, bowels carefully regulated, and glonoin given unless uraemia impend. Digitalis and iron not now to be given. Hot baths not allowed. THE ALBUMINURIAS OF PREGNANCY. General treatment:—First, determine, so far as possible, whether the albuminuria is func- tional or organic, and, if the latter, whether due to vaginal sources, to cystitis or pyelitis, or whether to renal organic disease. If the albuminuria is functional, see treatment of "Functional Albuminuria;" if to pyelitis or cystitis, see consideration of these subjects. If the albuminuria is plainly renal in origin, identify it so far as possible with the groups given in Table VI. If there is pus in the urine, consult the chapter on " Pyuria," and carefully 178 DISEASES OF THE KIDNEYS. 1 make distinction, if possible, between mere cystitis or pyelitis and suppurative nephritis. If the latter is the condition, see remarks on "Treatment of Suppurative Nephritis." Symptoms of renal insufficiency in pregnancy are headache, slight oedema of the face, change of temper, drowsiness, ringing in the ears or photopsia, dimness of vision more or less mark- ed, possibly blindness of one or both eyes, dizzi- ness, dyspnoea especially on exertion, nausea, vomiting, involuntary twitchings, general pros- tration, urine scanty, albumin several tenths up- wards, urea from half normal down to a few grammes in 24 hours. The essentials of treat- ment in most cases are as follows:—Non-nitro- genous, or better still, if possible, a milk diet, when there is much albumin. Bowels opened once daily. Fatigue and excitement avoided. Woollens next to skin, unless too much irrita- tion from them. Free action of skin by use of warm baths. Alcohol sweats, if oedema is marked and increasing. Beverages : Pure spring water, hard water to be avoided. In some cases, milk, together with Vichy water, when milk alone is not tolerated. Uniform temperature and avoidance of draughts or ex- posure to cold even for a moment. Remedies :—These are to be given according to the symptomatology. Consult, however, the ALBUMINURIAS OF PREGNANCY. 170 remedies mentioned under "Acute Nephritis," "Chronic Parenchymatous Change," "Diffuse Nephritis," "Sclerosis," and "Chronic Hyperse- mia,"for help in differentiating. Merc.Cor.,Apis, Terebinth, Hclonias, Euonymus, Kalmia are often indicated. Add to these Arsenicum, Antitnonium Tartaricum, Ap)ocynum, Cantharis, Glonoin, Helleborus, Sepiaf Lachesis. For the nervous symptoms and vascular excitement Dr. L. L. Danforth advises selection from the following: Aconite, Belladonna, Coffea, Chamomilla, Gelsemium, Hyoscyamus, Ignatia, and Veratrum Viride. (See "Indications for Use of Remedies.") Clinical Testimony:—Merc. Cor. 3x given every two hours for three months was useful in one case reported in Hahnemannian, Nov., 1889. Dr. F. F. Laird of Utica uses pilocarpine systemat- ically in every case of albuminuria, from the lightest to the most severe. Hypodermic dose 1-6 grain increased to 1-3 if necessary, once a week on an average, unless headache or dimness of vision are complained of, in which case dose repeated every third day. In fifteen cases of albuminuria no convulsions have thus far occurred. Convulsions :—[The reader is referred to an interesting article by Dr. Wm. G. Willard in the Medical Era of November, 1889.] The l8o DISEASES OF THE KIDNEYS. essentials in treatment are as follows : Patient to have, during the spasm, some soft object as a cork or folded towel between the teeth. Chloroform to be given not during a spasm, but in sufficient quantity to anticipate a spasm. During period of relaxation, patient's bowels to be opened and diaphoresis induced by alcohol sweat. Chloral per rectum or morphine hypo- dermically to prolong the quiet induced by the chloroform. Belladonna, Cuprum, Gelsem- ium, Hyoscyamus, or Veratrum Vir. either by the mouth or beneath the skin. In severe cases when all other means have failed, large doses of morphine, hypodermically, have been admin- istered with favorable issue. It is said that as a last resort a single hypodermic injection of one and one-half grains of morphine has been used successfully in two cases1. Dr. E. P. Hurd2 sums up the treatment, when the patient is in danger of convulsions, as follows : The patient must refrain from work, be put on a diet of milk, with or without Vichy water, and fruits, with a mini- mum of animal food. Saline diuretics, as cream of tartar or acetate of potassium, may be prescribed, and tincture ferri chloridi in full doses three times a day ; a full dose of Glauber salts in the morning to promote free elimination by the bow- els. It may even be expedient to give at bedtime a full dose of fluid extract of jaborandi to produce profuse sweating, or 1 Willard, Era, Nov., 1889. 2 Therapeutic Gazette, Nov. 15th, 1889. ALBUMINURIAS OF PREGNANCY. 181 administer hypodermically ^ of a grain of pilocarpine, or even resort to the wet-pack or hot bath. If, in spite of these efforts to relieve the engorged kidneys and protect the irritated nerve centres, the patient becomes worse and convulsions seem imminent, premature labor should be induced. Induction of Labor—Tyson's Conclusions :— Dr. James Tyson, of Philadelphia, in a paper before the American Medical Association, June 27, 1889, offered the following conclusions : The occasions justifying the induction of pre- mature labor are 1. In Bright's disease complicating preg- nancy, where puerperal convulsions attended nephritis in a previous pregnancy. 2. In all primiparse where Bright's disease had existed prior to pregnancy. Here prema- ture labor should be induced as soon as the foetus is viable. 3. In cases in which we have not the knowl- edge acquired in previous cases. [All will not agree with Dr. Tyson and espe- cially in regard to primiparse, but the subject does not properly come within the province of this work and will not be discussed here]. I have shown1 that albumin in the urine may be found from various causes during pregnancy and that such condition should not be con- founded with true Bright's disease, as under- l Hahnemannian, Jan., 1890. 182 DISEASES OF THE KIDNEYS. stood by Dr. Tyson in formulating his conclu- sions. I subjoin two analyses of urine in a case in which the patient went to the seventh month, had convulsions, but recovered after delivery. Both analyses were made before delivery. First Analysis. Second. Volume, 1400 c. c. 1020 c. c. Sp. gr., 1020. 1021. Solids, 56 grammes. 43 grammes. Urea, in 1000, 17. 20 « Urea, total, 24 grammes. 20 " Salts, not including urea, 32 gra's. 23 " Sediment :—Much mucus, vag- No casts whatever. inal and vesical epithelium, Vaginal and vesical triple phosphate. epithelium. Albumin :—Faint trace. One and one-half tenths. The second analysis was made a few days before convulsions, but some six weeks after the first analysis. In this case it will be seen that in both specimens urea was not seriously defi- cient and tube casts were not found at all. Puerperal Convulsions:—Dr. E. J. Doering, in a paper on this subject read before the Gyn- aecological Society of Chicago, summarized the treatment under three captions : 1st. For convulsions before delivery: The hot bath, mor- phia and pilocarpine hypodermically, chloral and bromide of potassium by mouth or rectum, veratrum viride to reduce heart's action and lower arterial tension, possibly bleeding, induction of labor. 2nd. For convulsions during labor: The hot bath, mor- phia, chloral, anaesthetics; a rapid delivery with all precautions. 3rd. For convulsions after labor: Control eclampsia by an- aesthetics and promote rapid elimination by all the emunctories. TREATMENT OF COMPLICATIONS. 183 TREATMENT OF COMPLICATIONS OF RENAL DIS- EASES. Ascites, Abdominal Dropsy. See "Dropsy." In extreme cases paracentesis abdominis. Aneurism : Death without uraemic symptoms from rupture of aneurism. Sometimes shown by hematemesis. Apoplexy :—There is often danger in those past middle age that there will be changes in the blood from the renal lesion and that the cerebral vessels will suffer, especially when at the same time, as is usually the case, there is associated cardiac hypertrophy. Preventive treatment: Bowels to be opened regularly at least once daily, together with the usual elimina- tive measures. Dr. Hale advises Arseniate of Strychnine. Try also Arnica, Belladonna, Nux Vomica, Opium, accord- ing to indications. [Ice to the head, purgatives, bleeding. -(Purdy).]. Asthma:—Amy I nitrite, second decimal. Palliatives: Porter advises pilocarpine muriate, elaterium, fluid extract of quebracho, all in full doses. Leech advises ethyl nitrite in half drachm doses of a 3 per cent solution. Roosevelt, cobalto- nitrite of potassium in half grain doses every two to four hours. Ozonic ether is also recommended. Bronchitis:—Merc. Cor., Arsenicum 3x, Kali Bich. 3x. Other remedies may be indicated. (See "Indications for Use of Remedies.") Guard against exposure to cold as preventive, but when established, keep patient warm. Dash the chest with cold water and rub briskly with towel. Cardiac Lesions :—In chronic parenchymatous change and in cases of the small, soft kidney (chronic diffuse nephritis without vascular thickening), expect to find a soft, small, atrophied heart, due to progressive and general mal-nutrition. In chronic diffuse nephritis -with vascular thickening, and in sclerosis, expect to find compensatory hypertrophy of left ventricle to overcome the general vascular resistance. 184 DISEASES OF THE KIDNEYS. Valvular lesions may precede chronic hyperaemia. (See "Treatment of Chronic Hyperaemia"). Valvular lesions may be brought on by endocarditis (caused by the deteriorated condition of the blood in renal diseases), in which case the prognosis is more serious than when either the valvular lesion exists without the renal, or the renal without the valvular. In the treatment of the atrophied heart, Dr. E. M. Hale suggests Digitalis, Strophanthus, and Baryta J\Iur. For the compensatory hypertrophy no treatment is neces- sary, save removal of the condition for which it compensates. Dr. A. L. Loomis calls attention to the fact that it is cardiac degeneration which is to be feared rather than hypertrophy : heart failure in other words. (See "Acute Nephritis, Pallia- tive Treatment"). For Endocarditis due to renal disease, Dr. Hale suggests Arsen. Iod. and Salol. He finds Arsenicum, in some form in- dispensable. In Angina Pectoris, which is a common symp- tom in sclerosis of the coronary arteries, Babcock1 advises prompt inhalation of amyl nitrite, or a glassful of hot whisky. If sub-sternal pain be dull and persistent, nitro-glycerine in doses of one-hundredth of a grain may be administered thrice daily. The body should be kept warm and absolute rest enjoined. Cardiac Asthma is promptly relieved by stimulants. Hy- podermic injections of one sixth or one eighth grain of mor- phine combined with one-twentieth as much atropine are highly praised by Dr. R. H. Babcock. Sclerosis of the coronary arteries :—Treatment of angina pectoris and cardiac asthma as above. General treatment :— Body warmly clad, only gentle exercise to be taken, consti- pation carefully guarded against, nutritious food taken, daily *0p at. TREATMENT OF COMPLICATIONS. 1S5 use of alcoholic stimulants and strychnine are advised. In order to overcome visceral hyperaemia, Turkish baths may be cautiously employed, diuretics, and even pilocarpine, if the indication is urgent. But digitalis is dangerous in these cases. Constipation :—Obstinate, chronic constipation, especially in sclerotic conditions: Plumbum. See also, "Indications for Use of Remedies." If constipation threatens the patient's life with distress from accumulation of gas, suppression of urine, etc., etc., Porter advises us to give a full dose of pilocarpine muriate, hypodermically, preceded by stimulants. Ordinarily, elaterium will prove sufficient. Sometimes nux vomica and belladonna in ponderous doses bring about the desired result. [In milder cases and when the liver is at fault, aloes or pod- ophyllin at night, with a glass of Hunyadi in the morning]. Insert a rectal tube if there is great accumulation of gases. Diarrhoea:—Often a natural effort at elimination, which should not be too quickly checked. When there is dropsy with diarrhoea, Helleborus is often indicated. (See also "Indications for Use of Remedies"). Salol is now used extensively in treatment of diarrhoea. If diarrhoea persist to an alarming extent, eliminative treat- ment may be necessary. In lardaceous disease diarrhoea is often very troublesome. It may be due to intestinal catarrh. Try Calc. Carb., and Phos., Phosph. Acid., Arsen., Merc. Cor., Sulphur. [If the diarrhoea is due to intestinal ulceration, Purdy ad- vises sulphate of copper \ to \ grain in pill form every four or six hours, and deodorized tincture of opium by the rectum. For the diarrhoea of the late stage oi sclerosis, Purdy declares against the use of opium and relies on tannin or gallic acid, combined with sulphate of copper]. Dropsy :—In Chronic nephritis (not sclerosis) try Digitalis (tincture or infusion), combined with Adonis Vernalis (10 186 DISEASES OF THE KIDNEYS. drops of fluid extract), occasionally substituting Convallaria Majalis for both or either.—(Purdy). Scoparius, tincture, in 15 drop doses, diluted with water, every three hours.—(Henry Sherry). Not in acute or sub- acute stages. Scoparius, infusion, is made by steeping an ounce of broom tops in a pint of water for half an hour; dose, one to two fluid ounces four times daily.—(Purdy). [Loomis recommends Fothergill's pill, in which there is one grain each of squill, digitalis, and calomel. Porter recom- mends a pill containing three grains of caffeine, one of pow- dered digitalis leaves, and one-twentieth of a grain of strych- nine]. Alkaline mineral waters. If the patient is not too anae- mic and there is no diarrhoea, saline cathartics, or elaterium. If the patient is not too weak, occasional hot-air baths and pilocarpine muriate. Digitalis fomentations to the loins. Success is claimed even in renal dropsies from the use of caffeine citrate, combined with paraldehyde. The caffeine in 4 to 8 grain doses during the day, the paraldehyde in capsules 30 to 45 drops in two or three doses at evening. Scilla lx, Ferrum Mur. lx, Apocynum in watery infusion, have been given with successful results. Saundby advises convallaria in 15 minim doses of the tincture in the dropsy of chronic (lithasmic) nephritis when there is heart failure with aortic regurgitation, but digitalis takes first rank; either may be combined with a grain of caffeine citrate, 5 minims of liquor strychninae, one minim of one per cent, solution of nitro-glycerine, and an ounce of infusion of broom-tops. S£e has confidence in sugar of milk. In the dropsy of the advanced stage of sclerotic conditions, remedies of the digitalis group. In severe cases, salines effective and allowable, even if diarrhoea is present.—(Purdy). Saundby, however, remarks that these cases, where there is TREATMENT OF COMPLICATIONS. 187 dropsy from heart failure, are eminently unsuited for purging, and it is sufficient to keep the bowels open. The end is very near and may be more easily precipitated than averted. Sudden reduction of dropsy, especially by purgation, has been known to precipitate convulsions or coma. Empirical treatment with ponderous doses of various drugs is a last resort, and in some cases hastens the death of the patient rather than prolongs his life. Nevertheless, there is always the hope that if he be tided over a crisis nature may tip the balance in his favor. Epistaxis :—Plug nostrils with cotton wool saturated with solution of ferric chloride or solution of the sub-sulphate of iron. Gaucher treated an obstinate case in interstitial nephritis by milk diet and a mixture of the extracts of cinchona and rhat- any. Saundby advises Ergotin, subcutaneously, two or three grains, or ergot by the mouth. An icebag to be applied locally. Success is claimed for the local application of lemon juice, solution of alum, or hot water alone. Dropping a large, cold, iron key down the back of the neck often succeeds. Erysipelas :—Not a common complication, but may follow puncturing or incising for relief of oedema, or be secondary to erythema or eczema. Sometimes it develops spontaneously. To prevent erysipelas after incisions, the incised member should be wrapped in hot, moist flannels, which should be changed at first every two or three hours, and at every change the legs, and especially the incised parts are to be thoroughly sponged with warm water and the flannels cleansed before reapplying. Drainage tubes have been used to avoid the dan- ger of erysipelas. Gangrene:—Rapidly fatal. Pack affected part in Fuller's earth to overcome odor. Gastric Symptoms: — Nitric Acid lx. Nausea, slimy mouth, yellow tongue, bitter, acid taste in mouth; alterna- l88 DISEASES OF THE KIDNEYS. tion between diarrhoea and constipation, piles, anorexia. [Nausea, with much mucus expectoration, Pulsatilla lx, Ipecac]. Arsenicum in the lower decimals when dyspeptic symp- toms are prominent. Nux Vomica for "gastric symptoms accompanied by heavi- ness and stupor. Patient is to avoid green vegetables and fruits temporarily, when gastric catarrh is a symptom. Saund- by thinks well of a teaspoonful of Carlsbad Salt, dissolved in a tumbler of hot water each morning before breakfast, and Euonymine before the principal meal of the day, or at bed- time. Vomiting:—Ice, carbonic acid water, milk, Kreasote 3x. Vomiting is often a natural effort at elimination, which should not be too quickly checked. It is often the case that the gastric symptoms persist and yield to nothing but the ordinary palliative treatment in renal diseases, viz., diuresis, catharsis, and diaphoresis. Headache :— Glonoin is often useful. Hot air baths may relieve. Ap- plications of hot water, or of cold, or both, alternately. Ferrum and China are sometimes useful. Porter advises local application of a cloth saturated with the following:— g Chloroformi et Tincturae aconiti - - - - aa li Chloralis Hydratis et Pulveris Camphorae - - - aa li M. Sig. External use. If the headache persist, it may be necessary to promote elimination as already described. Hydrothorax :—Arsenicum is the remedy in this affection. If it persist, eliminative treatment may be tried. TREATMENT OF COMPLICATIONS. 189 Hydropericardium:—Always a serious complication, often fatal, especially if spontaneous, without previous dropsy. Arsenicum is the leading remedy. At the same time in critical cases catharsis, diuresis, and di- aphoresis may be necessary. Stimulants, as ammonia or al- cohol, are often useful. Jaundice:—Attention should be paid at once to this com- plication, since by derangement of the liver more work is re- quired of the kidneys. The remedies are Nat rum Phos- phoricum, Podophyllum, Chelidonium, Mercurius, Euony- mine. Porter claims that there is great relief in some cases from a few grains of inspissated bile. It may be inclosed in a gelatine capsule. Nervous and mental derangements:—Convulsions, coma, delirium, sometimes becoming insanity, headache, dyspnoea, failure of vision and hearing, paralysis, neuralgia, itching, sometimes cutaneous eruptions, dead fingers, rarely symmet- rical. Gangrene may, according to Dr. R. T. Edes, follow acute and chronic diffuse nephritis. Eliminative treatment is necessary. The headaches of renal disease are often re- lieved by hot air baths. The characteristic headache of the pre-albuminuric stage of Bright's disease is, according to Seg- uin, occipital, extending often into the cervical region. Oedema— Glottis:—Symptoms: sudden inability to inhale air, cyanosis. Patient is able to perform the expiratory act. Scarification of the oedematous aryteno-epiglottean folds, tracheotomy, intubation of the larynx. Remedies:—Apis. Ice to suck. Lungs:—Symptoms: rapid, shallow breathing,dyspnoea, cyanosis. Pilocarpine must not be given when there are pulmonary complications. Dry cups to the chest, ammonia internally, followed by general eliminative treatment. Purdy gives dig- 190 DISEASES OF THE KIDNEYS. italis and ergot (20 to 30 minims of the fluid extract (Squibbs), every four hours if the stomach will tolerate it). Ipecac for the irritable, dry cough. Palpitation of the Heart:—Glonoin. Pericarditis:—Arsenicum 3x is recommended. Very ac- tive treatment is hardly judicious. Poultices or hot fomenta- tions locally. Peritoneal Effusion:—May be removed by tapping. Pleuritis:—In connection with renal diseases the subacute form with serous exudation is the most common. Arsenicum is a prominent remedy. Active treatment not judicious. Poultices or hot fomentations locally. Pleu- ral effusions should not be rashly interfered with (by tapping) especially if not recent.—(Saundby). A fly blister on affected side, with catharsis and diuresis^ is the treatment of those be- lieving in vigorous measures. Pneumonia:—This, in ail its forms, may precede or compli- cate renal diseases. Acute pneumonia is often a direct cause of acute nephritis (parenchymatous change). Pneumonia in chronic renal diseases is often fatal. Remedies:—Iodine, Phosphorus, Chelidonium. [Purdy advises ergot and digitalis to be given early]. Too active measures are not advisable. Dry cups to the chest and loins. Warm poultices to the loins. Stimulants are advised by many but the reaction is often serious. Retinal Lesions:—For retinal hemorrhage during stage of cardiac enlargement Purdy advises purgatives and ergot to begin with, followed by small doses of mercury, or iodide of potassium. Retinal hemorrhage during advanced stage of cirrhosis should be treated, according to Purdy, by leeching the temples, followed by use of ammonium hydrochlorate in aqueous solution, in doses of three to ten grains, its taste disguised by addition of extract or syrup of licorice-root. If TREATMENT OF COMPLICATIONS. I9I the retinal lesion is degenerative, iron, quinine, strychnine, after first reducing any inflammatory action. Septiccemia:—It has been shown by W. W. Sherman1 that renal lesions are often developed by surgical operations. Hence Porter advises that before all operations, the kidneys should receive attention. Fluids and non-irritating diuretics should be administered. After an operation the urine should be watched, and if signs of acute parenchymatous change appear, active eliminative treatment should be observed. The so-called septicaemia is more correctly an uraemic toxaemia. I believe that the time is not far distant when no surgical operation will be undertaken until a thorough analysis of the urine has first been made. Careful operators already see the necessity of more thorough knowledge of the condition of the urine than is obtained by merely "testing" the urine. UREMIA. The reader is referred to an interesting mon- ograph by Landois,2who claims that the various theories of ursemia in the past are not correct. He has lately introduced into the cerebral sub- stance of animals various substances found in the urine, as urea, kreatin, kreatinin, etc., and reasons from the effects produced that ursemia is due to irritation of the psycho-motor centres in the cortical substance of the brain. Kreatin proved to be the most active irritant. Landois also found that if the animals were narcotized at the beginning of convulsions that 1Porter, op. cit., p. 78. *Die Urcemie, Vienna, 1890. 192 DISEASES OF THE KIDNEYS. the latter immediately decreased in violence; moreover, during narcosis none of the phe- nomena of convulsions from irritation could be called forth. Dr. E. P. Davis1 calls attention to the fact that in puerperal eclampsia the liver is particu- larly at fault. The eclampsia is due not merely to retention of urea and of the potassium salts, but also to some of the compound albuminoids which should have been acted on by the liver. This is undoubtedly true in many cases. Under such circumstances the urine will resemble in general features that of acute parenchymatous change, Table VI. (a), in the earlier stages, and later, possibly, that of chronic parenchymatous change, Table VI. (b), II. The term acute is given to ursemia when the symptoms are decisive and marked from their onset. The term chronic is used when the symptoms are indefinite, vague, and various, becoming more and more pronounced as the renal lesion progresses. Acute uramia:—Symptoms maybe, in the be- ginning, convulsions causing death, convulsions followed by coma, or coma without convulsions, speedily causing death. Ursemic convulsions present the following features :—No initial cry; ^University Medical Magazine, Nov., 1889. 1 URvEMIA. !93 marked pallor and convulsions, followed by coma; urine albuminous; convulsions equal on both sides; no hemiplegia; patient unconscious; temperature usually above normal; peculiar ursemic odor of breath. Dr. Horace F. Ivins, of Philadelphia,1 has observed paralysis of the muscles moving the left vocal band, as a manifestation of ursemia. Uraanic Coma:—It is not always a simple matter to make the diagnosis of ursemic coma, especially in a case the previous history of which is not known. The physician is often summoned in great haste to attend a patient previously unknown to him, and may possibly arrive at a juncture when the diagnosis presents considerable difficulty. The conditions for which ursemic coma may be mistaken are (1) apoplexy, (2) epilepsy, (3) alcoholic stupor, (4) opium coma. Attention in all cases should be paid to the character of the respiration and stertor. In ursemic coma the stertor is labial, causing a peculiar hissing sound. Dr. Chas. W. Purdy has published2 a table of. differential diagnosis, in cases where ursemic coma is suspected, which brings out very clearly the essential points. His diagnosis is as follows : 1 Hahnemannian, Feb., 1890, p. 105. 2 Journal of the American Medical Association. Uremic Coma. Apoplexy. Epilepsy. Alcoholism. Opium Coma. Most common in the young. Almost confined to middle and ad-yanced life. Most common un-der 30 years of age. Common at all adult ages. Most common in the young. Previous attacks rare. Bright's disease present. Previous attacks rare. Heredity marked; granular kidney common. Previous attacks the usual feature. Previous attacks common. May be habit or accident. Pallid, cachectic. Normal. Dusky, purple, gradually becom-ing pale. Features suffused, bloated, lips livid, expression vacant. Features shrunk- en, pallid, cyanot-ic, expression ghastly. Increased from beginning, 100° to 102° F. Lowered 90° F. or lower. Increased slightly; 99° F. Lowered some-what. Somewhat lowered. Increased 90 to 120 per minute. Slowed: 60 per minute; full. Slightly increased, small, feeble, and dicrotic. Increased, feeble, small. Usually slowed, feeble. Tend to dilate. Unequal. Normal. Stertorous, gut-tural, unsteady. Dilated. Contracted. May be hastened or not; stertor labial. Slow, stertorous, guttural. Deep, slow, ster-torous, intermit-tent. Alcoholic breath.; vomiting present; injected conjunc-tiva; swollen fea-tures: supra-orbit-al pressure rouses the patient. Slow, shallow, feeble. Special Features........ Unconsciousness not complete; pe-culiar odor of breath; convul-sions recurring; frequent pulse; temperature in-creased ; albumi-nuria. Slow pulse; com-plete insensibil-ity; unequal pu-pils; hemiplegia, guttural stertor. History of former attacks; Uncon-sciousness not complete; coma of brief duration; great muscular re-laxation Contracted pupils, opium breath, slow respirut'ons: cyanosis; expres-sion ghastly. URAEMIA. J95 Figure 18 represents highly granular and fatty casts and masses from the urine of an Figure 18. Granular Casts. X400. adult male patient who died of ursemic coma. These casts were found in the urine two days before death. Treatment of acute ursemia must be vigorous and prompt. Dry hot-air baths, alcohol sweats, cupping of the loins, followed by warm poultices, pilocarpine, elaterium, digitalis. Benzoate of soda has been used in 2 to 5 grain doses hourly. Pilocarpine not advisable when respi- rations are abnormal. Remedies which may be given are as follows: I96 DISEASES OF THE KIDNEYS. When there is cerebral hypersemia, Apis, Bell., Conium, Glonoin, Gelsemium, Stramonium, Verat- rum Vir.; when there is sopor, Agaricus, Anar- cardium, Bell., Acidum Hydrocyanicum, Lac- tuca, Opium. Ansemia and paralytic symptoms: Arseu., Camph., Chin., Chin. Arsen., Phos., Phos. Acid. In the intervals between the attacks, simple diet, as milk, thorough disin- fection of the alimentary canal, attention to the hepatic function, and care that nutrient enemata do not contain nitrogenous substances, salts of potash, etc. Oxygen gas, passive exercise, or gentle exercise in open air, if possible, are also desirable. Dr. James Tyson1 outlines the treatment of convulsions due to Bright's disease, as follows: The first step is undoubtedly to bleed from the arm, and if the convulsions continue, chloroform may be inhaled. The same effect is often as well obtained by chloral. Indeed, the action of this remedy is often magical in controlling a con- vulsion (grs. lx, by enema). Pilocarpin (gr. ^, hypodermically) or a hot bath may be used in convulsions of Bright's disease. A steam bath may be extemporized by filling bottles with hot water and wrapping them in cloths wrung out of hot water, placing as many as possible alongside the body and between the legs. The sweating thus induced may be kept up as long as the convulsions last or recur. An enema should also be administered, if it is known that the bowels have not been recently moved. 1 University Medical Magazine, Jan., 1890. URAEMIA. 197 [Elaterin in sV to -^ grain doses, every four hours, till free watery stools, but when it produces vomiting or sharp irrita- tion, Purdy has found Hays' suggestion valuable, to-wit: an ounce of magnisium sulphate, or Rochelle salt, in an ounce and a half of water early in the morning, the patient to take no fluids for twelve hours before or six hours after]. Dr. William G. Willard, of Chicago, sums up the question of treatment, where ursemia threat- ens, during pregnancy, as follows: The continuance of symptoms of renal dis- ease, and their aggravation early in pregnancy, must be looked upon with much concern. To put the patient upon a strict milk diet; secure a free movement of the bowels every day; give her frequent alcohol sweats; guard her from all exposure to cold and mental excitement; pre- scribe such remedies as are indicated; and to note daily the effect upon the anasarca and the urine, would be sound treatment. If, under such regulation, her general health improves, anasarca diminishes, and the condition of the urine becomes more normal, pregnancy need not be interrupted. But should these measures not have the desired effect, and especially if headache, impairment of vision, or gastric de- rangement appears, the interest of the mother will call for the induction of labor. Chronic Uramia:—This disorder is far more common than generally supposed. It is im- portant that in all obscure disorders the rela- 198 DISEASES OF THE KIDNEYS tion of the weight of the patient to the amount of solids in the urine be noted. The accumula- tion of toxic products in the blood and tissues is often very slow, and prompt treatment in the beginning is of the utmost value. The medical profession is rapidly awakening to the importance of estimations of the total solids in urine, the ratio of urea to the salts, etc., etc. The number of cases in which I find deficiency of solids, and particularly of urea and phos- phoric acid, as compared with the weight of the individual, is simply remarkable.1 The effects of defective renal functions are sel- dom pronounced at first, and the patient declares that he is "perfectly well." 1 have known patients who voided less than a quart of urine a day to declare that their urine was "copious." Life insurance companies are beginning, in some lo- calities, to recognize the value of quantitative analysis as compared with mere testing of urine for albumin. Much dissatisfaction is expressed at the results of albumin testing in life insurance examinations. This is due partly to the fact that good risks are rejected, some of the newer tests for albumin giving a haze with nearly every specimen of urine examined. What is tvanted is knowledge of the power of 1 Medical Era, 1888 and 1889. URAEMIA. I99 the kidney to do its work; and this can not be determined except by weighing the applicant and determining the ratio of his urinary solids to his body weight, giving due consideration to any idiosyncrasies of diet, etc., etc. Dr. N. B. Delamater, of Chicago, has called my attention to the number of cases in which, reasoning by exclusion, after quantitative analy- sis of the urine, various vague and distressing nervous symptoms are to be ascribed to a con- dition none other than chronic ursemia. Albu- min and casts need not be present. Patients who have suffered from these symptoms for months, or even years, have been greatly helped by eliminative treatment when other measures failed. Increase in the quantity of urine is, as a rule, in these cases followed by not only abso- lute but relative increase of urea. If the urine is sufficiently abundant, increase in the quan- tity of urea is desirable. In the first class of cases, Lithium Benzoate and Londonderry water have been of service. In the second class of cases I have found Euonymine of service. The general principles of treatment in chronic ursemia are well laid down by H. W. Carter:— 1. Cut off the urinary poisons at their source, by limiting the quantity of potassium salts both in food and in medicine. 200 DISEASES OF THE KIDNEYS. 2. Employ the simplest and most easily assimilated food, as milk. 3. Disinfect the bowels. 4. Maintain at best the functional activity of the liver. 5. If nutrient enemata are required, take care as to their nature. 6. Directly or indirectly withdraw or dilute the poison (by the usual eliminative measures). 7. Burn up the poison by active exercise and administration of oxygen and oxidizers. 8. Antagonize the poison, or, at least, over- come special symptoms. When the patient begins to feel the effects of ursemia in renal disease, and to complain of headache, nausea, and diminution of urine, the general treatment is as follows : Rest in bed; non-nitrogenous diet; room well ventilated, and not over-heated; inhalations of oxygen gas; diluent drinks, copiously administered; hot-air baths, if not too debilitating; pilocarpine, except in post-scarlatinal nephritis, and in last stages of chronic nephritis, when the heart is dilated and weak; pilocarpine should not be given when respirations are abnormal. While eliminative treatment is being carried out, it is wise to give copious draughts of fluids, in case there is dropsy. I have previously Re- marked that sudden reduction of dropsy by URAEMIA. 201 eliminative means may precipitate convulsions or bring on coma. SYPHILIS OF THE KIDNEY. Syphilis, as already shown, is, properly speak- ing, a cause rather than a complication of renal disease. If albuminuria and the various manifestations of Bright's disease occur in the first months of syphilitic infection, the prognosis is favorable. Graver the slower the disease, and becoming the graver the more the disease is prolonged.1 Clinically, syphilis of the kidney in the early form presents itself in two different aspects: 1. More frequently simple albuminuria, more intense and persistent and characterized by pres- ence of albumin alone. If treatment is neglect- ed, true albuminous nephritis may result. 2. In other cases less common, the disease is introduced with the symptoms of acute scarla- tinal nephritis.2 There is still another form of renal syphilis in which, upon a chronic condition, there super- venes an attack of acute diffuse nephritis, ac- companied often by hematuria. The course is rapid and patients rarely recover. iTommasoli in Ann. of Univ. Med. Sci., 1889, quoted by Tyson. *Jaccoud, Ann. of Univ. Med. Sci., 1889, quoted by Tyson. 202 DISEASES OF THE KIDNEYS. The treatment is1 as follows: In the simple albuminuria occurring early in syphilis, the mixed treatment, mercury and iodide of potas- sium. In the acute form, introduced by symp- toms of acute scarlatinal nephritis, viz.: albu- minuria, fever, lumbar pains, anasarca, pulmo- nary oedema, etc., etc., the treatment should first be that of acute nephritis, and subsequently the mixed treatment used, together with milk diet. GENERAL INDICATIONS FOR THE USE OF REMEDIES IN NEPHRITIS, WITH CLINICAL NOTES. Aconite-.—Great and sudden sinking of strength without jerking, or twitching, or un- consciousness. Patient sleepless, restless, toss- ing about; scanty, high colored urine after tak- ing cold. Patient likely to be uneasy, to worry, and never bears his sickness with calmness and patience. Patient anxious, has feeling of apprehension, is not delirious. Antimonium Tartar i cum:—Complexion of bluish tint, respiration rapid, gastric derange- ments prominent, also bronchial: great rattling of mucus in the bronchia with scanty expectora- tion. Urine dark, brown-red, scanty, turbid, of strong odor. Dyspnoea, pulmonary oedema. To be thought of in cases where also there is in- flammation in the neck of the bladder. INDICATIONS FOR REMEDIES IN NEPHRITIS. 203 Autiiuonium Crudum: — Patient peevish, irascible. Aggravations from cold drinks or cold applications. White tongue, gastric symp- toms. Dysuria, strangury, mucous discharges from urethra. Apis:—Absence of thirst. Patient tired as if bruised all over. Erysipelatous, rosy appear- ance of the anasarcous limbs; or red pimples. Urine scanty, high colored. Pains of a stinging character. Useful in a cute exacerbeitions, when oedema of eye-lids is a prominent symptom. Suppression of urine. Figure 19. Yellow Casts. X400. 204 DISEASES OF THE KIDNEYS. Figure 19 represents yellow casts partly cov- ered with blood corpuscles, and found in the urine during an acute exacerbation of chronic diffuse nephritis. Apis was useful in this case. Apocynum:—No pain or uneasiness in region of the kidneys, but urine scanty; in dropsical conditions, with sense of general but transient debility. Used in form of aqueous extract to increase the flow Of urine. Clinical notes: — An excellent diuretic.—(Millard). A positive remedy for dropsy.—(Scudder). I have relieved severe cases of ascites by apocynum. —(Millard). Often acts as an efficient diuretic.—(Purdy). Will check dropsy, used hypodermically over the kidneys. —(Hale). Has remarkable virtues.—(Hughes). Restores the urinary secretion rapidly.—(Ruddock). Argent urn Nitricum:—Great prostration and disturbance of nutrition. Convulsions, preceded by great restlessness. Arsenicum:— Patient weak, restless, in great anguish, wishes to drink frequently, little at a time; urine dark, turbid; in the sediment, casts and detritus abundant. Clinical notes: — Useful as an aid to 7erebinth; best in nephritis of malar- ial origin.—(Hughes). * INDICATIONS FOR REMEDIES IN NEPHRITIS. When there is tendency to hydrothorax.—(Woodward). Post-diphtheritic nephritis: Arsenicum and Phosphorus. —(Blackley). Complete cure in a case of chronic nephritis, the result of cold, accompanied by nausea and anasarca, in a young man of twenty. The treatment consisted exclusively of Fowler's solution, five drops, three times daily, and drachm doses of tincture of cinchona.—( Millard). Has sometimes proved beneficial in diminishing albumin- uria and in relieving headache and nausea.—(Millard). Aurum Muriaticum:—In the dropsy of nephri- tis, as a diuretic. Clinical notes: — When Arsenicum is indicated but fails.—(Hughes). Has proved of great value in chronic interstitial nephritis especially when patient has nervous symptoms, hypochondria- sis, irritability, and vertigo. Dose, 1-100 to 1-10 of a grain. —(Millard.) The chloride of gold and soda (dose, 1-30 to 1-20 of a grain) in cirrhosis, when there is excessive nocturnal urin- ation.—(Bartholow, Purdy). Belladonna:—Useful to allay nervousness, es- pecially during pregnancy, when there is much jerking and twitching of the muscles and re- markable quickness of sensation or motion. Pains reach their acme and vanish in a second. Burning of the skin, urine dark colored. Calcarea Carbonica:—Disorders from living in damp places. In " fair, fat, and flabby" patients. Cantharis:—Internal pains: In the kidneys, loins, abdomen; with incessant desire to urinate; 206 DISEASES OF THE KIDNEYS. micturition painful before, during, and after flow of urine. Urine scanty, turbid. When pleurisy complicates. Very severe tenesmus. Clinical notes:— I have found it of use in alternation with the mercurials in acute nephritis with diminished or suppressed urine, the result being diminished albuminuria and increased urine when neither mercurial {Merc. Cor. or Merc. Dulcis.) would pro- duce it.—(Millard). As a diuretic, I employ it more as the case recedes from the acute character.—(Millard). In chronic (croupous) nephritis ha9 often been of use in diminishing albuminous secretion and promoting the secretion and flow of urine.—(Millard). Carbolic Acid:—Dr. Wm. Owens, Sr.,1 in an article entitled "Therapeutics of Post-Scar- latinal Nephritis," writes as follows of Carbolic Acid. "It gives us, first, copious flow of urine followed by diminished flow, passing on to enu- resis. The color of the urine is dark green, or very highly colored, bloody and smoky. The urine may be alkaline or slightly acid. Of other symptoms we have: frontal headache, sen- sation as if a rubber band were drawn tightly across the forehead and temples; disinclination for all mental work; pale face, livid counte- nance; cold clammy sweat; loss of appetite; a desire for whisky or stimulants." 1 American Homoeopathist, July, 1889. INDICATIONS FOR REMEDIES IN NEPHRITIS. 2Q^J Chelidoiiium:—-Used chiefly when pneumonia is a complication. Col eh i cum:—In cirrhosis of the kidney due to plumbism, in gouty diathesis, where there is am- aurosis.—(Ruddock). Convallaria Majalis: — With digitalis, in scarlatinal nephritis, when symptoms of cardiac hypertrophy become more marked. (Fluid extract of leaf, 3 to 10 drops).—(Purdy). With digitalis and adonis vernalis in cirrhosis, when there is dropsy from failure of cardiac power.—(Purdy). Cuprum:—Strong metallic taste in the mouth. Vomiting, stupor, convulsions of ursemic origin. Figure 30. Granular Casts and a Crystal of Uric Acid. X400. 20S DISEASES OF THE KIDNEYS. Cuprum aceticum, together with diaphoresis, in ursemia.—( Hughes ). Digitalis:—Scanty urine with slow pulse, greatly accelerated on rising. Hydropericar- dium. Figure 20 represents granular casts found in the scanty urine of a patient with chronic ne- phritis. The quantity of urine was increased by Digitalis. Clinical notes :— Quarter-grain doses of extract with water, as hypodermic injection, cured uraemia from contracted kidneys, the symp- toms being drowsiness, insensibility, and frequent convulsions. —(Ruddock). In acute nephritis one of the most valuable of diuretics. The muriate of iron with it is often of great use.—(Millard). As a general prescription in lithaemic nephritis, digitalis and sodium benzoate.—(Saundby). In chronic interstitial nephritis, digitalis is a valuable diu- retic where the diminished flow of urine is dependent upon enfeebled action of the heart. Has the merit of not being an irritant diuretic.—(Millard). In acute Bright's disease, digitalis in the form of infusion, combined with copious draughts of an alkaline water, is always to be first employed.—(Loomis). In cardiac dropsies I prefer the fresh infusion of digitalis to any other preparation of that drug.—(E. H. Dickinson). Euonymine:—Albuminuria dependent upon hepatic derangement. Clinical notes :— Dr.. W. H. Holcombe has used euonymine successfully sev- eral times: One where there was chronic catarrh, dyspepsia, INDICATIONS FOR REMEDIES IN NEPHRITIS. 209 sick headache, and albuminuria; another where there was dyspepsia, depression of spirits, pains in the back and head, and albuminuria. Etqiatori urn:—In cases due to malaria; chill in the morning, with great pain in the bones. Glonoin: — (One part of nitro-glycerine in nine of alcohol for the tincture). Throbbing headache, aggravated by stooping or jarring and by heat about the head. Clinical notes :— Useful where there is great vascular tension.—(Robson). For headache and giddiness.—(Saundby). One of the worst cases of uraemic dyspnoea I have ever observed —I prescribed small doses of nitro-glycerine, and if it failed, morphine. The dyspnoea was greatly relieved, I subsequently learned, by the nitro-glycerine.—(Dr. Stephen Mackenzie in London Lancei). Useful when there is great arterial tension, violent action of the heart with hypertrophy and polyuria.—(Millard). Ferritin:—Patient weak, much debilitated; secondary disorders of assimilation. Pulse drops a beat occasionally. Pale face, flushing suddenly. Clinical notes :— In convalescence, Ferrum Sulph.—(Ruddock). With digitalis, the chloride of iron, etc.—(Millard). See Digitalis. After subsidence of acute symptoms, the chloride of iron. —(Millard). Chloride of iron with Cantharides in a case where there was evidently debility of the renal circulation in acute nephritis after scarlatina and diphtheria, when Merc. Cor., 2IO DISEASES OF THE KIDNEYS. Arsen., and Apis had failed to diminish albumin, although bringing about subsidence of other renal symptoms.—(Mil- lard). In chronic interstitial nephritis, especially when there is enfeebled muscular action of the heart. In a case where there was frequent urination and debility, with history of fever and ague, chloride of iron and quinine.—(Millard). The chloride and phosphate of iron in subacute nephritis. —(Millard). The iodide of iron has proved wonderfully curative in acute nephritis.—(Allen). Iron should be given from the start in chronic parenchyma- tous nephritis as soon as decreasing specific gravity indicates functional failure. In many cases the milder forms (of iron) are more useful (than the tincture).—(Loomis). In many cases (of cirrhotic kidney) the nervous symptoms are decidedly aggravated by iron.—(Loomis). Iodide of iron in lardaceous disease.—(Loomis). Boudreau's pills were highly prized by the late Dr. N. F. Cooke. The peptonate of iron is also now prescribed. Blaud's pills in the anaemia from acute or subacute nephritis.—(Delafield). The ethereal tincture of chloride of iron in five to ten drop doses, three to six times daily, in chronic nephritis.—(Wyss). The ethereal tincture of acetate of iron.—(Bartholow). [Iron in ponderous doses is a favorite remedy in the anaemia of renal disease. It is, however, well known that when there are disturbances of digestion, coated tongue, etc., etc., iron will aggravate, if given in too large doses. I have seen anaemic patients who had run through the whole gamut of " tonics " without relief, helped by Euonymine. It has been suggested recently that what appears to be anaemia is in some cases really stercorcemia\. Helleborus:—Scanty urine with dark sediment INDICATIONS FOR REMEDIES IN NEPHRITIS. 211 like coffee grounds. Dropsy. Absence of thirst. Brain symptoms. Clinical note :— Helleborus (tincture) in many forms of dropsy, post-scarla- tinal, etc.—(Hughes). Helonias/—Albuminuria of pregnancy with scanty urine, soreness and pain in region of the kidneys, and great restlessness Hepeer Sulphur:—Post-scarlatinal dropsy when there is much mucus and epithelial debris in the urine. Clinical note:— Dr. H. M. Hobart reports success from use of the sixth decimal. Ipecac:—When there is blood in the urine and patient complains of nausea and cutting pains. Kali Iodeititm:—Subacute and chronic nephri- tis ; patient is chilly, and complains of cutting pains. Syphilitic cases. Clinical notes: — In nephritis, accompanied or caused by syphilis, I have known the iodide to effect cures.—(Millard). Potassium iodide to check development of hyperplasia of connective tissue in the kidneys in cirrhosis.—(Bartels, Ralfe). A promising remedy if given in the early stages and con- tinued over extended periods of time. Dose from five to ten grains, three times a day, well diluted, and, if digestion be weak, after food.—(Purdy). Kalmia:—Subacute cases, especially during pregnancy, with pains in the back, worse at 212 DISEASES OF THE KIDNEYS. night in bed. Pains in the heart and palpita- tions predominating, Lachesis:—In post-scarlatinal and post-dip- theritic cases and subacute inflammation of the bladder. Lithium Carbonicum:—Albuminuria in cases where there is marked acidity of the stomach. Mercurius Corrosivus:—Tongue seldom dry, saliva abundant, patient nevertheless thirsty. Sallow face. Urine increased or scanty, con- tains hyaline casts and cast detritus. Burning and tenesmus. Pain in the back, worse at night. Patient cachectic, anaemic. Of the value of this remedy in many cases of acute nephri- tis there is no longer a reasonable doubt. Dr. Woodward prescribes it after scarlet fever, when indicated, as soon as frequency of micturition appears and before albumin can be detected. Millard also speaks highly of it in post-scarlatinal (croupous) nephritis. It is also used largely in the treatment of chronic nephritis, but, for the most part, empirically, except, possibly, in syphilitic cases. Mercurius Cyanatus in post-diphtheritic acute nephritis.— (Hughes). Mercurius Corrosivus for the bronchitis of renal disease.—^ (Hughes). Protoiodide of mercury (dose l-6th grain after meals) to check the development of hyperplasia of the connective tissue of the kidneys. Less likely to induce ptyalism than the bichloride.—(Purdy). I have found calomel especially suited to early stages of chronic interstitial nephritis (prior to cardiac hyper- trophy and establishment of cirrhosis). Dose 5 to 10 grains INDICATIONS FOR REMEDIES IN NEPHRITIS. 213 of the first trituration, or perhaps of a preparation of 1 part in 1,000, sometimes giving cantharides in alternation with it, two or three hours apart.—( Millard). Nitric acid:—Tongue coated, canker sores in the mouth, reddish, often offensive urine, fetid breath, pressing pain in region of the kidneys; pale urine, frequent micturition. This remedy,either alone or in conjunction with Merc. Cor. or Merc. Dulcis, is of service in diminishing the amount of albumin, especially when there is anasarca or even in dropsi- cal effusions. Millard gave Merc. Dulcis and Nitric Acid in a case of acute nephritis with hydrothorax (post-scarla- tinal) with complete success. Dr. Kidd thinks well of Nitric Acid in gouty kidney when iron and quinine disagree. For the dyspepsia in renal diseases.—(Ruddock). Nux Vomica:—Patient morose, sullen, with desire to lie down and to keep still. Is abusive when spoken to, etc., etc. Nausea immediately after eating. Heat with red face and aversion to uncovering. Clinical note:— For the dyspeptic vomiting of renal disease (Jousset), and from alcoholic excess.—(Ruddock). Petroleum:—In chronic nephritis, when there is headache, with gastric symptoms, and dropsy. Phosphorus:—Fatty casts in the urine. (See Figure 21). Patient feels a weak, empty, and gone sensation in whole abdominal cavity. Hard, dry, tight cough. Heat and burning in back between shoulder blades. Dry and hard 214 DISEASES OF THE KIDNEYS. evacuations. Urine highly albuminous. Cases of impaired nutrition of long standing; tall slender patients. Clinical note:—• The best remedy in fatty degeneration.—(Hughes). Figure 21. Fatty casts. Phosphoric Aeid:—k marked characteristic is found in the mental condition which is that of complete indifference. Diarrhoea lasting a long time, apparently without any weakening effect. Patients rise at night to urinate and pass much urine. INDICATIONS FOR REMEDIES IN NEPHRITIS. 215 Clinical notes :— The most promising remedy in waxy kidney.—{Hughes). Dilute phosphoric acid has proved of value, particularly after the subsidence of the most acute symptoms, in lessening and even controlling the albuminous secretion.—(Millard). Phytolacca:—Chronic nephritis with pain and soreness in the right side. Urine dark red, even mahogany colored, with painful micturition. Picric Acid:—Subacute and chronic cases with scanty urine, dropsy, profound weakness, dark, bloody urine. Plumbum:—Interstitial nephritis. Sensations of numbness and paralysis. Clinical notes :— Dr. S. A. Jones used Plumbum with good effect in pro- longing life in a case of cirrhosis. The patient resumed and continued work for a year after Plumbum had been given. Plumbum is known to decrease albumin and increase urea. —(Hughes). Rhus Toxicodendron:—When acute nephritis follows sudden and thorough wetting from rain, especially when in perspiration. Patient re- lieved by changing position but stiff on first movement. Urine usually not reduced in quan- tity. Seeale:—Post-scarlatinal nephritis. Cheesy sediment in urine. Sci Ha:—Dropsy, with profuse urination or too frequent micturition, or both. Spongia:—When larynx and trachea are in- 2l6 DISEASES OF THE KIDNEYS. volved. Tight, dry cough. Difficulty in breath- ing, etc. Stramonium:—Suppression of urine,with men- tal symptoms. Strychnine:—Used in albuminurias when there is dyspepsia, headache, etc. The phos- phate is often prescribed. Dr. Hale uses the double remedies, arsenic and strychnine, when there is danger of apoplexy. Terebinthina:—When blood in the urine is very abundant, as in post-scarlatinal acute dif- fuse nephritis. Urine scanty, dark, and highly albuminous. Clinical notes :— The leading remedy in chronic parenchymatous nephritis, after an acute attack from cold, wet, etc.—(Hughes.) In cases where albumin and blood keep recurring so soon as the patient is allowed to get up and move about (not over five minims at a dose).—(Carter.) CHAPTER VI. Systematic Application of Urinary Analysis to Diagnosis, Continued—Pyuria and hematuria. If pus and blood, pus alone, or blood alone, be found, attention is to be paid more espec- ially to conditions affecting the pelvis of the kidney, the ureters, bladder, prostate, and ure- thra. Tumors, abscesses, etc., etc., must be kept in view. The diagnosis presents many dif- ficulties. Often the evident presence of severe affection of the urinary tract leads us to the di- agnosis rather than specific information obtained from examination of the urine. Nevertheless an examination should be made with scrupulous care, as in many cases information of the utmost value is obtained. EXAMINATION OF THE URINE IN DIAGNOSIS OF DISEASES OF THE KIDNEY-PELVIS AND BLADDER. The various physical characteristics having been observed and the test for albumin having been made, the sediment should be examined more particularly for pus, mucus, phosphates, bacteria, epithelium; as well as for urates, uric acid, calcium oxalate, cystin, blood; for tubercle 317 2l8 DISEASES OF THE KIDNEYS. bacilli if tuberculosis be suspected. [A method for the detection of tubercle bacilli has already been given in Chapter IL, where the microscopic examination of urinary sediments is described. Several other methods are described in that part of the work further on devoted to the con- sideration of " Tuberculosis of the Kidney." It is advisable to try several methods before aban- doning the task altogether, since the bacilli are with difficulty found in the urine in any event. The detection of them in the sputa is easier, and in cases where tuberculosis of any kind is suspected, examination of the sputa for the tu- bercle bacillus should certainly be made.] If the prevailing color of the sediment be reddish, test for urates, uric acid, and blood; if whitish, for phosphates, pus, mucus (light colored), urates, calcium oxalate. Use the microscope and look for various kinds of epithelium, and cancer cells. See Chapters I. and II. Cancer cells are only accidentally found, as a rule, and the diagnosis should not be negative because of inability on part of the observer to find them. Read the section on " Malignant Disease," and note the various points in regard to the diag- nosis other than the examination of the urine. The following table will be found of service when pus is found in the urinary sediment: TABLE X.—Pyuria—Differential Diagnosis. Suppuration in the kidney. Suppuration in the kidney-pelvis. Suppuration in the bladder. Suppuration in the neck of bladder. Suppuration in urethra. Marked chills, emaciation, gastric disturbances. If urse-mia present, it is of a typhoid kind, with dry tongue and fee-ble pulse. Acute: febrile condition, pain in back. Chronic: course in-sidious, symptoms may not be marked. Scalding urine, pain in passing water. Urine in both glasses equally turbid, last drops usu-ally very turbid. Micturitions frequent and painful at beginning and end. Urine in first glass more turbid than that of second. Urine in first glass turbid, in second, clear. Pus sediment like that of py-elitis, if urine acid; hyaline and granular casts possibly lound. If urine alkaline,sedi-ment like that of cystitis. Pus sediment flocculent, not shreddy nor sticky in uncompli-cated cases. Pus corpuscles small. Pus plugs seen with microscope. Pus sediment sticky, clings to the glass. Sed-iment contains trifle phosphate, bladder ep-ithelia, bacteria. Pus corpuscles swollen. Pus sediment shreddy, sometimes surmounted by blood. Shreds may be streaked with blood. Pus oozes from meatus betw'n micturitions. Reaction first acid, later alkaline. Reaction usually acid, may be alkaline if cystitis compli. cates. Reaction usually al-kaline. Reaction usually acid. Reaction usu-ally acid. Urine contains more albumin than pus accounts for. Urine contains more albumin than pus accounts for. Urine contains but little albumin and that due to pus. Ammo-nium carbonate abun-dant. Urine may contain more albumin than pus accounts for. Urine in first glass will re-spond to albu-min tests. 24 hours'urine decreased in 24 hours' urine decreased in acute cases, greatly iucreasedlacute cases, greatly increased in chronic. in chronic. 24 hours' urine usu-ally normal or not in-creased. 24 hours' urine usually decreased. 24 hours' urine not increased. 220 DISEASES OF THE KIDNEYS. Remark on Table X:—In making the differ- ential diagnosis in pyuria, cause patient to void urine during one micturition, into two glasses, and note the character of the urine in both. Blood in the Urine:—If, in the examination of the urine, blood is found, make the differential diagnosis between hemoglobinuria alone, and hematuria, observing the points specified in the following table: TABLE XL HEMOGLOBINURIA. HEMATURIA, 1. Albumin moderate, sometimes abun-dant. 2, Sediment brownish and not consid-erable. 3. Color yellowish and urine transpar-ent in thin layers; dark red (port wine color) in bulk. 4. Blood corpuscles few or wanting. 5. Urine usually clear when voided. 6. Urine often changes color on stand-ing. 7. Voiding of bloody urine paroxys-mal and often preceded by chill and generally accompanied by nausea, gastric disorder and slight jaundice. 8. Often the result of malaria. 1. Albumin often very abundant (as in acute nephritis). 2. Sediment often very abundant. 3. Color not yellowish nor urine trans-parent in thin layers. 4. Blood corpuscles abundant (in acid urine). 5. Urine turbid when voided. 6. Urine does not change color on standing. 7. Voiding of bloody urine persistent; often preceded by pain in lum-bar region. 8. Often result of kidney or genito-urinary disease. In alkaline urine blood corpuscles may have been dissolved and not appear under the micro- scope. Test for blood coloring matter, and if this be found, together with considerable albu- min and considerable sediment, it is probably hematuria, and not hemoglobinuria alone. Hemoglobinuria is often observed in conse- quence of poisoning, especially by potassium DIAGNOSIS IN HEMATURIA. 221 chlorate, arsenic; sometimes in poisoning by pto- maines. In a few cases, after transfusion of blood. The spectroscope is of value in the differ- ential diagnosis between hematuria and hemo- globinuria. The spectrum of the urine of he- moglobinuria is characteristic of hemoglobin, but in addition to the bands in d and e, charac- teristic of hemoglobin, there is invariably a third present near c, which corresponds with that given by methemoglobin in acid solutions. Paroxysmal hemoglobinuria has been noted in malarial districts. Hemoglobinuria is some- times noted in rheumatism. At a recent meeting of the Soci^te" Mddicale des H6pitaux, M. Hayem made a communication on haemoglobinuria in rheumatism. The patient, a woman aged thirty-seven, was attacked with rheumatism in 1886, and again in 1887. She was then suckling her sixth child. Six days after the second attack came on she entered the hospital. The urine was com- pletely red ; there was pain, adynamia, rheumatic oedema in the arms and hands, copious perspiration, rheumatic pneumo- nia of the right lung, followed by symptoms of pericarditis. The urine, which was scanty at first, became abundant, and the patient recovered. She did not lose her milk, and began to suckle her child again. The urine presented the character- istics of haemoglobinuria ; it contained no red corpuscles, but a large proportion of albumin and white corpuscles. The blood was normal. This case shows that haemoglobinuria may ap- pear during an attack of acute rheumatism. If the condition is not hemoglobinuria, but hematuria, consult the following table: Table XII.— Diagnosis in Hematuria. to to to Blood prom the Kidneys. Blood from the Bladder. Blood prom the Prostatic Portion op the Urethra. Blood prom the Urethra. Blood corpuscles spherical, small, and brownish. Blood corpuscles spherical, small, brownish. Blood corpuscles of normal disk-form, with central de-pression and reddish-yellow color. Blood corpuscles like those from neck of the bladder (prostatic urethra). Albumin more than blood ac-counts for. Albumin less than blood ac-counts for. Albumin less. Albumin less. Blood only during micturitions. Blood only during micturitions. Urine more and more tinged as bladder empties itself. Blood at the beginning of mic-turition. Sometimes a few drops at the end only. Blood flows from meatus be-tween micturitions, or may be squeezed out. Blood in the first glass only on micturition. Urine may contain casts. No casts. No casts. No casts. Clots rounded corresponding to diameter of ureter. Clots very large and irregular in shape. Clots leech-like, ovoid. Long bougie-like clots. DIAGNOSIS IN HiEMATURIA. 223 Remarks on Table Nil:—There are certain difficulties in fixing the locality whence blood comes. In some cases, when the blood is derived primarily from the neck of the bladder and is large in quantity, it may flow into the bladder, and then, on micturition, the urine in both ves- sels is equally bloody. Whenever, therefore, the urine in both glasses is equally bloody, keep the patient under observation for some little time, and if, on some occasions, it be observed that blood is present only at the beginning or at tlte end of urination, the trouble is in the neck of the bladder It is often very difficult when casts, regular-. shaped clots, etc., are absent from the urine, and in the patient usual signs of renal disease are also absent, to decide whether the blood is from the kidneys or from the bladder. It is then necessary to fall back on instrumental explora- tion of the bladder.1 With the patient in the horizontal position, introduce into the bladder an English elastic catheter, or, better, a French coude charierre, No. 19 or 20, with large open- ings through which clots may be drawn. Inject cool water (using a syringe holding 100 to 150 c.c.) until the water flows out clear and free from blood. Then sweep round against the ^Ultzmann, Vorlesungen Ueber Krankheiten der Hamorgane, Vienna, 1888. 224 DISEASES OF THE KIDNEYS. walls of the bladder with the elastic catheter in all directions, and if the bleeding at once be- gins again, the trouble is in the bladder and not in the kidneys. Another test is by the use of solution of potas- sium iodide : a soft catheter of vulcanized rub- ber is introduced into the bladder, and the latter washed with cool water until it is free from blood. Then further there is injected 50 c.c. of a one and one-half per cent, solution in water of potassium iodide, and the catheter removed at once. After fifteen minutes, cause the patient to expectorate into a beaker, add a few drops of boiled, thin-flowing starch, and stir with a glass rod which has been dipped in fuming nitric acid. If there appears a blue coloration, the trouble is in the bladder.1 If there is no colora- tion, then the hemorrhage is from the ureters, kidney-pelvis, or kidneys. In the latter case, determine which kidney is affected by means of catheterization of the ureter, if possible, or by compression. It is possible that the hemorrhage may be from the entire urinary tract. Collecting urine separately from the two ure- ters is, if possible, the most certain means of ascertaining the seat of origin of the blood. 'For explanation see Ultzmann, Vorlesungen, 1888, p. 23. DIAGNOSIS IN HEMATURIA. 225 Compression of the ureters is an easier opera- tion, but its results are not so reliable. New- man1 has devised a spectroscopic apparatus by use of which the quantity of hemoglobin is estimated and compared with that of albumin. If the ratio of albumin to hemoglobin is as 1 to 1.6, it may be inferred that the albumin in the urine is due to the presence of blood. If much above this proportion, the indication is in favor of renal hematuria. Wp. cit.,-p. 81. CHAPTER VII. Hydronephrosis—Cystic Degeneration—Renal Hydatid Cysts. The diagnosis is often made more certain by the discovery of a renal tumor. If pus or blood be found in the urine, and at the same time a renal tumor can be made out, the chances are that the condition is one of the following : hy- dronephrosis, cancer, cystic disease, pyonephro- sis, or perinephritic abscess. Hydronephrosis is recognized when, in addition to a fluctuating tumor, we have intermittent discharge of pale, watery urine ; the tumor may occasionally dis- appear with increased flow of urine ; but little constitutional disturbance, no dropsy, and no ca- chexia. We find in cystic degeneration that the urine is not intermittent; that the patient has often the complexion, cardiac hypertrophy, and arterial tension of interstitial nephritis. Table XIII. will help in the diagnosis. 226 TARI.K XIII.-- DlKFEREXTIAI, DIAGNOSIS IN R.KNAE TuMORS. Hydronephrosis. Cancer. Cystic Disease. Pyonephrosis. Pekinephkitk- Abscess. Tumor, unilateral or bi-lateral. Unilateral. Unilateral or bilateral. Unilateral or bilateral. Unilateral,rarely bilateral Fluctuant, as a rule, sometimes hard. Non-fluctuant. Non-fluctuant. Fluctuant. Fluctuant in time. Irregular form. Irregular form. Shape of kidney. Irregular form. Irregular form. Varies in size from time to time. • No variation in size. No variation; hydatid cysts: diminution .n size of tumor after re-nal colic. Varies in size. No variation in size. Painless or feeling of weight and dragging. Severe and almost con-stant pain. Usually painless until suppuration. Considerable pain in lumbar region, worse on pressure in front, re-lieved by pressure be-hind. Severe, lancinating, and increasing pain. Hsematuria rare. Frequently recurring hsematuria. Hsematuria moderate. If due to renal calculus, hsematuria after exer-cise. When very large, blood and blood casts in urine. Fluid pushes forward. Aspirated fluid, neutral or feebly acid, never al-kaline. Fluid accumulations push forward. Fluids push forward. In hydatid cysts, aspira-ted fluid never acid, sometimes neutral.usu-ally alkaline. Fluids push forward. As-pirated fluid contains pus. Fluid accumulation push-es backward. Intermittent discharge, Df pale, watery urine. Urine not intermittent. Urine not intermittent. Intermittent discharge of muco-purulent urine. Urine not intermittent. But little constitutional disturbance. No drop-sy, no cachexia. Eventually well-marked cachexia. Loss of llesh. Aiucmia. Ascites and (edema lower extremi-ties when pressure on abdominal veins. Sallow complexion, hy-pertrophy of heart, ar-terial tension as in in-terstitial nephritis. Sometimes dropsy. May be signs of ursemic poisoning, but usually absence of marked fe-ver. Great constitutional dis-turbances; continuous elevation of tempera-ture. Marked rigors and sweat. 228 DISEASES OF THE KIDNEYS. How to detect presence of renal tumor:—Patient in bed or on a sofa, knees drawn up so as to flex the thighs upon the trunk. Pass one hand along margin of the false ribs till space between them and crest of ilium is reached; then, with other hand, depress greatly wall of abdomen, push aside intestine, using tips of fingers; then, with disengaged hand, make pressure in the loins with the fingers as much as possible, so as to push kidney as far forward as possible against other hand. Practice and experience required for successful detection of a tumor. Differential diagnosis bettveen renal tumors and non-renal:—In enlargements of the liver patient is usually jaundiced and tumor is affected by ordinary movements of respiration, In enlargement of the cecum or colon there are usually intestinal disturbances, and tumor may disappear after purgatives. In enlargements of the spleen the tumor is influenced by respiratory movements. In ovarian tumors vaginal examination often gives information. It is often a help to remember that renal tumors are more or less covered by the trans- verse colon. HYDRONEPHROSIS. 229 HYDRONEPHROSIS. Definition:—Distention by serous fluid of cav- ity of kidney-pelvis. Etiology:—Congenital or acquired. If the latter, due to tumors or abscesses of pelvic organs pressing or twisting ureters; urethral stricture, enlarged prostate with hypertrophy of the bladder, tumors or abscesses of abdominal organs, displacements of pelvic organs with torsion of ureters, bands and adhesions com- pressing ureters, renal calculi, displacements of the kidney, tubercular disease of the bladder, tumors of the bladder, ureter entering renal pelvis at acute angle. A noteworthy cause is spasmodic contraction of the ureter, which may be sufficient to bring about complete anuria. The ureters may be closed by traction and compression against the arcus pubis; by torsion or angular insertion of the ureter at the hilus.—(Landau.)1 The general cause, then, of hydronephrosis is retention from obstruction in the ureters. Tumors of the pelvic organs pressing on ureter, stricture of the urethra, enlarged prostate, and renal cal- culi are the most usual causes of the obstruction. Diagnosis:—Renal tumor with intermittent discharges of pale, watery urine. Hematuria 1 Wiener Med. Woch., No. 18. t 230 DISEASES OF THE KIDNEYS. and albuminuria occasionally noticed. If com- plicated by pyelitis or cystitis, pus and blood will be found. If the tumor be punctured and liquid withdrawn from it, urea will be found, though occasionally it is absent; the liquid is of low gravity, 1004, neutral or slightly acid, never alkaline when freshly drawn off, contains an abundance of sodium chloride (but not so much as hydatid cyst fluid), often contains pus. I have repeatedly called attention to the fact that the reaction of the aspirated fluid is the most reliable diagnostic point, since urea and uric acid may be absent. In five cases reported by Landau urea was found but once, uric acid but once. If there is urethral stricture and bilateral constriction of the ureters, the quantity of urine voided may be decreased, even to complete anuria, and uremic symptoms may supervene. Hydronephrosis is frequently found in con- nection with pathological conditions of the female genital apparatus; when it follows upon uterine disease no symptoms may be noticed, or, if present, may be regarded as hysterical. Landau's patients complained merely of tem- porary, vague sensations—sensations of weight, as of a foreign body. Prognosis:—Congenital, death at birth or in a few months or years. Acquired: if bilateral HYDRONEPHROSIS. 23I and obstruction complete, death within a short time. If unilateral, prognosis guarded. If due to renal calculus or uterine displacement, the cyst may disappear when calculus is dis- lodged or uterine displacement overcome. If degree of the hydronephrosis be slight, duration variable. Death seldom from hydronephrosis itself. Causes of death:— Suppression of urine, rupture of sac into abdomen, interference with functions of other organs than kidney. If surgical operations on lower urinary tract, suppurative pyelo-nephritis. Treatment:—If due to lesions, such as dis- placements, renal calculi, etc., careful manual pressure, emptying the sac, friction over tract of ureter, or on the sac, hot baths, etc If due to pelvic tumors, lower bowel to be emptied daily: support of tumor as in prolapsed uterus by pessaries. If tumor rapidly increases and cannot be emptied by ordinary pressure, surgical means necessary: as tapping, nephrot- omy, or nephrectomy. (Newman.) Landau thinks nephrectomy contra-indicated. [Recent- ly another mode of operating has been tried, viz.: stitching the sac to the skin.] J. K. Thornton holds that if the fluid re-accumulates after several tappings, nephrectomy is prefer- able to nephrotomy and drainage. 232 DISEASES OF THE KIDNEYS. CYSTS OF THE KIDNEYS. Cavities containing fluid formed within the substance of the kidney itself. These are of several classes: (1) simple cysts, cystic degene- ration, (2) hydatid cysts, (3) congenital cysts. Cystic degeneration is usually a consequence of chronic interstitial nephritis. When the symptoms of the latter are found, and, in ad- dition, a non-fluctuant swelling in one or both loins, rounded, nodulated, not painful on pres- sure, and of slow growth, it is probably a case of cystic degeneration. Prognosis and treatment: that of interstitial nephritis. In hydatids1 of the kidney the urine may con- tain hydatid vesicles; a renal tumor may be present, and the discharge of vesicles and hook- lets is attended with symptoms of renal colic, and simultaneously with the renal colic or fol- lowing, there is a sudden diminution in the bulk of the swelling in the loin. Hydatid fremitus, a peculiar vibratory thrill, may possibly be dis- tinguished by laying fingers of one hand on one side of the tumor while giving a sharp per- cussion stroke with two fingers of the other hand to the opposite side of the tumor. In doubtful cases, withdraw the fluid by aspirator and examine; it is clear, usually alkaline, some- times neutral, never acid, not urinous, sp. gr. i Due to parasite called ecliinococcus. CYSTS OF THE KIDNEYS. 233 about 1009, never below 1006; does not contain albumin unless cyst is inflamed, usually con- tains hooklets and vesicles, which may, how- ever, be absent. Prognosis in hydatids:—Prognosis favorable when tumor is small and near pelvis of the kidney. If large and tends to suppurate, prog- nosis according to freedom with which pus is allowed to escape. If cyst ruptures into renal pelvis, prognosis favorable. Causes of death in cases of hydatid cysts:— Rupture of cyst into important viscus, or solitary kidney becoming seat of disease. Treatment of hydatids:—[The disease is rare, especially in America. Dr. F. H. Newman, now deceased, recorded in the Medical Era one case in Chicago of late years.] After rupture, give large quantities of fluids. During the renal colic, gentle friction in course of ureter, warm baths, hot fomentations, morphine subeutaneously. If cysts impacted in the ureter and cause considerable pain and incon- venience, or if cyst increases in bulk so as to endanger life, then surgical interference. David Newman advises cutting down on cyst, evacuating contents, and stitching edges of, the cyst to the parietes. Congenital cysts:—These are often associated with malformations of other parts and are of no clinical importance. CHAPTER VIII. Suppurative Diseases of the Kidneys, Renal Pelvis, and Ureters. If the disorder be not hydronephrosis, or cys- tic disease, but pus of renal origin is present in the urine, endeavor to discover whether the dis- order is suppurative nephritis, pyelo-nephritis, or pyelitis. Differential diagnosis : —Suppurative nephri- tis and pyelo-nephritis are distinguished from pyelitis by the severity of the constitutional symptoms. In pyelitis fever is not marked, pain seldom severe, and often absent. In pyelo- nephritis and suppurative nephritis there is a high fever, with rigors. Pain in the loins is severe,and worse on pressure over the abdominal walls. Pyelo-nephritis is distinguished from suppur- ative nephritis as.follows : in the former, pyuria precedes constitutional symptoms ; in the latter, pyuria follows the constitutional symptoms. ACUTE SUPPUEATIVE NEPHRITIS. Synonyms :— Purulent or suppurative inter- stitial nephritis. Multiple renal abscesses. Pathology:—Acute suppurative inflammation 234 ACUTE SUPPURATIVE NEPHRITIS. 235 of renal substance, without affection of renal pelvis or ureters. Etiology:—Zymotic diseases, and those asso- ciated with presence of specific organisms. Traumatism. Symptoms:— See " Pyelo-Nephritis." Prognosis :—Unfavorable. Inmost cases the disorder is rapidly fatal, but death is not inva- riable. Treatment:— See " Pyelo-Nephritis." PYELO-NEPHRITIS. Synonyms: — Obstructive nephritis. Ascend- ing nephritis. Puerperal kidney. " Surgical kidney." Pyelo-nephrosis. Pathology:—Suppurative inflammation not only in pelvis of the kidney, but extending beyond the renal pelvis and attacking the renal substance, forming in it independent accumula- tions of pus. Essentially a chronic disorder, but subject to acute intercurrent attacks. Etiology : — Septic inflammation, extending from bladder to ureter and renal pelvis. The most common causes are enlarged prostate, stricture and cystitis, uterine and ovarian tumors, pregnancy, pyo-salpinx, tubercle and tumors of the bladder, procidentia uteri. Symptoms : — Severe. Pain in loins severe ; worse on pressure over abdominal walls. Spasm 236 DISEASES OF THE KIDNEYS. in neck of bladder and along ureters. Patient has high fever, with rigors, and wears an anx- ious expression. Face at first flushed, but later may be sallow or jaundiced. Mouth dry, tongue coated, fissured, crusted. Pulse rapid, feeble ; thirst, loss of appetite, headache, vomiting, hic- cough, diarrhoea, profuse sweats, drowsiness, sopor, low delirium may be noticed. Micturition frequent, but quantity small. Urine decreased in quantity and acid in reaction, if the inflam- mation was primarily in renal pelvis and has extended to the renal substance. In such cases pus well preserved; usual signs of renal pyuria. When the disorder is chronic there maybe poly- uria (2500 to 3000 c. c. of urine in twenty-four hours), albuminuria, and, in addition to pus, renal tube casts and pus casts may be found. The urinary solids in such cases are below nor- mal. If, however, the disease is the result of disorder of the bladder, the urine is alkaline and offensive, contains muco-purulent sediment, triple phosphates, and micro-organisms ; tube casts can then not be found. Consult Table X. With the microscope, flask-shaped or spheri- cal colonies of micro-organisms inclosed in a capsule are sometimes seen in the sediment.1 Several varieties of bacteria and micrococci may usually be found ; bacilli and mycelium-like 1 Saundby, Bright's Disease, 1889, p. 237. PYELO-NEPHRITIS. 237 threads are to be met with. Zoogloea masses of bacteria are often plenty. Clinical note:— The following analyses were made by the author in cases of suppurative nephritis or pyelo-nephritis. Case 1. Acute intercurrent attack. Volume of urine in 24 hours........500 c. c. Specific gravity...................1013 Urea, per litre.....................21 grammes. Urea, total,.......................10.5 grammes. Phosphoric acid, per litre...........0.4 gramme. Phosphoric acid, total...............0.2 gramme. Sediment:—Pus and Bacterian cylinders. Plain trace of albumin. Blood. Patient had rigors, was confined to his bed, face flushed, only semi-coherent in speech, tongue dry and dirty brown, pulse rapid and rather tense. Death in a few weeks from date of analysis; case shows importance of complete analysis of the urine, together with microscopic examination of the sedi- ment. The amount of albumin in the urine was insignificant, and the amount of urea relatively not far from normal, but the relative deficiency of phosphoric acid was very great and microscopic examination of the sediment revealed a number of cylinders of bacteria and micrococci. Case 2. Chronic pyelo-nephritis. Urine in 24 hours.................2000 c. c. Specific gravity...................1014 Urea, per litre......................12 grammes Urea, total..........................24 grammes Phosphoric acid, per litre.............1 gramme Phosphoric acid, total................2 grammes. Sediment:—Pus corpuscles abundant. Some few blood corpuscles, micrococci and bacteria termo very abundant, 238 DISEASES OF THE KIDNEYS. mucous casts, a few small hyaline casts, one or two large and perfect hyaline casts. Case 3. Probably acute intercurrent attack. Volume in 24 hours not known. Specific gravity...................1016 Urea, per litre......................25 grammes Phosphoric acid, per litre............0.6 gramme Albumin, plain trace. Sediment:—Pus and swarms of bacteria. No casts. Death with urasmic symptoms in a few weeks. In this case, although the albumin was insignificant, urea was normal, relatively, and no casts could be found. The deficiency in phosphoric acid -was very great, relatively, and I gave unfa- vorable prognosis after results of ophthalmoscopic exami- nation were reported to me. Complications:—Pulmonary oedema, erysip- elas, dropsy, perinephritic abscess. Death pre- ceded by profound coma. Convulsions rare. Prognosis:—If due to removable pressure, as in pregnancy, and uncomplicated by cystitis, prognosis favorable. When disorder due to some long standing cause, prognosis unfavor- able and death usually rapid. Treatment: — In the first place consider prophylaxis against pyelo-nephritis. If a pa- tient has a chronic disease of the lower urinary passages, the greatest preceiittions in use of instruments must be observed for fear of pro- ducing septic infection. All instruments used for the relief of retention or incontinence of urine must be thoroughly carbolized. Enforced PYEEO-NEPHRITIS. 239 retention not to be thought of; patient to be supplied with India-rubber urinals, and to avoid exposure to cold and damp. If any obstruction to the flow of urine occur, it must be relieved completely, but with as little irritation as possible. Effort is to be made to prevent the urine .from decomposing within the bladder. On this account various authors advise washing out the bladder with acid solutions, as, for example, 30 grains of boracic acid in four ounces of water, or equal parts concentrated solution of boracic acid and solutioA of sulphate of quinine, half a grain to the ounce of water. I have seen good results, however, from internal use of boracic acid, which passes unchanged through the kidneys. Dissolve 120 grains of pure boracic acid in a fluidounce of glycerine, and 8 fluidounces of hot water, and flavor to suit taste; for example, with syrup of orange peel.1 A few teaspoonfuls of this solution taken three or four times daily will usually suffice to keep the urine acid,2 and prevent decompo- sition within the bladder. If now, in spite of or without prophylactic measures, either pyelo-nephritis or suppurative 1 Formula of Ralfe. 2 According to the French Academy of Medicine, pure boracic acid is less poisonous than ordinary table salt. Cure must be taken to obtain a pure article, if it is to be given in large doses. 240 DISEASES OF THE KIDNEYS. nephritis has become established, the patient must be put to bed at once and the diet regulated. Diet:—Soups, milk, yolks of eggs, free from white and beaten up with brandy, arrowroot flavored with Madeira, broth from veal stock thickened with cream and arrowroot, .boiled sago or tapioca with a little milk. Stimulants to be given freely, if there is much asthenia. If urine scanty, give large quantities of diluents, barley water, linseed tea, warm water, but no saline diuretics. ' Remedies:—I have seen favorable results from internal use of Acidum Boracicum. In severe cases, from half an ounce to an ounce of the solution already described four times daily: when the urine is foul, intensely alkaline, and loaded with muco-pus. In one case stimulants, boracic acid, and Chin. Arsen. snatched the patient from the jaws of death. The bowels must be opened daily with warm enemata or mild purgatives. [If there is con- stipation, together with scanty urine, strong purgatives as elaterium may be required; or ergot if there is constipation with polyuria.] Terebinthina is often of use in this disorder. Creosote is also recommended. If foul urine accumulates in the bladder there is probably less risk in drawing it off than PYELITIS AND PYONEPHROSIS. 24I in allowing it to stay,1 and after it is withdrawn an antiseptic solution may be introduced. If the disease is in consequence of pregnancy the propriety of inducing labor must depend on the urgency of the symptoms.2 Dr. Hale often prescribes Eucalyptol. It is possible, also, that Salol may be useful. Cupping the loins is sometimes of help. "Dry cupping to the loins relieves renal congestion and favors diuresis. By this temporary abstraction of blood into the subcutaneous capillaries a diminished pressure is produced in the lumbar arteries, which supply the integuments of the loins, and this diverts a certain amount of blood from the renal arteries. The object of the cupping is to draw the blood into the capillaries, in order that it may be taken up and removed by the veins. The cups should be removed as soon as filled, and reapplied. No cups are better for the application of this remedv than the ordinary tumbler, which is always at hand. A good method of applying these is to dampen the bottom of the glass, so that the piece of loose dry cotton which is to occupy the bottom of the glass does not fall when the cup is used. The skin is to be moistened with warm water, and the glass applied instantly after the cotton is lighted, when an excellent vacuum is produced, and the integument rises into the glass. The cupping glass with rubber bulb is also a con- venient instrument for dry cupping." PYELITIS AND PYONEPHROSIS. Pathology:—Pyelitis: suppurative inflamma- tion of mucous membrane of the renal pelvis ' Ealfe, Kidney Diseases, 1885, p. 291. 2 Saundby, op. cit, p. 242. 242 DISEASES OF THE KIDNEYS. without distention of that cavity. Pyonephro- sis: the same with accumulation of pus, as the mechanical result of some obstruction. The pyelitis has become chronic, there is occlusion of the ureter, the renal pelvis is distended with pus and the renal substance liquefied and de- stroyed; or the liquid being absorbed, only a chalky or putty-like material is left. PYELITIS. Etiology:—Not common as primary disorder. Associated with renal or vesical affections es- pecially septic inflammation of lower urinary tract. Accompaniment of pyaemia, enteric fever, scarlatina, small-pox, measles, cholera, acute nephritis, diphtheria, scurvy, pregnancy. May be due to poisons as turpentine, canthar- ides; or to retained blood-clots. But the most common cause is renal calculus. Symptoms:—In uncomplicated catarrhal pye- litis without retention and rapid decomposition of urine, the symptoms are as follows: Pain:—Seldom severe, often absent alto- gether. Character dull, dragging, worse on pressure, following course of ureter, or in lumbar region; occasionally extending down- wards to. the bladder. Fever:—May be present during attacks of pain, but as a rule is not marked and, when present, transitory, and usually nocturnal. PYELITIS. 243 Urine:—In acute cases diminished in quan- tity. Mucus increased. Then slowly increasing persistent pyuria; acid urine with complete separation of sediment from urine. Slight hsematuria possible. The acid urine from the healthy kidney is usually able to overcome the alkaline urine from the diseased kidney; but on standing the urine may soon become alkaline, and crystals of triple phosphate be seen in the sediment which were not observed in the fresh- ly voided urine. If the pyelitis is associated with retention and rapid decomposition of urine, it is sometimes very difficult to make the diagnosis, and to distinguish it from pyelo- nephritis and suppurative nephritis. In chronic pyelitis the quantity of urine is greatly increased, even to as high a figure as 2,500 to 3,000 c.c, with diminution of solids both absolute usually and relative. When the disorder is due to septic inflam- mation of the lower urinary tract, micro- organisms (usually micrococci, but also fila- mentous fungi and bacilli) may be found in the urine. Small gelatinous masses are de- scribed by David Newman,1 composed of rod- shaped bacilli with a little calcium oxalate. Prognosis:—Simple catarrhal pyelitis arising 1 Surgical Diseases of the Kidney, 1888. 244 DISEASES OF THE KIDNEYS. for example in course of enteric fever, scarla- tina, small-pox, measles, etc.; prognosis that of the disorder on which it depends; the pyelitis usually disappears when convalescence sets in^ But when pyelitis occurs as a complication of acute nephritis, cholera, and diphtheria, prog- nosis grave. Calculous pyelitis:—Prognosis favorable, if. stone can be removed. If the pyelitis happens for any reason to be bilateral, the prognosis is grave. Pyelitis associeded with grave vesical dis- orders .-—Prognosis unfavorable as in pyelo- nephritis, to which it may lead. Simple pyelitis becoming chronic may lead, in consequence of prolonged suppuration, to lar- daceous disease, or be complicated by sclerosis, in which case prognosis ultimately unfavorable. Treatment:—Acute simple pyelitis1 usually yields to the following treatment: absolute rest; plenty of warm, diluent drinks; hot baths, es- pecially hip baths; hot water bottles to loins, flannel being interposed. Satterthwaite suggests that the patient sit over a steaming decoction made by putting a bunch of wormwood in a chamber or other 1 For treatment of calculous pyelitis and of tuberculous pyelitis, see consideration of Renal Calculus and Tuberculosis. PYELITIS. 245 receptacle in a closed water-closet chair and then pouring on it some boiling hot water. Patients subject to pyelitis should be caution- ed in regard to sexual excesses. The remedies usually of service are Hepar Sulphur, Cantharis, and Mercurius. Hepar Sulphur:—Patient very sensitive in regard to everything. Pus in the urine abun- dant. Urine escapes slowly or with difficulty and the last drops are tinged with blood. Patient complains both while passing water and after. Mercurius is indicated when there is much pus in the urine. See "Indications for Use of Remedies." Other remedies are, Nux Vomica, Petroleum, Phosphorus, Pulsatilla, Sepia, and Sulphur. Those in favor of vigorous measures advocate wet cupping followed by warm poultices; application of leeches to the loins, removing in robust patients 12 to 16 ounces of blood. Alkaline, demulcent drinks when there is irritation caused by hyper-acid urine. Porter calls attention to the fact that pyelitis is often due to sexual excesses. He also recommends inspissated bile. Hyoscyamus and bicarbonate of potash are frequently prescribed, also damiana. Clironic pyelitis:—The object of treatment is to diminish the amount of pus and mucus, pre- venting, if possible, the development of lardace- ous disease or complication by chronic inter- stitial nephritis. 246 DISEASES OF THE KIDNEYS. Hygienic:—Patient to have nourishing food and, as a rule, unless there is great weakness, non-stimulating diet. Change of air highly im- portant. Sea shore best locality. Warm salt baths. In some cases, if patient's strength permits, sea bathing is allowable. The remedies in the simple chronic form are those already mentioned.1 Hepar sulphur and Mercurius; the latter when the amount of pus is very great. If the urine is strongly acid, Terebinthina. The following remedies may also be found useful:— Barosina:—Recommended by Dr. E. M. Hale, in chronic pyelitis. Benzoic Acid:—After the pain and fever of the acute stage have subsided, but urine is still cloudy, scanty, of dark brown color, and strong urinous {not ammoniacal) odor. Berberis:—Useful in the pains of ehronic pyelitis. Suppuration on the left side, very severe pain from left kidney down ureter to hip, Berberis vulgaris, first decimal dilution.2 Ber- beris is a remedy which is especially suited to disorders of the lumbar region. 1 For treatment of calculous or tuberculous pyelitis, see Rena] Calculus and Tuberculosis. 2 S. D. Johnson, Medical Current, September, 1889. PYONEPHROSIS. 247 Eucalyptol:—Dose, two to five minims in an emulsion. Ferritin:—It may be advisable to use this remedy in cases where there is great weakness and emaciation. See Chapter Y. (Other remedies will be mentioned under heading of Renal Calculus.) Those in favor of vigorous measures recommend turpentine (dose, 2 to 5 minims in an emulsion) and borax (dose 5 to 20 grains) when the urine is acid; boracic acid (dose 2 to 5 grains) when it is alkaline; creasote (1 to 2 minims) when the urine is fetid. The chronic pyelitis of the gouty is often benefited by alkalies and Vichy water; when associated with oxaluria by nitro-muriatic acid (dose 5 to 20 minims) and Contrexd- ville water—(Ralfe). If the condition is due to obstinate urethral stricture, the- surgeon must enable the urine to pass freely, and if there is evidence of decom- position within the bladder, the latter should be washed out with an antiseptic solution and kept thoroughly aseptic for fear of pyelo- nephritis. Relief is usually experienced from dilating strictures, but sometimes not until perineal drainage of the bladder is tried according to the method of R. Harrison.1 PYONEPHROSIS. Definition and Pathology:—See Pyelitis. 1 London Lancet. Dec. 7, 1889. 248 DISEASES OF THE KIDNEYS. Etiology:—Among the indirect causes are those of hydronephrosis, which, if inflammatory, becomes pyonephrosis. A very common cause is impaction of stone in the renal pelvis. Septic inflammation, pyelitis, tubercular disease of kidney, malignant disease of neighboring organs. Said to occur, like pyelitis, in course of acute nephritis, diphtheria, and other zymotic diseases. Direct cause:—Occlusion of the ureter. It is a frequent termination of pyelitis. Symptoms:—Renal swelling, elastic, fluctuant, etc. See Table XIII. Previous to the progres- sive development of tumor in lumbar region, there have been symptoms of pyelitis and dis- appearance of pus from the urine as the tumor is perceived. The swelling occupies the space between the crest of the ilium and the floating ribs, hence abdomen is unsymmetrical. Per- cussion reveals increased area of dulness 1 often crossed by a resonant zone indicating position of colon. Aspiration will show presence of pus. The quantity of pus in the urine varies from day to day, according to posture and nature of the obstruction. 1 Remember that the situation of the kidneys is from the level of the twelfth dorsal vertebra to the first to third lumbar. The right kidney borders above on the liver, the left on the spleen. Percus- sion determines the lower and outer border; the latter is about four inches external to the spinous processes. PYONEPHROSIS. 249 Prognosis:—Unfavorable, if primary disease is tuberculosis of renal pelvis or bladder, or malignant disease of uterus or rectum. Unfavorable, if distention of the renal pelvis is rapid and due to sudden impediment in escape of pus; the danger to life is in such cases great, unless surgical interference is possible, (nephrotomy or nephrectomy). Unfavorable, if urine is alkaline and there is vesical irritation. Xot immediately unfavorable, if urine acid, pus in small bulk in the renal pelvis, obstruc- tion and suppuration unilateral in otherwise healthy patient. Pyonephrosis is essentially a chronic disorder and the pyuria and hsematuria may continue over a long period of time. Farorable, if tumor ruptures into some part of conducting portion of the urinary tract and at the same time, no grave structural change has taken place in the affected kidney. Amelioration, if rupture takes place into alimentary canal, though constant danger of acute peritonitis. Death soon follows rupture into retroperi- toneal tissue, peritoneal cavity, or thorax. Death may follow inflammation induced in renal substance or neighboring parts. The patient may succumb to slow, gradual exhaus- 250 DISEASES OF THE KIDNEYS. tion and ansemia with low fever, symptoms of lardaceous degeneration of various organs, pysemia and septicaemia. Recovery has been known to take place when formation of pus ceases and the sac contracts on a cheesy mass. Treatment:—Attend to cause of obstruction; displacements of pelvic organs, tumors, renal calculus, urethral stricture, enlarged prostate, etc., must be looked for and, if possible, reme- died. If the purulent discharge from the kid- ney is found intermittently in the urine, and there are signs of calculous obstruction, keep patient at rest on sofa, or specially con- structed couch, administer diluents, as distilled water, freely. If the urine is over-acid, give Londonderry Lithia water and Terebinthina. If alkaline, render acid with boracic acid unless the irritation is primarily due to uric acid as shown by history, in which case alkalies may prove more serviceable. If swelling increases in bulk and there is more pain, and pus is not freely found in the urine: if fever, gastric symptoms, rigors, sweat, and emaciation are noticed, together with evidence of extension of the inflammation, then surgical interference is immediately required.1 First, -nephrotomy with free antiseptic drainage at point of election 1 David Newman, op. cit. p. 229. PYONEPHROSIS. 25* behind. If the purulent discharge from the sinus is continuous and undiminishing, neph- rectomy is to be performed. Mortality from operation is lower when there is no calculous obstruction. Clinical note: Dr. E. R. Lyon, resident physician to Charity Hospital, New York, reported to Dr. Prudden the following case of carcinoma of the cervix uteri invading the bladder, occluding the openings of both ureters and causing hydronephrosis and pyonephrosis. The patient was a German female, seventy years of age. On admission she complained only of a little cough, and was very feeble; she was stupid, and at times mildly delirious. She was not much emaciated, but had a sallow, cachectic appearance; no fetid discharge was noticed from the vagina. She gave the physical signs of bronchitis. There was considerable oedema of lower extremi- ties. The pale, alkaline urine had a specific gravity of 1.010, and contained two and one-half per cent, of albumin. It con- tained pus in considerable quantity. She remained in the same stupid condition, and died suddenly four days after ad- mission. Autopsy: Heart, normal; lungs, bronchitic. The pelvis and ureter of the left kidney were filled with pus. The kidney substance was somewhat encroached upon by the ac- cumulation of pus in the pelvis. The right kidney was converted into a sac. The right ure- ter was completely occluded as it entered the bladder, and was dilated to a diameter varying from seven millimeters to two centimeters. The pelvis and ureters together contained 300 c.c. clear amber urine, sp. gr. 1.010, containing no albu- min, but considerable numbers of hyaline casts, fatty epithel- ial cells, and ordinary urinary and cholesterin crystals. Dr. C. C. Lee of the Woman's Hospital, New York, re- ports an interesting case: The patient's urine was alkaline, of specific gravity 1.012, slightly purulent, quite albuminous and 252 DISEASES OF THE KIDNEYS. after a few days contained hyaline casts. After drawing off the urine with a catheter the presence of uterine fibroids was discovered, the woman was pregnant and the pregnancy was estimated to be between the third and fourth month. There was retention of urine produced by pressure on lower part of bladder and pyonephrosis, the latter condition confirmed by post-mortem.—{Medical Record?) PERINEPHRITIC ABSCESS. Definition:—Abscess forming in the tissue im- mediately surrounding the kidney. Etiology:—Connective tissue surrounding the kidney is prone to suppuration. Most frequent cause, extension of inflammation from within re- nal tissue. General pysemia. Septic infection in febrile conditions. Purulent absorption in cases of inflammation of connective tissue about uterus, vagina, or rectum after child- birth or operation. Not an uncommon compli- cation of pelvic cellulitis. Operations on the testicle or spermatic cord following inflamma- tion of connective tissue about the bladder. Operations on perinseum, rectum, uterus. Sup- purations in gall bladder, liver, spleen. Symptoms:—See Table XIII. In perinephri- tis a large tumor is present while in suppura- tive nephritis there may be merely well-defined swelling in lumbar region extending down- wards. PERINEPHRITIC ABSCESS. 253 Pain:—Severe, and worse on pressure over the lumbar region and on movements of the patient. Swelling:—No diminution on complete evacu- ation of bowels, not affected by respiratory movements. Skin:—Red, waxy, and oedematous in situa- tion of tunior. Temperature:—Persistently elevated. Urine:—Normal unless abscess is the result of bruises or lacerations, then hsematuria and pyuria; or if due to pre-existing disease of blad- der or kidney, then characters of that disease. If abscess very large, then urine of passive congestion of the kidney, albumin, blood, blood casts. Prognosis:—Favorable if disorder primary and recent, provided early surgical treatment is resorted to, drainage of abscess, etc. Unfavor- able if pus is allowed to burrow; abscess may rupture into peritoneum, pleura, or intestines. Unfavorable if secondary to grave lesions of the kidneys or of neighboring organs, or in dis- eases of the spine. Least favorable when dis- ease follows the puerperal state or septic con- ditions. Possibilities of recovery:—Depend largely on constitution of patient. Cases of recovery on record even when abscess has burst into bowels. Treatment:—In primary or traumatic cases as 354 DISEASES OF THE KIDNEYS. soon as diagnosis is made, absolute rest, cold applications, bowels thoroughly opened. If there is no redness or fluctuation, ice bags or cold compresses. When skin is inflamed, hot emollient poultices. Remedies:—Aconite, Arnica, Belladonna, if due to exposure to cold or if after external in- jury. Hepar Sulphur, Mercurius, and Silicea for the abscess. [Those advocating vigorous measures advise cupping, leeches, and a sharp purge, and if inflammation subsides hot emollient poultices, application of ointments, one, for example, containing iodides of potassium and lead.] In secondary conditions and especially in the case of deli- cate women vigorous measures like the above cannot be* thought of; treatment must be directed, first, to relief of pain: try inunctions of belladonna; or liniment of equal parts chlor- al hydrate and camphor. Morphine by mouth or rectum. Bowels must be kept open. As soon as suppuration is sus- pected (pyrexia, rigors) puncture swelling with aspirator needle and apply large poultices. Incision must be made if fluctuation can be made out or if there is increase in the swell- ing, pain, fever, rigors, redness and oedema of the skin over affected kidney. Clinical note:—Dr. M. H. Fussell reports a case origin- ally puerperal cystitis which went on to pyelitis and peri- nephritis. Pus was found in the urine the first day after con- finement and the case treated as one of puerperal cystitis; pain caused by the catheter was great and there was frightful dysuria when the urine was passed voluntarily. The least movement caused urine to be voided with frightful pain and tenesmus. The usual remedies for puer- peral cystitis gave no relief; washing of the bladder also failed to help the patient. The only relief was PERINEPHRITIC ABSCESS. 255 from injections of solution of cocaine, twenty grains to the ounce, half a drachm at a time. Six months later, severe pain in region of right kidney. Two years later another child born, and violent pain afterwards on voiding urine. Urethra was stretched. Bladder found thickened, bleeding profusely but no growth. Relief from operation so far as tenesmus was concerned but eventually chills, pain, and tenderness over the right kidney, urine diminished to one pint; finally dulness was found and the edge of the kidney felt in the flank. Complete recovery after lumbar incision and evacua- tion of pus. The case was regarded as originally a severe cystitis with development of mild pyelitis, acute exacerbation after stretching the urethra, finally occlusion of the ureter, re- tention, increased inflammatory trouble in the distended pel- vis, and perinephritis either by the rupture of the pelvis in. the post nephritic space, or simply by inflammation by con- tiguity. Suppose now that the urine contains renal blood or pus witli or without pyelitis or pyone- phrosis. It is of importance to know whether the pa- tient is suffering from renal calculus or not. Ex- amine the urine carefully for pus, as it is advan- tageous to distinguish calculus without suppur- ation from calculus with it. CHAPTER IX. Renal Calculus. Etiology:—Occurs most commonly before age of fifteen and after fifty. Causes: faults in digestion, urenal inadequacy,"1 heredity. Composition of calculi:—Crystals deposited from the urine cemented together by organic matter. Calculi may be formed of uric acid, urates, calcium oxalate, calcium carbonate, cys- tine, xanthine, indigo; also of phosphates. Uric acid calculi are more common abroad and oxalate calculi in America. Diagnosis:—1. Calculus without suppuration: The chief symptom is haematuria, small in amount, either constantly present, or often re- peated. Sometimes very slight. Sometimes the only symptom. Increased by movements of the body but not always immediately; may take place 12 to 14 hours or even days after the exercise. Hoematuria appreciably less on rest in bed. Urine is clear above the sediment of blood corpuscles and when there is no blood there is no albumin. No blood casts. 1 Whether "renal inadequacy" is "fanciful" or not, the fact re- mains that renal calculi are common in those patients whose renal secretion is below par. 256 RENAL CALCULUS. 257 Pain:—Slight feeling of dulness or weight in the loin aggravated by jolting movements. Pa- tient can walk but cannot drive. Pain varies with posture. Sometimes only in lower ex- tremities. Micturition:—Frequent and painful. Irrita- bility of the vesical neck. General symptoms:—There may be reflex digestive disturbances and at times intestinal colic. In one case which I saw, an attack of intestinal colic was rapidly followed by renal colic and subsequent passage of much sand and gravel. The urine:—May contain in freshly voided samples, crystals or bits of the calculus, to- gether with pus and blood, a trace of albumin, usually considerable mucus. 2. Calculus with suppuration:—The chief points are the pain, as already described, and the pyuria. The pus separates rapidly and completely from the acid urine, forming a sedi- ment, on top of which blood may, in time, be seen. Sudden and marked variation in quantity of pus is one of the most certain signs of partial or complete obstruction of the ureter whence the pus flows. Disappearance of pus from the urine with increase in lumbar swelling followed by sudden flow of large quantity of purulent urine and subsidence of the swelling is sign that the blocked ureter is now open. 2^8 DISEASES OF THE KIDNEYS. WHAT TO DO WHEN RENAL CALCULUS IS SUSPECTED. If renal calculus exists, it is of the utmost importance from a therapeutic standpoint to ascertain its chemical composition, its situation, whether more than one kidney is affected and, if but one kidney, which one. First, study the prevailing character of the sediment, using microscope. If crystals of uric acid1 are persistently found, as soon as the urine settles, especially jagged ones, the cal- culus is of the uric acid variety. Suppose, how- ever, no crystals are to be found, but the urine is strongly acid in patients either young and vigorous, or in older ones subject to gout. In such cases, if there are symptoms of renal calculus, it is probably of the uric acid variety. The uuric acid diathesis" usually shows itself by the following symptoms: So-called neurasthenia, nervous prostration or exhaustion, "malaria," general worthless- ness, inability to do anything, or make any exertion, indolence, laziness, even though habits are good. Patient irritable, fretful, peevish, and discontented with those around him, but rarely finds fault with himself, or is hypochondriacal. May rise at night to void urine, which latter is high-colored and deposits a sediment frequently reddish in color. Con- 1 See page 48. RENAL CALCULUS. 259 stipation, drowsiness, headache, restlessness at night. Examine the urine for sediments of urates and uric acid, especially in patients who lead sedentary lives, spending their time in offices or at home and taking little exercise, who drive, or ride in street cars, but seldom walk. The urine in uricsemia after standing may show on microscopic examination skeins of mucus, sometimes wound up and sometimes spread out over the whole field (Cutter). I have repeatedly observed these skeins of mucus. If, now, on the other hand, the urine is clear, containing a large quantity of lime salts, and on standing precipitates crystals of calcium oxalate1 especially those of the dumb-bell variety, suspicion should point to a calculus composed mainly of calcium oxalate, always supposing that the usual symptoms of renal calculus (pain, hematuria, or pyuria, or both) are present and that the patient complains of the usual symptoms of oxaluria as follows: The urine may be normal in quantity and specific gravity, but pale green in color, mic- turition frequent and urgent though no great quantity of urine be voided. Burning sensation across loins, with feeling of tightness and drag- ging round the abdomen, shooting and burning 1 See page 49. 26o DISEASES OF THE KIDNEYS. pains in the lower limbs, twitchings of the muscles; feelings of numbness, deadness, and coldness in different parts of the body. Patient generally amiable to those around him, but is himself filled with gloom and forebodings, and excessively hypochondriacal. Bowels irregular. Nervous dyspepsia. Urine to be examined microscopically every day for at least a week, for sediments of calcium oxalate; look particu- larly in morning urine voided on rising. If dumb-bell crystals of calcium oxalate be found, the condition may lead to renal calculus. (Di- agnoses of incipient locomotor ataxy and of syphilitic disease of the spinal cord have been made in cases where the condition was relieved when the patient voided a small concretion of calcium oxalate). Patients subject to oxalate calculus often have serious nervous prostration, which is, as a rule, different in character from the uric acid "indolence," being much more severe. If signs of both uric acid and calcium oxalate are wanting, it is possible that the stone is phos- phatic. Examine the urine for crystals of triple phosphate or calcium phosphate.1 [Note that such crystals may be found not only in alkaline urine but in urine acid when voided. If one kidney is healthy and the 1 Pages 19 and 52. RENAL CALCULUS. 26l other diseased, the acidity of the urine from the healthy kidney may cause partial solution of phosphatic crystals in the bladder. But on exposure to air these crystals soon form again and may appear as soon as the sediment has settled]. If the urine is alkaline from increase in volatile alkali, shown roughly by fading after drying of the blue color given red litmus paper when dipped into urine, some disease of the conducting or collecting portions of the urinary tract is shown. Situation of the calculus'.—If the calculus be in the substance of the kidney, and there is no pye- litis, pain slight, or severe for a time and then disappearing for years. Sometimes constant dull pain in the loin. No premature or general disturbance. If the calculus be free and moving in some large cavity of the kidney or in renal pelvis, the pain is felt not only in the loin, but along the course of the ureter and even as far as to testicle, inner aspect of thigh, or lower part leg. even in the heel. Pain much worse on motion. If the calculus be dislodged from the infundi- bula or from fixed position in renal pelvis, pain, then severe and paroxysmal, nausea, faintness, vomiting. If the calculus be in the ureter, then renal colic, agonizing pain, nausea, faintness, writh- 262 DISEASES OF THE KIDNEYS. ings and contortions, even convulsions. After some hours, pain subsides suddenly. There maybe sudden suppression of urine on one side; urine reduced suddenly to half the normal quantity. If the calculus be impacted in the ureter, pain sets in suddenly and is only gradually relieved ; does not cease suddenly, but there are paroxysms of pain until finally the ureter becomes habituated to the presence of the stone. If the calculus be impacted in the ureter close to vesical exit, site of pain after having for some time shifted in a direction generally downward, suddenly becomes fixed; there is evidence of suppression of urine on one side. If the calculus has become merely displaced from renal orifice of ureter, but is not yet in bladder, another paroxysm of pain may take place at any time. If calculus has passed into bladder, patient may possibly be aware of it. The renal colic ceases and after a time signs of the presence of the stone show themselves as follows: hsematuria after strong bodily exertion, disappearing after a long rest. Day #urine contains more blood than night. The urine begins to show the features of cystitis. (See Cystitis.) Sounding for stone will sometimes reveal its presence. Both kidneys affected or one only ? If the RENAL CALCULUS. 263 stone is primarily phosphatic the disorder is limited to one kidney. If the stone is uric acid or oxalate, both kid- neys may be affected. If during renal colic, while one ureter is blocked, the urine voided be perfectly normal, then the one kidney is healthy. In doubtful cases try compression of ureters or catheterization. It must be remembered that absence of the symptoms mentioned above does not necessarily signify absence of calculus. In some cases the diagnosis cannot be made with certainty. The urine is often normal in all respects and gives no sign of the presence or character of the cal- culus. Renal colic may be the first marked symptom. Moreover, the symptoms of calculus, viz., lumbar pain, extending at times to the groin and testicle, paroxysmal, aggravated by movements, accompanied or followed by hsema- turia, pyuria, and frequent micturition, may all be present and yet there be neither stone in the kidney nor disease of the bladder. (See Tu- berculosis of Kidney.) ANALYSES OF URINE IN CASES OF RENAL CALCULI. In the following cases the diagnosis was confirmed by renal colic and passage of small calculus: 264 DISEASES OF THE KIDXEYS. Case I. Uric Acid Calculus. First Analysis. Second Analysis. 24 hours before pas- First 24 hours after sage of calculus. passage of cal- culus. Volume in 24 hours...... 960 c.c. 600 c.c. Specific gravity.........1020 1016 Urea, per litre.......... 21 grammes 23 Urea, total.............. 20 " 14 Phosphoric acid, per litre 2.25 " 1 95 Phosphoric acid, total___ 2.16 " 1.20 Reaction...............strongly acid. ditto. No albumin. Trace albumin. Sediment...............Muco-pus; and Blood and pus not abundant. corpuscles, pus plugs, uric acid crystals,mucous casts. The calculus in this case was rough, hard, weighed 0.02 gramme, was of light brown color, and composed of urates and uric acid. It is a noteworthy fact that although the quantity of urea was relatively increased in the cysto-pyelitis following the passage of stone, the quantity ofi phosphoric acid became rel- atively diminished. Case II. Phosphatic Calculus. I was consulted in the spring of 1888 by a well-known scientific man who for several years past had been troubled with great urgency of micturition, and at times with a cutting pain in the urethra during urination. Failing to obtain a satisfactory diagnosis of his affection, he had undertaken the examination of his own urine, according to the directions laid down in one of the numerous manuals of urinary analysis.1 1 The Practitioner's Guide in Urinary Analysis, Gross & Del- bridge, Chicago. RENAL CALCULUS. 265 He was not long in discovering that his urine deposited on standing a few hours a heavy sediment of crystals, which he recognized as those of ammonio-magnesium phosphate. On coming to Chicago, he collected his urine for twenty-four hours and gave it to me for analysis. I found that his own examination was correct so far as the sediment of triple phosphate was concerned. The urine was free from albumin and from sugar.. The total quantity in twenty-four hours was 1,225 cubic centimeters. It contained approximately 83 grammes of solids. The amount of urea, estimated by the hypobromite process, was 41 grammes, more than was nor- mal for his weight, which was 175 pounds. In the sediment, in addition to the triple phosphate, I found a considerable quantity of amorphous calcium phosphate. There was no pus and no blood. I made during the next few months several examinations of the twenty-fours' urine, and found from time to time about the same conditions present, viz.: total quantity normal, solids in excess, sediment heavy. The twenty-four hours' urine was invariably alkaline on reaching me, as he lived some distance from Chicago, but he stated that his urine was often acid when voided, and even after standing some little time. He spent his vacation, as advised, in the mountains. I saw him on Oct. 15th, and found him greatly improved in appearance and spirits. Nevertheless he again collected the twenty-four hours' urine, and gave it to me for examination. There was now some improvement in the character of the urine. The solids were less in amount, urea but 37 grammes, sediment somewhat less than ever before. But I did not feel warranted in taking a hopeful view of the case, although he had been, while in the mountains, free from his urinary troubles. On careful microscopic examination of the sedi- ment, after dissolving the phosphates in the field, I was able to find several pus corpuscles, but no epithelial cells at all dis- tinctive in character. There was still no trace of albumin. z66 diseases of the kidneys. He came to Chicago again in December, and, after a fatigu- ing day in the city, was seized next morning with severe pain, accompanied by a rise in temperature. He had been irregular in his meals and had eaten food which had disagreed with him, so that at first the case seemed possibly one of gastro-intestinal disorder. But his family physician, know- ing his history, suspected that the pain was of renal origin, and, after a consultation, it was decided to treat the case as one of renal colic due to incarceration of a phosphatic calcu- lus. Boracic acid was given, and results showed the correct- ness of the diagnosis and the efficacy of the treatment. I made frequent examinations of his urine, and the records are of interest in that the changes which went on in the body are so clearly shown by a study of the character of the urine. First Collection. Quantity of urine in 24 hours. .1350 c. c. Total solids (approximately). .. 55.00 grammes. Total urea................... 48.00 " Weight of sediment........... 1.53 " Constituents of sediment......Ammonio-magnesium phos- phate, amorphous calcium phosphate, amorphous ur- ates; pus corpuscles seen by aid of microscope. The effect of the treatment had been apparently to soften and disintegrate the incarcerated calculus, and to aid in re- moving much gravel. The quantity of urine was, therefore, not reduced from mechanical reasons. I collected the entire sediment of twenty-four hours on a filter, dried, and weighed it in the usual manner. The total quantity of urea was far above normal, as might be expected during the febrile con- dition. Pus and blood could not be seen with the naked eve nor demonstrated chemically, but under the microscope the corpuscles were now more numerous than I had ever seen RENAL CALCULUS. 267 them in the patient's urine. The sediment of urates (amor- phous) appeared for the first time since my examinations had begun, and I regarded it as a not unfavorable sign. Second Collection.—Patient's Urine Now Showing the Influence of Boracic Acid. Quantity of urine............1357 c. c. Reaction...................Faintly acid. Total solids.................57 grammes. Total urea..................43 " Weight of sediment......... 0.83 " Sediment (constituents)......Same as in first collection, but fewer crystals and more amorphous urates. Pus cor- puscles numerous, but no pus macroscopically. The sediment was now reduced to nearly one-half the weight of that of the first collection. The reaction of the urine was still acid at the end of twenty-four hours and even longer. ThirdCollection.—Made Five Days After the Second. Patient Now Convalescing. Quantity........................1180 c. c Reaction........................Strongly acid. Solids...........................45 grammes. Urea...........................38 " Sediment (weight)............... 1 " Sediments (constituents)...........Uric acid and urates. The phosphatic sediment had now completely disappeared. The urine was strongly acid, and the sediment contained free uric acid and urates. The color of the urine was red, and the urea diminished in quantity to about normal, though relatively still high. In order to ascertain whether he was still voiding a notable quantity of phosphates in solution in the urine, I made a quantitative analysis of the total phos- phoric acid, and found it considerably below the normal figure, 268 DISEASES OF THE KIDNEYS. viz., but 1.35 grammes. Decided, therefore, that the trouble was probably over for the present. Fourth Collection.—During the twenty-four hours the patient rids himself of remaining ills, voiding the remains of the stone and much pus with it. Quantity...............1505 c. c. Solids.................. 48 grammes. Urea.................. 35 " Sediment..............Pus in great abundance with a little triple phosphate. Albumin................0.3 of one per cent. Calculus ...............Soft, friable, phosphatic. Weigh- ed when dry^ 0.4 gramme. The albumin in the urine I regarded as due to a cysto- pyelitis, excited by the calculus, for there was more than the pus would account for. The pus and albumin soon dis- appeared, as the record of the next collections will show. Note the small quantity of phosphoric acid as compared with that of urea. Fifth collection. Quantity..............1888 c. c. Solids.................. 57 grammes. Urea................... 30 " Sediment...............Mostly mucus with still a little pus Albumin................About 1-20 of one per cent. Sixth collection. Quantity................1770 c. c. Solids.................. 64 grammes. Urea................... 32 " Sediment...............Mucus with a faint white line of pus. Albumin................Barely perceptible trace. Not long after this, the patient left the city, feeling "clearer in his head," he asserted, than during vears past. A number of distressing symptoms had disappeared after the date of the second collection. RENAL CALCULUS. 269 This case shows (1) the value of routine examinations of the urine in obscure cases ; (2) the help to be had at a critical moment in the patient's life from records of the previous character of his urine; (3) the importance of an early recog- nition of a tendency to calculous formation, and (4) the aid, from a therapeutic standpoint, to be had from a knowledge of the chemical composition of the stone. I should say in conclusion, however, that in this particular case the favorable termination was also due to the assiduous care and attention of the family physician. Seventh collection.—Made one year later. Patient in good health and has gained fifty pounds. Volume................ 920 c. c. Specific gravity.........1032 Urea, per litre.......... 32 grammes. Urea, total............. 29 " Phosphoric acid, per litre, 2.20 " Phosphoric acid, total___ 2.02 " Reaction...............Acid. Albumin...............None. Sediment..............Amorphous urates and phosphates but no crystals. Some mucus and leucocytes. We cannot help noticing the relative deficiency of phos- phoric acid in cases when the kidneys (or even the kidney pelvis) are inflamed. The quantity of urea may be normal or even above normal, but the phosphoric acid does not as for- merly thought, vary either with the diet or with the urea. An interesting point in this case was the variation in reac- tion of the urine. Before the passage of the stone he would send me a specimen for examination and I invariably found the urine alkaline in reaction. In answer to my questions he replied that his freshly voided urine was acid in reaction. When in Chicago, he called at my office and voided urine for examination. I found it alkaline in reaction. He expressed 270 DISEASES OF THE KIDNEYS. surprise, for having tested his freshly voided urine several times he had always found it acid. On another occasion I tested his freshly voided urine and this time I too found it acid. After the diagnosis of renal calculus had been confirmed, and the chemical character of the stone established, an inter- esting solution to the variations in acidity occurred to me. One kidney was diseased, the other healthy. The acidity of the normal urine of the healthy kidney was at times able to overcome the alkalinity of the urine from the diseased renal pelvis. At other times not. Hence, sometimes the urine was acid when voided, at other times alkaline. The alkaline reactions were found to be due chiefly to volatile alkali from decomposition of urea either in the dis- eased renal pelvis or bladder. Now, whenever the normal urine from the healthy kidney was at its lowest ebb of acidity at the times of the "alkaline tides" so-called, the volatile alkali either overcoming the feeble acidity of the normal urine or, adding itself to the fixed alkali rendered the freshly voided urine alkaline in reaction. On the other hand, such was the acidity of the normal urine of the healthy kidney at the times of its "acid tides" that it overcame the volatile alkali from the diseased kidney, and the freshly voided urine was then slightly acid in reaction. I think it desirable from my experience with this case that the time of the acid and the alkaline tides of persons in health be observed. A series of simple tests with litmus paper will often show by degree of coloration at what different hours of the day the urine is most acid and least acid. In some indi- viduals whose meals are at 8, 1, and 6 to 7, the greatest acidity has been shown to be between the hours of 11 a. m. to 1 p. m. and from 11 p. m. to 8 a. m. Ralfe found the acidity of his urine from 11 a. m. to 1 p. m., to be equal to. 0.20 grammes of oxalic acid per hour. From 7 p. m. to 11 p. m., it was onlv equal to 0.02 grammes per hour. RENAL CALCULUS. 27I Knowing the normal acid and alkaline tides of any individ- ual, marked changes in them might throw light on a dis- order which, all other circumstances being equal, would pos- sibly escape notice. For example, persistent acidity at the times when experience had shown the alkaline tide to be due, would suggest tendency to uric acid formation long before the evil results of such a condition were perhaps thoroughly realized. On the other hand it is known that there is increase in the amount of fixed alkali secreted, or a diminution in the quantity of free acid eliminated, associated with grave organic diseases as chronic Bright's, phthisis pulmonalis, cirrhosis of the liver, diseases of the spinal cord, etc., and further, that the condition where there is increased fixed alkali may exist for some time before our attention is attracted to the urine by ureal decomposition, presence of volatile alkali, etc., which eventually may follow the increase of fixed alkali. The following analyses were made in cases with previous history of passage of calculus and at times subsequently when trouble from gravel was marked. Case I. History of renal colic and calcium oxalate calcu- lus. Patient now has much pain on passing water. Volume of urine in 24 hours............ 850 c. c. Specific gravity.......................1025 Urea, per litre....................... 29 grammes. Urea, total........................... 25 Phosphoric acid, per litre..............1.90 " Phosphoric " total ................1.62 " Albumin: trace. Sediment: amorphous urates, and abundance of pus cor- puscles. A few days later much calcium oxalate in the freshly voided urine. Case II. History of uric acid calculus. Calculus small and not hard, passed 18 months ago. * 272 diseases of the kidneys. Volume of urine.................... 920 c. c. Specific gravity......................1025 Urea, per litre...................... 25 grammes. Urea, total.......................... 23 " Phos. acid, per litre.................2.26 " " " total....................2.07 " Sediment: blood, uric acid (free)—sharp spiny crystals and rhombs, columnar epithelium, tailed cells. Albumin 1-20. Six weeks later calculi removed by operation. Treatment of renal calculus:—The prophylactic treatment of renal calculus is of great importance and under this head I shall consider uricaemia, oxaluria, and phosphaturia.1 Etiology:—Morbid conditions of the nervous system. URICEMIA. Etiology:—Disorders of digestion. Sedentary life. Heredity. Highly nitrogenous diet with immoderate use of alcohol in districts where the soil is wet. Diagnosis:—Urine contains uric acid rela- tively or absolutely in excess, together with rela- tive or absolute excess of other urinary solids, as urea, etc. Urine may or may not contain a sediment of uric acid and urates. If without any errors of diet a patient un- der 40 habitually passes urine which soon deposits a pinkish sediment, or which 1 These disorders may, it is true, be due to morbid conditions of the nervous system, and be unaccompanied by calculus, but to avoid repetition I mention them here. URICyEMIA. 273 though clear when voided soon beeomes thick and opaque, or covered with a delicate film or pellicle exhibiting faintly a play of pris- matic colors—or if in a few hours there is seen in the sediment a deposit of free uric acid —" red pepper" crystals—there is undoubtedly an undue tendency, either inherited or acquired, to produce uric acid. (Thompson.) [If there be no such sediment and yet the patient mani- fest symptoms already described (see " What to do when renal calculus is suspected "), a quanti- tative analysis of the uric acid must be made. See method of Arthaud and Butte (described in British Medical Journal, March 1,1890). There is no simple method of quantitative analysis.] Treatment:—1. Hygienic: Moderateout-cloor exercise. Mountain air. Bathing with friction of surface of body or dry rubbing after exercise, according to temperament. Woollens next to skin. Warm clothing in winter. Avoidance of unnecessary exposure to cold. Cheerful surroundings and congenial occupation. Change of air whenever possible; a course of Congress water at Saratoga, followed by mountain climb- ing intheAdirondacks, is my favorite prescrip- tion. Diet: It has recently been shown by Dra- per that the lithsemic patient should avoid sweets, starchy food, and fats. My own ex- perience has shown me that this, in the ma- 274 ISEASES OF THE KIDNEYS. jority of cases, is true. Sir Henry Thompson thinks rice and sago puddings, as ordinarily made, inventions of the devil for the lith- semic ; whole-wheat bread, pearl-barley, oat- meal, etc., are highly recommended by him; but I find some American lithsemics not wholly at ease with the food, either of gram- nivorous animals or of things with gizzards. The prejudice against a moderate meat diet in cases of lithsemia I cannot understand. It is now held that a certain amount of meat is positively essential for those engaged in intel- lectual work. To cut off meat entirely is inju- dicious; the retrenchment should be made along the line of sugars, starches, and fats. The Lith^emic Patient May Take: Tender, lean beef and mut- ton. Fish and poultry. Well- made bread. Gelatine prep- arations. Fresh or green veg- etables. Well-cooked celery, asparagus, baked potatoes. Butter in moderation. Milk only with other articles of diet, as tea, coffee, etc. White of egg to be used in cooking only. Baked apples without sugar. Moselle, Rhine wine, Bor- deaux. In some cases a little good whisky in distilled water. The Lith^emic Patient Should Avoid: Fat pork and fat meats gen- erally. Herrings, mackerel. Ham, sausage. Turkey. (The abomination of desolation is the American rural dietary of ham and eggs, doughnuts, and pie.) Sugar, sweets, starchy food and fats. Ice-water. Watermelons, raw apples, oranges. All berries and pre- serves. Cheese, eggs, es- pecially omelette, cream, champagne, sherry, port, beer. URICAEMIA. 275 Mineral Waters:—For the lithsemic, waters containing sulphate of soda are by far the best; alkaline waters, like Yals, Vichy, etc., may cause the urinary sediment to disappear tempo- rarily, but their curative range is limited. The best known sodium sulphate waters are Pullna, Hunyadi Janos, Friedrichshall, Marienbad, Carlsbad, etc. The full dose of Hunyadi Janos is from five to seven ounces taken an hour before a light breakfast, during which a cup or two of some hot liquid is to be taken. Marienbad water is far more agreeable than Hunyadi Janos, since it contains no sulphate of magnesia. Dose, half a pint or more. Carlsbad contains no magnesia. It is best suited to robust patients. Sir Henry Thompson recommends Carlsbad water to which a little Hunyadi Janos is added. From four to seven ounces of Carlsbad at a dose, heated, to which as much Hunyadi Janos is added as is demanded by the bowels of the pa- tient. In this country, in default of sodium sulphate water,1 the best saline waters are probably the Congress and the Hathorn. I have found Congress water admirably suited to those lithse- 1 There is great need of an American water which shall without much lime, contain an abundance of sodium sulphate. 276 DISEASES OF THE KIDNEYS. mic patients who complain of "emptiness" or " goneness '' at the stomach, for which sensation the prescription of a sherry and egg " is often made and fails to relieve. I have known pa- tients who did better on Congress water than on such Carlsbad as is to be had in America. When the patient is passing considerable gravel and sand I have derived advantage tem- porarily from use of the Londonderry Lithia water. Millard thinks the Buffalo Lithia water useful when there is a torpid liver. The funda- mental objection to American mineral waters is the relatively large proportion of lime salts which they contain. The desideratum is a min- eral water not only containing sulphates, but large quantities of chlorides. Continuous use of water containing sulphates without chlorides in- terferes with digestion. When chlorides are present they exert a favorable influence on di- gestion and tissue change generally.1 The Sara- toga waters are, many of them, rich in chlo- rides. If alkaline waters are given care should be taken not to make the urine too alkaline persis- tently and too long, for fear of jumping out of the uric acid frying-pan into the fire of phos- phatic calculus. The conditions necessary for uric acid formation are present chiefly during 1 Von Mering, Frerichs, Henry Thompson. URICAEMIA 277 the hours of sleep, so that it is not necessary to drench the patient with strongly alkaline waters during the day. Solvent Treatment:—So far as actually dis- solving uric acid calculi is concerned, it is possible, according to Ebstein, that it may be done,1 but it should not be attempted on account of the danger to the system of an alkaline regime. Careful use of alkaline waters is often desirable up to the point when the urine becomes slightly acid or neutral. As soon as the urine becomes distinctly alkaline, discontinue the alkaline water. Vals Desiree water, after two days' use, has been known to render gravel and stone fragments soft, pliable, and to cause loss of weight. In acute cases Goldenberg9 recommends the sodium carbonate waters, Vals, Vichy, and per- haps also Fachingen, or 3 to 5 gramme doses daily of bi-carbonate of sodium largely diluted in carbonated waters. Prolonged use of lith- ium carbonate is dangerous, and as soon as dis- continued, its action ceases. In chronic cases, milder treatment: Fachingen water and magne- sium boro-citrate. (The use of Cantani's poav- der—one part lithium bicarbonate, one part so- 1 The majority of the claims as to the success of solvent treat ment are, as a rule, not worthy of credence. 3 Medical Record, May 12, 1888. 278 DISEASES OF THE KIDNEYS. dium bicarbonate, two parts potassium citrate —is not without danger.) 2. Remedial treatment:—For the general con- dition of uricsemia, Bryonia, Lycopodium, Euon- ymine, Nux Vomica, Podophyllum. It cannot be denied that the tendency to uric acid formation is difficult to overcome. There may be general indications for a variety of remedies, among which Arsenicum, Belladonna, Calcarea, Phos- phorus, Silica, and Zinc. In cases of uric acid gravel and calculus (renal), renal colic, etc., study the following: Argentum nitric, according to Dr.C.Preston, is preferable to every other remedy when the pas- sage of sand or sediments in general through the urethra produces active symptoms; is supe- rior to Lycopod. and Nux Vomica in renal catarrh and attacks of nephritic colic. Little or no pain during urination is an indication for the remedy, although it also relieves when the symp- toms seem to call for Canthar. The pains may be very severe, almost driving one crazy, and extend from the kidneys along the ureters to the bladder; at other times they are burning in char- acter, and are accompanied by the voiding of red sand or uric acid sediments. Its main indi- cation is catarrh of the kidneys. Berberis is useful in renal colic from uric acid gravel or calculus. Cutting pains go from URICAEMIA. 2 79 kidneys and radiate to the loins, hips, and back; the urine has a gray, meal-like sediment. Calceirea Carbonica is said to be useful when Berberis, Lycopodium, and other remedies fail in renal colic, or when there are general indi- cations for its use. (See Chapter V.) Cantharis:—Cutting and contracting pains from the ureters to the penis with relief from pressure on the glans penis. Urine turbid, scanty, cloudy when passed during the night, with white sediment. Hsematuria (not pro- fuse) from renal colic: constant, inefficient de- sire to pass water. Cannabis Sativa:—When in consequence of passage of sand or gravel, there is much sore- ness along entire urethra. Corn-silk:—In calculous pyelitis (see Stigma- ta Maid is). Copaiba:—In calculous pyelitis. Hydrangea:—Calculus passing from kidney. (A preparation called "Lithiated Hydrangea" is advertised extensively.) Lycopodium:—Dull pains in the kidney re- lieved by voiding urine. Urine high-colored, * scanty, red sandy sediment of uric acid and urates. Solids normal in character and quantity but ivater deficient. If much irritation from crystalline urates in children, urine may contain mucus and pus, causing whitish sediment; or 280 DISEASES OF THE KIDNEYS. even blood from laceration of mucous lining of the bladder. Dr. Dowling reports a case of lithsemia suc- cessfully treated with Lycopodium. Nux Vomica:—Pain running from right kid- ney extending to genitals and right leg; painful and ineffectual desire to urinate; urine comes in drops with burning and tearing pain at neck of bladder and in urethra. Ociiiiiim:—Nausea excited by pains; urine scanty, contains uric acid in sediment; pains go tearing down right ureter only. Papaine:—Recommended as worthy of trial as a preventive of renal calculi; in one grain doses, to be taken with meals. Pareira Brava:—Stone in the bladder or try- ing to pass from the kidney; constant urging to urinate; violent pains in the glans penis; straining; pain causes screaming; patient goes down on all fours to urinate; urine contains much viscid, thick, white mucus or deposits red sand and has strong ammoniacal odor; the pains go down the thighs during efforts to urinate. Piper Methysticum is said to be useful in renal colic from uric acid calculus. (Dose of the fluid extract from 10 drops upward, after meals.) Pichi is said to be of undoubted value in lithiasis and renal stone, controlling hsematuria URICAEMIA. 2Sl and pain, especially in wineglassful doses of the fresh infusion. (Dose of the fluid extract 10 to 30 minims or upwards.) Useful to allay irritation after passage of uric acid calculus. Stigmata Maid is:—(Corn-silk.) Not easy to procure at all seasons of the year. In chronic pyelitis and renal colic this drug, in wineglass- ful doses of the fresh infusion, is said to be of great value. Thlaspi:—It has been claimed that this rem- edy is exceedingly useful in causing expulsion of " red sand." (Tincture, 30 drop doses.) Uva Ursi:—Calculus passing from kidney. Renal haemorrhage and pyelitis. Constant urg- ing to urinate; straining with passage of blood and muco-pus, or straining without any dis- charge or few drops at most, after which cut- ting and burning in the urethra with discharge of blood. Stools hard. For calculous pyelitis try especially corn-silk, copaiba, pichi For the general condition Can- tharis, Merc. Cor., Nux Vom.,Petrol., Phosphor., Puis., Sepia, Sulphur. Palliative Measures :—" Benzoate of lithium is theoretic- ally of special utility in the treatment of gout, since it con- tains benzoic acid, which renders uric acid soluble, converting it into hippuric acid and lithium urate, which promotes its ex- pulsion from the system. It is important that the base should be lithium and not potassium or sodium. And it is also better that the acid used in the preparation of the compound should be that obtained from benzoin. The dose is from one to ten 282 DISEASES OF THE KIDNEYS, grammes (15 to 150 grains) a day, given in divided doses, dis- solved in water. ,In the interval of the attacks a daily dose of 15 grains is sufficient; but on the first approach of an acute at- tack it should be rapidly increased in order to hasten the transformation and expulsion from the organism of the uric acid and the urates." In ordinary cases (not severe) where the benzoate of lith- ium is used I have found that quarter-grain doses of the chemically pure drug are quite sufficient to decrease acidity of the urine, increase the flow and the quantity of urea. Alexander Haig has shown that not only the acid in wines or beer but other forms of acids diminish excretion of uric acid and cause pains from retention of uric acid in the system. He has also shown that while pure phosphate of sodium is a solv- ent of uric acid and increases uric acid excretion, all speci- mens of the drug do not act equally well. He has shown that a certain form of headache is accompanied by a very large excretion of uric acid. Dr. Haig has also attempted to show that, within certain limits, it is possible to increase or diminish the excretion of uric acid at pleasure, by means of acids and alkalies. Alkalies always increase, acids invariably diminish the excretion. The form of headache alluded to is curable by a dose of salicylic acid. It would appear that salicylic acid forms an important exception to the above statement, for, while it in- creases urinary acidity, it does not in any way diminish the excretion of uric acid. Further, acids given while salicylates are present in the circulation have no longer the power of di- minishing the excretion of uric acid. This action of salicylic acid and salicylates is of great importance in explaining the value of these drugs in gout, rheumatism, and other diseases connected with uric acid. Excessive excretion of uric acid taking place under salicylates is not accompanied by any headache, and salicylates have previously been found useful in this headache. The action of acids and alkalies on uric-acid excretion is probably due to the fact that alkalies increase and OXALURIA. 283 acids diminish its solubility, and the same with the exceptional action of salicylic acid; for salicyluric acid, which it is sup- posed to form, differs from uric acid in being very greatly more soluble in water, and probably also more soluble in dilute acid. See also u Renal Colic." OXALURIA. Etiology:—Obscure. Under nearly same con- ditions one patient is lithsemic while another is oxaluric.1 Diagnosis:—Patient voids urine which soon de- posits crystals of calcium oxalate. In patients subject to oxalate calculus, I have found the crystals in the sediment as soon as the latter set- tles. Crystals found at the end of 24 hours may signify nothing. Freshly voided urine should be examined. The symptoms of oxaluria have already been given ( see " What to do when renal calculus is suspected"). Large crystals of calcium oxalate may almost always be found in the deposit of urine containing spermatozoa. Diet:—Patient should avoid articles of food known to contain oxalic acid, as for example, rhubarb, sorrel, cresses, tomatoes, and fruits rich in citric, tartaric, and malic acids, especially apples and currants ; champagne and Moselle 1 Many deny altogether that there is a distinct disease of nutri- tion which leads to increased excretion of oxalic acid in the urine, and attribute the sediments to use of certain fruits and veg- etables. 284 DISEASES OF THE KIDNEYS. wine and beers, especially strong ones, are to be strictly abstained from. If alcoholic stim- ulants are required brandy, whisky, and gin are to be preferred. Stale or toasted bread al- lowed, but no flatulent vegetable food. Tea in moderation, but no coffee. Diet in other respects liberal, but cooking plain; sugars, pastry, etc., to be avoided. Picard advises food rich in phosphates, such as fish-roe, calf and mutton brains. Beaumetz advises patients to avoid tea, cof- fee, chocolate, coca, coarse bread, spinach,— quoting Esbach's table. The best waters for the oxaluric are those containing very few solids. Pure distilled water1 or very soft water is the best. The patient should avoid alkaline waters and all waters containing lime. It is well known that nearly all American mineral waters contain a consid- erable percentage of lime. Out of door life in the mountains is suitable to the oxaluric, but in regions where it is dry, as for example, in New Mexico. 2. Medicinal:— Treatment should be di- rected to the relief of catarrhal conditions, if dyspepsia is associated with more or less per- sistent deposits of calcium oxalate. Carlsbad salts, in doses of a teaspoonful dissolved in 1 Thanks to American enterprise, pure distilled water is now an article of commerce. FORMATION OF PHOSPHATIC SEDIMENTS. 285 ten to fifteen ounces of water as hot as the patient can bear it, should be taken every other morning an hour before breakfast. Remedies:—There are no u specifics." The general treatment for nephro-lithiasis may be tried with selection from the following, according to symptomatol- ogy: Arsen., Aspar., Calc, Cann. Sat., Erigeron, Silica, Zinc, probably also Bell., Canthar., Phos., Sarsap., Sep., Tabac, Uva Ursi. Remedies directed to the relief of the dys- peptic conditions are of most value. Oxalic Acid:—Acid urine with uric acid and calcium oxa- late in the sediment, burning pain during micturition. Milky white sediment, with pains in region of kidneys. Washing out the stomach is serviceable in some cases. The use of a cold-water compress over the abdomen at night is recommended by Ralfe, not only for relieving the abdominal ca- tarrh, but for protecting the patient against a return of the malady. [Nitro-muriatic acid is a favorite prescription with those re- lying on ponderous doses. When there is acidity of the ali- mentary canal, Picard advises carbonate of magnesia.] FORMATION OF PHOSPHATIC SEDIMENTS. Etiology:—Causes which tend to make urine alkaline. Urine alkaline from fixed alkali is found in cases of general debility, where there is feebleness in respiratory action, diminished secretion of bile, flatulent dyspepsia. Urine al- kaline from volatile alkali is found in disorders of the conducting and collecting portions of .286 DISEASES OF THE KIDNEYS. the urinary tract. Urine persistently alkaline from fixed alkali after a time may become alkaline from volatile alkali, due to decomposi- tion of the urine within the urinary passages, and conversion of the normal constituent urea into ammonium carbonate. Diagnosis:—Test the sediment for phos- phates as directed p. 26 (d), observing whether the urine is alkaline from fixed or from vola- tile alkali. Look for crystals with microscope (pp. 49, 52), especially for triple phosphate, in urine a few hours after voided, but not so late as 24 hours, especially in hot weather. Cause patient to urinate into a perfectly clean vessel. The best vessel for such purpose is a neck- less glass pitcher, six or more inches in diam- eter at the top, which can be thoroughly cleaned with scalding hot water, inverted, and allowed to drain till dry. Observe also whether the urine, when boiled, as in testing for albu- min (p. 13), but tvithout acetic acid, throws down a white precipitate, readily dissolved with effervescence on addition of two or three drops of 20 per cent, acetic acid. Such urine, even if of acid reaction before being boiled, is deficient in acidity. There may be no great sediment of phosphates in such urine. [If there is no sediment of phosphates and yet there are obscure nervous symptoms, it is well to estimate the total quantity of phos- TREATMENT OF PHOSPHATURIA. 287 phoric acid, using the. volumetric process with uranium nitrate.] TREATMENT OF PHOSPHATURIA. 1. Urine alkaline from fixed alkali: — Sedi- ment of earthy phosphates. Urine usually alka- line when first passed, effervesces, and clears on addition of hydrochloric acid. Creamy dis- charge of phosphates at end of micturition, with considerable irritation at neck of bladder. Or slightly acid urine, becoming turbid when boiled, turbidity soluble in acid. Patient usu- ally debilitated and suffering from flatulent dyspepsia. Diet:—The diet is that of flatulent (not acid) dyspepsia in general. Patients should masti- cate their food thoroughly. All food should be tender, easily digested, and well cooked. Meals to be taken with regularity, and the intervals between them not too prolonged ; in some cases patients should eat a little something every three or four hours, before going to bed, and on rising in the morning. Patient to avoid milk, taking cream instead, in tea or coffee, the latter being sparingly taken. Alcoholic drinks to be avoided. If absolutely necessary, a tablespoon- ful of brandy, diluted with two of water, at the principal meal. Mineral waters and fluids in general to be avoided at meals ; a small tumbler of Apolli- 2S8 DISEASES OF THE KIDNEYS. naris allowed. Fluids, as, for example, Vieliy water, to be taken two hours after meals, but not if there is intestinal flatulence with oxa- luria. Other measures :—Ralfe advises use of the cold, wet compress before patient goes to bed ; or, in the case of delicate and feeble patients, a little tea, with toast, is given on first waking in the morning, and the compress is applied ; three hours later the compress is removed, and the skin gently rubbed with a bathing glove or Turkish towel. Remedies -.—Bismuth may be given before meals, and pepsin after. When there is great foetor of the stools, vegetable charcoal, the lat- ter taken before meals if the flatulence is m the stomach, or after meals if in the intestines. In highly flatulent cases a drop or two of chlo- roform in a teaspoonful of glycerine, after meals, often gives relief when there are cramps and spasmodic pains. Sulpho-carbolate of soda:—Patient complains of pain, often most marked on one side of abdo- men, generally the left, under the ribs. [5 to 10 grain doses immediately before or after food.] Other remedies are : Nux Vomica, Phosphate of Strychnine, Carlsbad Salt, Terebinthina (drop doses). Systematic employment of Carlsbad Salt, a teaspoonful in 10 to 15 ounces of as hot TREATMENT OF PHOSPHATURIA. 2S9 water as patient can bear, every other morning, an hour before breakfast. 2. Sediment of earthy phosphates, coupled with increase in total phosphoric acid above normal.1 The symptoms are as follows : Great nervous irritability ; derangements of digestion ; pos- sibly great emaciation ; aching rheumatic pains in loins and pelvic regions ; dry, harsh skin, with tendency to boils, and ravenous appetite ; possibly cataract; polyuria, or normal quantity of urine, with high specific gravity. Excessive elimination of phosphoric acid, associated with nervous derangements, or with phthisis, is a difficult disorder to control; prog- nosis unfavorable. Excessive elimination of phos- phoric acid, running a course like saccharine dia- betes, but without sugar, or alternating with saccharine diabetes, is more easily managed; prognosis more favorable. A sediment of earthy pltosp)ltates in the urine is not necessarily of any clinical significance whatever, unless the total amount of phosphoric acid in the urine is increased. This can be ascertained by quantitative analysis only, with uranium nitrate solution, care being taken to use a specimen of the mixed urine of 24 hours. The great feature is considerable and constant elimination of phosphoric acid, with or 1 Normal quantity of phosphoric acid in 24 hours is 2.5 to 3.1 grammes. In some cases of disease the quantity may rise to 7, 8, or even 9 grammes. 29O DISEASES OF THE KIDNEYS. without increase of the other constituents of the urine. The treatment consists chiefly in enforcing rest and promoting nutrition. The remedies are : Ferritin, Phosphorus, China, Nux Vomica; if syphilitic history, Kali Iod. Warm baths, fol- lowed by tepid douches, give great relief to the neuralgic pains. Alcohol and coffee to be avoided. Food light and nutritious; milk advis- able. Cod liver oil, maltine, and hypophos- phites may prove serviceable. Country air and massage. For the severe rheumatic and neuralgic pains, Ralfe recom- mends codeia in full doses, one-quarter to one-third of a grain at night. During the day, hydrochloric acid, with nux vomica, and cod liver oil. For consideration of sediments of triple phos- phate, see "Cystitis." TREATMENT OF RENAL COLIC. Warm diluent drinks, alkaline tvaters in case of uric acid calculus; pure distilled water in case of oxalate calculus, acid drinks (solutions of boracic acid), if calculus be phosphatic and urine ammoniacal. Hot fomentations to loins ; hot baths; emollient enemata; cupping of the loins. If pain intermittent: Try external manipula- tion in renal regions or along course of ureter. During paroxysms, change position of patient. TREATMENT OF RENAL COLIC. 29I Moderate open-air exercise. Diet to be regu- lated according to nature of stone. (See Diet in Uricaemia, Oxaluria, and Phosphaturia.) During renal colic give Belladonna, if there are spasms and crampy straining along the ureter, as calculus goes down. Cautharis (high) when intense pain above crest of ilium. Drosera:—Writhing, twitching, crampy pains. Arnica:—Piercing pains ; patient chilly and inclined to vomit; violent tenesmus of the bladder. Arsenicum:—When there is also gastralgia, tickling and itching in urethra from gravel, etc. Tabacum:—Patient has violent nausea. Nux Void.:—For the effects of morphine. Clinical notes:—Cede. Carb., thirtieth tritura- tion, has its admirers. So also has tincture of Berberis and Pareira Brava. Hypodermics of morphine have, however, found considerable favor, particularly with patients, who, as a rule, demand them. For the effects of the morphine give Belladonna and Nux Vomica. Antipyrine in fifteen grain doses, frequently repeated, is advised by Tyson. Morphine, opium, belladonna are given in ponderous doses. When, after repeated attacks, morphine fails to relieve, try antipyrine for a time. (Lund.) If pain so violent that patient is in convulsions, or nearly, give chloroform or ether. 292 DISEASES OF THE KIDNEYS. Various French authorities1 claim that the paroxysms may be aborted by sandalwood oil in doses of 20 minims, fol- lowed by a hot bath. Manipulation, without incision, in a case of stone in the kidney, when the latter is easily felt with the hand. In patients attacked with renal colic, caused by uric acid calculi, Dr. Crittenden prescribes 20-grain doses of biborate of ammonium every two hours, until a free passage of urine takes place, and then every four hours until all ill feeling passes away. He then decreases the dose to 15 grains, three times a day, before meals, in a glass of flaxseed tea, and continues this treatment for several months, discontinuing it for a day or two at a time every two weeks. When given for a length of time, he states that he has found it to be a good plan to combine it with lithiated extract of hydrangea in teaspoon- ful doses. Johnson at present recommends the carbon- ate, or citrate of lithium, to be taken in a tumbler of Bethesda water three or four times daily. In a very few days the pain and other distress- ing symptoms abate, and in a short time there will be evidence of the passage of a small cal- culus down the ureter, or through the urethra. Sir Henry Thompson2 gives the patient sub- 1 Philbert, Gipoulon. 2 Calculous Disease, 1888. Philadelphia: P. Blakiston. TREATMENT OF RENAL COLIC. 293 ject to renal colic half a grain of blue pill, with three or four grains of compound extract of colocynth at night, followed next morning by three to four ounces of Hunyadi Janos, taken with a little hot, plain water ; on each succeed- ing morning, six ounces of Carlsbad, with about two of Hunyadi Janos, and four of hot water, daily, until the end of the first week; subse- quently, four to seven ounces of Carlsbad every morning. Hematuria of Renal Calculus:—If profuse, rest in recumbent posture. If slight, but prolonged, try cold local appli- cations. Remedies: Cantharis, Terebinth., Uva Ursi. Gallic acid and ergot are often given in ponderous doses. (See " Renal Hematuria.") Hydrastinine may be thought of. When to operate for renal calculus:—As already shown the usual symptoms of renal cal- culus may be present and yet no renal calculus exist; on the other hand, renal calculus maybe present without unusual disturbances. The question arises, therefore, in regard to the desira- bility of operation, which will not be discussed in full here, but the reader is referred to the conclusions of Henry Morris, quoted by David Newman.1 ^Diseases of the Kidney Amenable to Surgical Treatment. London, 1888, p. 253. 294 DISEASES OF THE KIDNEYS. Jacobson1 calls attention to the following symptoms and conditions which justify nephro- lithotomy : These are: 1, continued hsematuria, or pass- age of blood and pus \ 2, pain or tenderness in the loin or elsewhere; 3, points connected with the previous history, for example, family history, habitat, habits, lithiasis, oxaluria, passage of previous stones, renal colic; 4, frequency of micturition; 5, absence of any condition in the rest of the urino-genital tract to explain the symptoms; 6, failure of previous treatment. Care should be taken not to confuse transient deposits of uric acid coinciding with suppres- sion of acute nephritis, or alternating with albuminuria. In all cases examine the urine for albumin, casts, and tubal epithelium. Bruylauts claims that decrease or absence of the sulpho-cyanide of potassium is a test of the lithsemic state. Nephro-Hthotomy for calculus without suppur- ation is, according to Newman, very successful. In forty-two operations no deaths. Renal colic or uncamia in children: Examine the napkins for reddish-brown stains. If the stream of urine is abruptly checked, suspect stone in the bladder or deep urethra. ^British Med. Journal, Jan. 18, 1890. TREATMENT OF RENAL COLIC. 295 In young children prolapsus ani, priapism, and ha3maturia are signs of calculous disease. Retention of urine in a child often means a concretion impacted in the urethra. The prognosis is, as a rule, favorable.- In the treatment of uricaemia in children and infants order copious drinks, warm baths, limitation of nitrogenous articles of diet, sodium phosphate and the phosphate of soda and ammonia (12 grains three times a day) and the benzoates. Miscellaneous Surgical Measures: Bozeman, of New York, treats chronic pyelitis in women by kolpo-uretero-cystotomy, irrigation of the pel- vis of the kidney and intra-vaginal drainage. Before nephrectomy, Fenwick recommends collection of urine directly from the other kid- ney with view to ascertain its working capacity by means, in the case of male patients, of suc- tion of the ureters.1 This is accomplished by use of an instrument the principle of which is a slight suction, which is exerted on the ureteral orifice by means of a catheter and a small India rubber ball. Fenwick believes that in certain cases the pelvis of the kidney may be washed out by dis- tending the bladder with fluid in which pres- sure is exerted by means of a certain apparatus (the evacuator usually employed in lithotrity)- 'See Lancet. Sept., 1886. 296 DISEASES OF THE KIDNEYS. Iversen, of Copenhagen, by means of epicys- totomy, with antiseptic precautions, and use of the cystoscope, has catheterized the ureters in the diagnosis of suppurative inflammation of the kidneys. CHAPTER X. Chronic Renal Tuberculosis. Carcinoma. Tumors. After preparing the specimen as directed in Chapter II., look with a power of 750diameters for minute rod-shaped bodies stained the color of the staining fluid used, 3 to 7 micromillime- ters long, sometimes straight, more frequently curved or bent at an obtuse angle, frequently beaded, in bundles or singly. Norderling, of Rockford, prefers the following process for staining: One part of aniline oil is thoroughly shaken for a few minutes with ten parts of distilled water, and then filtered through a filter previously moistened with water. To the perfectly clear solution is then added four or five drops of a saturated alcoholic solution of fuchsin. In this solution (fuchsin aniline water) is immersed the prepared cover-glass. The solution is slowly heated a few minutes, until vapor appears; then the cover-glass is taken out and washed in dis- tilled water, and afterward immersed in a saturated solution of oxalic acid. It must remain here until it is completely decolorized, when it is taken out, dried, and immersed in a weak solution of methylin blue, until it has received a light- blue color (about one-half to two minutes). After this it is dried again, and examined in Canada balsam with a homo- geneous immersion lens. All is now colored blue except the bacilli, which have a beautiful red color. 297 298 DISEASES OF THE KIDNEYS. Figure 22. Tubercle Bacilli and Gonococci. 1. Tubercle Bacilli. 2. Pus-cell with Gonococci. 3. Gonococci. If tubercle bacilli are found, ascertain by ureteral catheterization, if possible, which kid- ney is affected, obtaining urine from each kid- ney and examining, as before, for the bacilli. Symptoms of renal tuberculosis: If tubercular bacilli cannot be found—as is often, if not usu- ally, the case—attend to the symptoms the patient presents. The Urine: 1. Urine may present signs of pyelitis proper, with clear urine of acid reaction above sedi- ment. Blood corpuscles may be found in the sediment, and a tinge of blood noticed above CHRONIC RENAL TUBERCULOSIS. 299 the pus sediment. The blood will be found in the night urine, as well as in the day. Albumin in early stages may be present in amount greater than blood accounts for. ( Some- times diffuse nephritis sets in, and tube casts are found.) Later, when pus and blood more abundant, not so rapid and complete separation of the sediment from the urine, as in calculous pyelitis. 2. If the disease begins in the kidney and extends downward, the condition of the urine is that of pyelitis proper at first, as above; but if the bladder be invaded, the urine contains mucus, as well as pus, and the urine is no longer clear above the pus sediment, and the reaction becomes feebly acid, more often alka- line. The sediment does not settle completely but the urine is hazy, from mUcus and sus- pended pus; is viscid, cloudy, and opaque. Albumin may possibly be no more than pus accounts for. The condition is now one of cysto-pyelitis. The urine is likely to contain continuously a large amount of pus and granular debris; there may be cheesy masses, insoluble in acetic acid, shreds of connective tissue, beautiful meshes of elastic fibres from the cast-off patches of disin- tegrated mucous membrane. It is always wise to suspect tuberculosis, if a pyelitis or cysto-pyelitis exist, without evidence 3°° DISEASES OF THE KIDNEYS. of stone. Examine the patient thoroughly for the following symptoms: Micturition :—When the disease is advanced there is frequent micturition, and invariably with pain in bladder. The pain is severe at the middle of the flow of urine, increases toward the end and subsides immediately when the bladder is empty. Escape of blood with last few drops of urine is rare. There is no pain in the penis nor sudden stoppage in the flow of water as in the case of vesical calculus. Pyuria without pain on voiding urine excludes tuber- culosis of the bladder. Fever .-—Temperature usually 2° to 4° higher at night than during day or intermittent periods of fever for several consecutive days. Miscellaneous /—Profuse night sweats, emaci- ation, loss of appetite, exhaustion early in the disease, diarrhoea obstinate. Confirmatory tes- timony to be had from discovery of phthisis pulmonalis, tubercular disease of the bones and joints, of testicle, prostate and vesiculse semi- nales, mesenteric glands, intestines, or lower urinary tract. Look for scrofulous scars, swelling of the testicles, with tense plastic ex- udation, for which there is no assignable cause; deep and difficultly healing rectal fistula?. There may be renal colic from caseous masses, plugs of mucus, or from tubercular ulcers. Physical Signs:—If urine is pale and of low CHRONIC RENAL TUBERCULOSIS. 3OI specific gravity, renal swelling, sometimes in greater part of one side of the abdomen, may be noticeable with indistinct fluctuation, pain, and general constitutional disturbance. Tu- bercular pyonephrosis, in other words. Com- plete suppression of urine may take place with ursemic symptoms. In many cases the order of symptoms is as follows :— Backache, hsematuria, and albuminuria; then a putrid, alkaline urine; later, swelling, pyuria, suppression, ursemia, and death. To distin- guish from calculus: the evening temperature rises, hsemorrhage when at rest, more contin- uous discharge of pus, frequent urination, which is very painful when the bladder is affected. Figure 23. Fungous growth of no clinical significance. Found in albuminous urine. 302 DISEASES OF THE KIDNEYS. The prostate is probably affected before the kidneys, and as a rule the testicle or epididy- mis first. The epididymis first on one side and then on the other becomes swollen, hard, and then may suppurate. Cases have been known in which pale urine with albumin and casts have been found prior to signs of trouble in testicle or prostate. In a case which I recently examined, there was family history of tuberculosis, and there were scrofulous scars. Patient complained of pain when bladder was full, ceasing when empty; the locality of the pain was the per- inseum. He was obliged to urinate every three- quarters of an hour; the.urine was voided into several glasses and all were equally turbid. The reaction was alkaline as soon as the urine was voided, the specific gravity 1017, urea, parts in 1000, 14, phosphoric acid, parts in 1000, 1.86, albumin one and one half tenths of one per cent by weight. No tube casts could be found in the sediment, which was composed almost entirely of pus, debris, and cheesy masses in- soluble in acetic acid. Nevertheless tubercle bacilli could not be found, owing probably to the alkaline reaction of the urine when first voided, the putrefactive bacteria having destroyed the specific bacillus. TABLE XIV.—Differential Diagnosis in Tubercular Pyelitis, Calculous Pye- litis and Renal Cancer. Tuberculous Pyelitis. Calculous Pyelitis. Renal Cancer. Pus in the urine abundant, early and continuous. Great quantities of vibriones and rpicrococci. Pus in the urine in small quantities at first, slowly increasing. Preceded by mu-cus. Little or no pus or debris, Hsematuria not frequent, slight, and in night urine as well as day. Frequently absent for long intervals. Occasional attacks of slight, sometimes severe, hematuria after exercise, none at night, or after repose. Hcematuria usually light at first, but later profuse. Spontain ous, continuous, aggravated at intervals; and both after re pose and exercise. Pain:—Greatest in bladder, relieved when bladder is empty. Pain:—Paroxysmal and radiating. Worse on motion. Pain not affected by movements. Pyrexia, marked. Pyrexia not marked. Pyrexia not marked. Emaciation, loss of appetite, etc. General nutrition good. Loss of flesh, amernia, cachexia. 3°4 DISEASES OF THE KIDNEYS. Prognosis:—Unfavorable if bilateral, or ex- tends from one kidney to urethra, ureter, or bladder. Not immediately unfavorable, if dis- ease is confined to one kidney. Considerable time may elapse before it invades other parts. Favorable, in rare cases: if unilateral, there is a chance that the lower urinary tract may escape; the diseased kidney may be destroyed by suppuration or dry up into a firm, caseous mass. Treatment:—Surgical interference sometimes useful early in the course of the disease. If it is possible, by catheterization of the ureters, to discover that the disease is unilateral and if it is of small area, a lumbar incision may give great relief.1 If the wound continues to dis- charge, nephrectomy, with scraping out of cas- eous material. If the disease is unilateral, either by proof or strong presumption, and covers large area, nephrectomy as a primary operation may be performed.2 If the bladder is extensively affected, cystot- omy may possibly prolong life.3 1 In twenty cases of nephrotomy in tubercular disease, six died (Newman). In nine cases, two died (Guyon). 2 In thirty-three cases thus operated on twelve died (Newman). In twenty-lour cases eleven died (Guyon*). 3 Ealfe records a case (op. cit. p. 337) in which life was prolong- ed by this operation. CARCINOMA. 3°5 The strictest asepsis should be sought for in all operations. Medical Treatment:—In later cases, and es- pecially where the disease has invaded both kidneys, the ureters, bladder, etc., medical treatment must suffice, even washing out of the bladder being contra-indicated. The diet should be nutritious and digestible and the treatment that of tuberculosis in general:— Cod liver oil, the iodide of iron, Galea rea, Kali, Mercurius, Sulphur, etc., etc. For the pyrexia, cold sponging. Diarrhoea should be checked, except possibly when there are urse- mic symptoms. MALIGNANT DISEASE—CARCINOMA. Etiology:—-More common in children and old people, in men than in women. Largest and most rapidly increasing growths occur usually in children. Diagnosis:—Renal swelling, lumbar pain, pressure on neighboring parts, cachexia, signs of disease in regions beyond the kidney, changes in the urine. Swell ing .—See Table XIII. Pain:—Usually dull ache, paroxysmal, but not affected by movements of the body. More severe in situation of affected kidney, but in later stages extends. If there is pressure on lumbar nerves, extreme pain is felt in the chest, lumbar region, back, hip, testicles, thigh, leg. DISEASES OF THE KIDNEYS. Pressure:—If on abdominal veins, then there may be oedema of lower extremities, as- cites. Dilatation of superficial veins from oc- clusion or thrombosis of intra-abdominal ves- sels. If pressure on abdominal viscera, vomit- ing, constipation, anorexia, icterus. Cachexia:—Significant loss of flesh, anaemia, change of color when patient has not lost much blood and has fairly good appetite. May not be noticed, however, in sarcomatous affections. Micturition: — Considerable difficulty and pain in micturition in early stages and even when bladder is not affected. Varicocele:—Guillet declares that an import- ant symptom is the presence of a suddenly oc- curring and rapidly growing varicocele. The Urine;—Normal, if tumor limited to kid- ney alone. If pelvis of the kidney involved, hsematuria; deposit of blood corpuscles mixed, if with anything, with sanguinolent material, epithelium, portions of growth, etc., etc. Hem- aturia constant, both in repose and after exer- cise; albumin usually due to blood, but albumin more than blood accounts for, and blood casts may be found, if there is coincident nephritis. Hsematuria rarely severe in early stages, with some exceptions. After it once starts likely to be profuse, spontaneous; continuous, subject to aggravation; formation of clots liable. Hsema- turia in elderly persons often precedes the tu- CARCINOMA. 3°7 mor; cancer cells not as a rule to be found. Sometimes it is possible by filtering the urine to obtain portions of the growth on the filter. Differential diagnosis between renal tumors and those of other organs:—Renal tumors, according to Stiller, present the following characters: 1. Unilateral occupation of abdomen. 2. Spherical contour. 3. Downward growth. (Palpation reveals lower margin.) 4. Absence of any influence of the rhythmi- cal movements of the diaphragm in breathing, when the tumor is fixed against the abdomen. 5. Relation to intestines: intestines lie over small tumors; in larger ones, are pushed toward median side.1 6. Presence or absence of tympany depend- ing on amount of intestine covering the tumor. 7. Bulging posteriorly. Prognosis:—In children, disease fatal in from ten weeks to a year. In adults, five months to seven years; average, two and one-half years. Treatment:— In general, Arsenicum. If hsematuria is profuse : complete rest, cold applications to lumbar region; internally, Ham- aiiielis, Secale, Ferrum, Ipecac, according to indications; or, ten-grain doses of gallic acid 1 Ann. of the Univ. Med. Sci., 1889. G 31. 3o8 DISEASES OF THE KIDNEYS. every four hours, with ice in a bladder to abdo- men. Prevent tumor from dragging by flannel roller. Enemas for constipation, to avoid diar- rhoea. Remove clots and coagula by gently washing out bladder. For the pain: apply belladonna or aconite liniment; mixture of chloral hydrate and cam- phor. Opium by rectum. Subcutaneous injec- tions of morphine acetate. In certain cases nephrectomy may be per- formed early in the course of the disease, before it has spread.1 OTHER TUMORS. The kidney may be the seat of sarcoma, aden- oma, fibroma, congenital rhabdo-sarcoma, angi- oma, lipoma, lymphoma, osteoma, cavernous tumors, and gummata. The symptoms of sarcoma are about the same as those of carcinoma, except that there is usually less pain, sometimes little or none, and more profuse hsematuria. Nephrectomy is accompanied by high mor- tality. Adenoma may occur in early life. Syphilitic gummata are not common, but are more frequent than formerly supposed. FLOATING KIDNEY. Synonym:—Movable kidney. 1 In sixty-one operations there were thirty-three deaths.. (Newman.) FLOATING KIDNEY. 3°9 Etiology:—Rapid wasting of the body. Vio- lent concussions. Tight lacing. Hydronephro- sis. Of much greater frequency among women than men; i'claxation of tissues which comes of an inactive, sedentary life. Diagnosis:—If the female patient complains of a feeling of " something loose'1 in that region of the abdomen which moves, for example, on turning over in bed, with a sense of dragging or gnawing at the spot, sometimes amounting to sharp pain; and if there is also distinct neu- ralgic pain in the course of the lumbar nerves, shooting round the abdomen to the hypogas- trium, and down the thighs, examine the pa- tient as follows: stand at the right side of the patient, place the right hand against the anter.- ior abdominal parietes, and then press the left against the back of the lumbar region, so as to press the kidney forward. Then place the pa- tient on her side, with the knees drawn up. By sharply shaking the body the^ kidney, if mov- able, will fall forward. In both sexes in all cases with obscure ab- dominal pains, systematic search for a mov- able kidney ought to be made. The right kidney is the movable one in the majority of cases. Prognosis:—As a rule, causes no discomfort, produces no symptoms and requires no treat- ment. In some cases severe symptoms occur 3IO DISEASES OF THE KIDNEYS. which can be relieved by simple means. In a few cases such severe symptoms occur that op- erative measures are required, even nephrec- tomy as a last resort.1 Treatment:—Patient, if a female, to avoid dancing or riding, especially during menstrua- tion. Tight lacing to be avoided. Bowels reg- ulated so that no straining at stool. Prolonged rest in recumbent posture after delivery. Mas- sage and electricity, properly applied. Lindner2 treats the abnormality by careful bandaging. Niehaus3 has devised a pad to hold the kidney in place. Landau recommends an abdominal bandage or a peculiar u corset." A crescentic pad is the best. In case symptoms of so-called strangulation of the kidney set in, to-wit, after some sudden exertion (though occasionally while at perfect rest) severe abdominal pain, great tenderness in the neighborhood of the kidney, frequently accompanied by^ rigors, nausea, and vomiting, urine dark and scanty: the patient should at once be placed in the horizontal position and an attempt made to replace the kidney. If the attempt fail put patient into a warm bath and try again. Make hot applications, apply poultices, etc., etc. 1 Ralfe. - Ann. Univ. Med. Sci., 1889, G. 22. 3 Ann. Univ. Med. Sci., 1889, G. 24. FLOATING KIDNEY. 311 In a few days, at most two weeks, according to Ralfe, it will certainly be possible to replace the kidney, the first sign of recovery being a copi- ous discharge of urine, which may possibly con- tain pus. If mechanical support cannot be borne -or fails to relieve, Ralfe holds that where the symptoms are so severe as to incapacitate for the ordinary duties of life, operative interfer- ence is necessary and justifiable. Nephrorra- phy is indicated in troublesome cases. GENERAL TREATMENT OF RENAL HEMATURIA. If the bleeding becomes serious, absolute rest in bed in a horizontal position, while the pelvis is somewhat raised. Cold applications should be made in the vicinity of the kidneys, ice bags, etc. Internally, Hainamelis, in doses of thirty to ninety minims of the fluid extract; fluid extract of Gelsemiiim, fifteen to thirty minims. Ergot may be necessary, and may be given as follows : ^ Extr. Secalis cornuti, - - - gr. xv. Sacch. albi, - gr. xxx. M. F. pulv. Div. in dos. Nr. sex. Sig. one powder three times daily. In this way the patient takes less than three grains of ergot in each powder. Hemoglobinuria requires Ferrum and China principally. CHAPTER XL Suppurative Diseases of the Ureters, Bladder, Prostate, and Urethra. If the suppurative disorder is not one of the kidneys or renal pelvis, study Tables X. and XII. still further, in order to make clear whether the pus or blood be derived from the bladder, neck of the bladder, or urethra. URETERITIS. RENAL TENESMUS. Before entering upon a study of cystitis, something must be said in regard to inflamma- tion of the ureter. Diagnosis:—The diagnosis must be made chiefly by exclusion. If there are no evidences of trouble elsewhere, and yet the urine contains pus and epithelial debris, especially in women, after a cleansing injection, it maybe reasoned that the ureter is the seat, at least partially, of the inflammation. Often, however there occurs what is known as renal tenesmus, violent and painful contractions of one or the other ureter and corresponding pelvis of the kidney, with marked tenderness or soreness under pressure of the latter organ, proceeding from morbid irritability of both structures. 312 URETERITIS. RENAL TENESMUS. The pains occur in paroxysms, which vary in frequency, duration, and severity in different cases, according to the stage of the preceding ureteritis and the extension of the lesion to one or both sides. As a rule, it is confined at first to the groin on one side of the body, and after- ward to the corresponding lumbar region. In the more severe attacks, the pain, besides being violent in these situations, radiates to the hip, the outer and inner sides of the thigh, the knee, leg, and even to the toes. Cramps of the mus- cles of the lower extremity on the affected side also occur in these severe paroxysms. In the well-marked cases, attacks of this sort come on daily, or even several times a day. They are most frequent and severe during the menstrual periods. The patients describe them as occur- ring most often during the night. They awake with a pressing desire to urinate; the emptying of the bladder is accompanied by more or less pain and spasm, and its evacuation is followed by a cramp-like pain, ascending along the course of the ureter to the kidney, and radiating to the lower extremity. The patient sleeps, as a rule, on the affected side, with the face turned toward the pillow, and it is the habit of many to draw the opposite thigh up over its fellow against the abdomen. The pain is excited in the early stages by the marital rela- tion, which in nearly all cases becomes intoler- able in the advanced stages of the disease. 3H DISEASES OF THE KIDNEYS. Other symptoms are associated with the renal pain and the disturbance of the functions of the bladder. Anorexia, nausea, and vomiting are almost always present, especially during the menstrual periods, and as the attacks of vomit- ing are generally long continued, the vomited matters become stained with bile. Jaundice, even, is not an uncommon result. Hysterical symptoms form a marked feature of most of the eases. The patients start at the slightest noise, become despondent, cry, and laugh without suf- ficient cause, and sometimes have well-marked hysterical convulsions, followed by a period of unconsciousness. Finally, in the advanced stages of the disease, after years of almost ceaseless pain, when dyspepsia, loss of appe- tite, nausea and vomiting, torpidity of the liver, constipation of the bowels, and yellowish tinge of the complexion shall have supervened, the general aspect of the subject is that of inanition or starvation, from which, with continually increasing physical and mental sufferings, death puts an end to the roll.1 Differential Diagnosis between Renal Ten- esmus and Renal Colic—An attack of renal colic continues, as a rule, with only short inter- missions, until the calculus escapes into the bladder, and the concretion is afterward usu- 1 Bozeman, Medical Record, Aug. 4, 1888. URETERITIS. RENAL TENESMUS. 31 ally discovered in the urine; the paroxysms, moreover, recur at irregular and usually long intervals. On the other hand, the pain of renal tenes- mus is less severe; it comes on more fre- quently, and the paroxysms, as we have seen, occur several times a day, and often from the most trivial causes. The most important diag- nostic feature of renal tenesmus, however, is the facility with which an attack can be excited. When any doubt of the causation of the pain exists, it may be set at rest by making pressure over the ureter where it lies in the vesico-vag- inal septum, or by injecting the bladder with warm water. The pressure of the water, when sometimes only a few ounces are used, causes an irresistible desire to urinate, which, if not promptly relieved, is followed by the pain along the ureter and in the kidney, even in the corre- sponding hip and lower extremities, down to the ends of the toes. The patients recognize the pain produced in this way as the symptoms which have been their chief source of suffering. The attacks of renal tenesmus brought on by either of these procedures may last for several hours or days, and are frequently accompanied by great mental excitement and hysterical man- ifestations. Hence the necessity of caution in adapting these means to the peculiarities of the case. (Bozeman.) 316 DISEASES OF THE KIDNEYS. Prognosis —Essentially the same as pyelitis. When, however, there is renal tenesmus, the prognosis is less favorable, unless relief is ob- tained from operative procedure. Treatment:—Ureteritis and renal tenesmus are the almost inevitable consequences of dis- ease of the lower urinary passages. In the female, urethrocele, with cystitis following on it, leads to ureteritis; consequently, the prevent- ive treatment of ureteritis is that of disease of the urethra and bladder. (See "Cystitis.") The treatment advocated by Bozeman of renal tenes- mus, once established, is kolpo-uretero-cystot- omy. An opening through the vesico-vaginal septum not smaller than a silver half-dollar is made, having specific and close relation to the outlet of the affected ureter and kidney. Remedies:—The chief remedies in ureteritis are, Aconite in acute cases; Arnica when the result of traumatism; Mercurius if there is much pus. For the renal tenesmus see indica- tions for remedies in the chapter on " Renal Calculus." CYSTITIS. Definition:—Inflammation of the bladder. Etiology:—May possibly be a primary dis- order, but is usually secondary to diseases of the spinal cord, injuries, etc.; or may follow inflammation or suppuration of the prostate, urethral stricture, urethrocele, vesical calculus, CYSTITIS. 317 pelvic or other abscesses, growths, etc., etc. Highly concentrated urine irritates the bladder, and may in the end induce cystitis. Syming- ton Brown1 claims that the so-called " hysteri- cal " urine of low specific gravity, almost desti- tute of saline ingredients, is a common cause of irritation and pain. In women the larger number of cases arise from not emptying the bladder often enough. Diagnosis:—Acute cystitis may be distin- guished from acute nephritis by the abundance of ropy pus and mucus in the urine, by the com- paratively small quantity of albumin, usual absence of blood, absence of casts. Cystitis may be differentiated from suppu- rative nephritis *by absence of severe constitu- tional symptoms, kidneys not enlarged or tender, etc., etc. See Table X., p. 219. Cystitis may be differentiated from spasm of the bladder by the presence of mucus and pus, scalding urine, and absence of difficulty in pass- ing water, except for pain. Summary:—In cystitis, urine leaves the kid- neys usually normal in amount of solids and in character, but in bladder is exposed to action of bacteria, and undergoes change. Reaction, therefore, faintly acid, neutral, or alkaline, even when first passed. Deposits an abundant sedi- 1 Amer. Pract. and News, Feb. 2, 1889. 3iS DISEASES OF THE KIDNEYS. ment, usually leaving supernatant urine clear. In sediment we find pus, bladder epithelium, and sometimes some of the mucus from the mucous membrane, innumerable bacteria, in the form usually of short rods in active movement. Odor ammoniacal, quantity in twenty-four hours normal, or not increased. Viscid masses are found in severe cases in the sediment, which can be drawn out into threads, arising from pus-corpuscles and dissolved epithelium. Albu- min, usually traces only, will be found in the urine. "WHAT TO DO IN CASES WHERE CYSTITIS IS SUSPECTED. Collect total amount for twenty-four hours. Test the urine for albumin, and sediment for pus and blood. Take reaction/ Calculate total amount of solids. Estimate urea in the freshly voided urine. Look for bladder epithelium in sediment. If the quantity in the twenty-four hours is normal, the amount of solids normal, the reaction neutral or alkaline, the amount of albumin small, corresponding to the pus, no tube casts and no dropsy or other symptoms of kidney trouble present, the trouble is probably not with the kidney, but the pus, blood, etc., are from the bladder. Kidney complications shown by deviation from standard of the quan- tity in twenty-four hours, solids, presence of considerable albumin, etc., etc. CYSTITIS. 3*9 Ammonium carbonate may be suspected by the ammoniacal odor of the urine, and a test for it may be made as follows: bore a hole through a cork, using a cork borer the thick- ness of a lead pencil, and fit into it a glass tube. Into the tube put a strip of moistened red litmus paper. Warm the flask gently, avoiding boiling, and if ammonium carbonate is present, the paper will be colored blue. In cases where by the symptoms and condi- tion of the urine chronic cystitis is suspected, effort should always be made to discover the cause of the disease. Cystitis is seldom a pri- mary disorder and intelligent treatment must rest on knowledge of the true cause of the malady. Random and casual prescriptions will seldom prove profitable either to the physician or his patient. I cured one case of mild cys- titis in an elderly patient by merely prescribing distilled water in quantity sufficient to increase the quantity of urine, which was scanty, con- centrated, highly acid, and loaded with crystals of uric acid. The desire to urinate and the scalding were relieved in 24 hours and have not returned under continuance of the treat- ment. Few cases, • however, are so easily traced and so readily relieved. Disease. Quantity. Color. Si>. Gk. Reaction. Sediment. Abnor. C onstit. Contents or Sedi-ments. Non. Constit. Cystitis, Acute, 1st Crude; as in in-flammation of pros-tate, after gonor-rh Lachesis:—Subacute cystitis. Gelsemium:—Paralysis or paresis of the blad- der in elderly patients or after diphtheria. "-H.N. Lyon, Medical Visitor, 1890. TREATMENT OF CYSTITIS. 329 St. Clair Smith relieved a case of puerperal cystitis with Eepiisetum 30, after Cantharis, Pruiius Spinosa, Pareira, Brora, Uva Ursa and other remedies had failed. Saccharin, internally, alternated with Euca- lyptus or Chimaphila is Hale's prescription for chronic catarrh of the bladder.1 S. D. Johnson2 relieved a case of tenesmus in cystitis with fluid extract of Chimaphila, twenty drops in half a glass of water, tea- spoonful doses every hour. In acute cystitis hot baths are of value. General irritation over the hypogastric region with heat there and in the perinseum will often relieve the pain. Injection into the rectum, twice daily, of water at a temperature of 120° is mentioned by Palmer.3 In acute cystitis Gross' favorite treatment was by hops and infusion of uva ursse. Ultzmann gives 2 or 3 grains of lupuline with f grain morphine, three or four times a day, or morphine suppositories for the urgency of urination. If the pain specially affect the rectum and perinseum, a few leeches to the latter region will give relief. If suppositories are not well 1 The New Remedies, 1890, p. 59. 2Medical Current, Nov., 1889. 3Amer. Pract. and News, 1889, p. 200. 33° DISEASES OF THE KIDNEYS. borne, the bladder may be washed out with warm water containing 10 or 15 drops of laudanum. In case of retention, use soft catheter. Keyes, in acute (gonorrhceal) cystitis, insists on rest in bed with elevation of the pelvis, alkaline diluent drinks, an empty rectum, opium in the rectum, pichi, and a few drops of a ten grain solution of silver nitrate carried to the deep urethra. According to Yandell, pichi is especially use- ful in subacute cystitis, and its efficiency is much increased by three pints daily of carbonated Silurian water. For gonorrhoeal tenesmus, pichi is said to be invaluable. Chronic cases :—To sterilize the urine, boracic acid internally in 10 to 20 grain doses, in chronic cases. It is claimed by Drey- fuss1 that internal use of salol is greater in range of utility than injections of antiseptic fluids. Dose 20 to 60 grains a day. Saccharin, in one grain doses, three times a day in water acidulated with lemon juice, is recommended by Hale. In chronic cystitis the bladder is washed out with saturated solutions of boracic acid at 100° F; and, in addition, a dash of mercuric chloride, 1 in 50,000 used. Chronic cystitis has been treated with great success by Mosetig-Moorhof, of Vienna, with iodoform injections. His method of treatment is as follows: The bladder having been previously irrigated with moder- ately hot water, an injection of the following emulsion should be made: 1 Wiener Med. Blatt., Dec' 19, 1889. TREATMENT OF CYSTITIS. 331 IjS,.—Iodoform, ... 50 parts. Glycerin, - - - 40 " Distilled water, - - - 10 " Tragacanth gum, - - 1-4part—M. In the treatment of chronic cystitis Ultzmann believes in efficient washing out of the bladder, with the after-employ- ment of antiseptic or astringent solutions. In washing out the bladder a soft catheter is to be used. In most cases a sim- ple India rubber tube is sufficient, one end of which is slipped over the end of any ordinary syringe. By nipping the tube the liquid can be retained or the syringe refilled without trouble. After micturition the soft catheter or tube is passed and any urine left behind drawn off. Several ounces of luke- warm water are now injected and the catheter is withdrawn a little so that the end is brought to the neck of the bladder. On now opening it the organ is completely emptied. The injections should be continued until the returning liquid is quite clear. The patient should stand during the process, for in this way the sediment is most readily evacuated. After the bladder is washed out antiseptic solutions may be introduced. (See, also, " Catheter Fever.") Solutions used in washing out the bladder. These, as the schoolboy would say, are " too numerous to mention." Three per cent, solution of boracic acid is a favorite; \ per cent, cocaine, \ per cent, resorcin, 1-6 percent, carbolic acid, 5 per cent, sul- phate of soda are used; also, 10 drops tincture of opium in 100 c. c. of water. Astringent injections are \ per cent, alum, \ per cent, zinc sulphate or carbolate, 1-15 per cent, potas- sium permanganate, 2 per cent, tannin, 1-10 per cent, silver nitrate. When the urine is very offensive and strongly alka- line, any of the following may be used: 1-10 per cent, po- tassium permanganate, lukewarm water with a few drops of amyl nitrite, half a liter (one pint) of water containing 3 to 5 drops of amyl nitrite, 1-10 to 3-10 per cent, solution of salicylic acid, \ per cent, creolin solution, 25 per cent, solution of per- oxide of hydrogen. When there is a heavy sediment of phos- 333 DISEASES OF THE KIDNEYS. phates, 1-10 per cent, solution of equal parts hydrochloric acid and carbolic acid, or 2-10 per cent, solution of salicylic acid, or 2 per cent, salicylate of soda. In bacteriuria, 1 in 10,000 of corrosive sublimate. Supersaturated solution of boracic acid may be made as fol- lows: Add to 100 parts of boiling water 15 parts of boracic acid and 1 part of calcined magnesia; let cool. Lavaux has used this solution successfully in chronic cystitis when the ordinary four per cent, solution failed to relieve. In severe forms of chronic catarrh of the bladder it may be necessary to use drainage, the patient lying in bed and the urine flowing off continually through a catheter introduced and tied to the penis. CYSTITIS IN THE FEMALE. Functional Disorder of Bladder or Urethra. Urine normal or nearly Read Cystitis, Urine loaded with triple phosphate and muco-pus. Alkaline in reaction. Great and prolonged ten- esmus. Pain and straining af- ter water has all been voided. Micturition frequent and painful, but relieved when bladder is empty. Treatment:—If the trouble is functional, attend to causes. A displaced womb must be replaced and retained in its proper position; a diseased womb must be cured, rectal trouble relieved, a foreign body in the bladder removed, etc. Chronic cystitis often proves to be a very diffi- cult disorder to treat satisfactorily. Dr. Madden, of Dublin, treats severe cystitis in women by dilating the urethra, which permits cystitis in the female. 333 a continuous outflow of the secretion. This treatment, together with mild washing of the bladder, usually effects a speedy cure. If not, the fundus and neck of the bladder should be wiped with a bit of cotton soaked in car- bolized glycerine and passed through the dilated urethra. The use of cocaine will pre- vent the pain of the operation. In general, before any operative interference is undertaken the urine should be normally acid; this can generally be accomplished by the free use of citric acid in the shape of lemonade or lemon juice and water; the min- eral acids act more slowly, and benzoic acid Figure 25. Flake of amorphous calcium phosphate studded with blood corpuscles. X 400. 334 diseases of the kidneys. is not often well borne by the stomach if administered for too long a period of time. The use of citric acid in one day has been known to remove a thick phosphatic crust on the edges of a vesico-vaginal fistula, or on the wound through the perinseum in lateral lithot- omy. McGuire1 treats obstinate chronic cystitis by drainage and dilatation of the urethra. Symptoms present in a case of cystitis are often but an expression of the organ that there has occurred a lesion or a morbid process at a distance from the part seemingly affected. Anal and rectal inflammation are not uncom- mon causes of cystitis. Resort to dilatation of the urethra will be followed by the best results in cases where tenesmus is an important symptom, and in which the parts around have been contracted and hypertrophied. Faradism with one pole near the uterus and the other over the bladder gives speedy relief. Corro- sive sublimate, 1 to 2,000, will often prove of benefit when no marked organic changes have occurred, the train of symptoms due to sup- puration, fermentation, and the uncleanliness generally. No general rule of application can be laid down in all cases. Some will yield readily, others will defy all recognized methods 1 Canada Medical Record. CYSTITIS IN THE FEMALE. 335 of treatment, and can be cured or corrected only after the most ingenious and skillful operation.1 Dry heat in the treatment of cystitis in the female is advocated by C. Hoyt.2 He uses the apparatus of Dr. Philip Porter, of Cincinnati. The bladder being emptied, a heater is intro- duced into it. The heater is similar in size and * shape to the ordinary double canula catheter, but closed at the point instead of open. An even supply of hot water is furnished by means of the use of a tin vessel arranged on a bracket over a gas jet. CAJHETEEISM AND WASHING-OUT OF THE BLADDER. Whenever the bladder becomes sufficiently distended to produce pain and the ordi- nary remedies fail to give relief, recourse is to be had to the catheter. Before employ- ing a soft catheter, it must be soaked for ten minutes in hot soap-water, and flushed out with it; then it is disinfected with a strong germicide lotion, preferably corrosive subli- mate, from which it must be freed again by another flushing with salt water before it is anointed with iodoformized vaseline for intro- duction. (The salt water should be tepid, and, in 1Med. Record. 2Hahnemannian, August, 1889. 336 DISEASES OF THE KIDNEYS. strength, a teaspoonful of salt to a quart of water. The iodoformized vaseline should be 1:50 in strength.) A simple India rubber tube is preferable for use in cases in which it can be passed. After use, the 'catheter should be again flushed out thoroughly with carbolic or mercu- rial lotion, dried, and put away in a tight box or wide-mouthed bottle. If needed frequently, the catheter should be kept immersed in a nye per cent, carbolic lotion. Before using, however, the adherent carbolic lotion must be always removed by washing in salt water.1 Injections may be made by use of an ordi- nary fountain syringe. Whatever solution be used the temperature of it should be 100° F. when it reaches the bladder, say 105° to 110° in the syringe. In giving injections an ounce or two only of fluid at a time should be used first, and pain should not be inflicted. The water, after remaining in the bladder for a few moments, should be allowed to run out. It will bring with it at first whatever substance is mixed with the urine— always mucus—sometimes pus and mucus. The injection should be repeated until the water runs away clear. After a time there will either be an improvement in the bladder itself, or it ^erster. CATHETERISM of the bladder. 337 will have grown accustomed to injections, when larger quantities of water, and often of much higher temperature, maybe introduced.1 Catheter fever: In cases of chronic retention of urine, death sometimes results from removal of much urine. According to Klophel,2 in operations for the relief and cure of chronic retention of urine, the complete evacuation of all the urine at first should not be permitted, but rather the with- drawal of a few ounces, and the immediate injection of a solution of boracic acid, in vol- ume equal to one-half of quantity of urine withdrawn, lessening at each succeeding injec- tion the quantity of fluid thrown in, and increas- ing the amount of urine withdrawn. Thus, by regular gradation the bladder is emptied, and the circulation, in its abnormal walls, is accommodated by degrees to the new order of things. The same may be said of the ureters and of the kidneys. It must be carefully borne in mind that in nearly all chronic diseases of the lower urinary tract, the kidneys become involved in time. ( See " Suppurative Nephritis.") TREATMENT OF HEMORRHAGE OF THE BLADDER. Rest as in renal hsematuria, with cold appli- 1 i"an dell, in Amer. Pruct. and Neivs. 2 Therapeutic Gazette, 1890, page 160. 33-s DISEASES OF THE KIDNEYS. cations to the hypogastrium with the remedies Hamamelis, Geranium, Ergot, Hydrastinine hydrochlorate, etc. Empty the bladder with a thick Nelaton catheter and inject cold water or ice water, till the bleeding ceases.1 In severer hemorrhages, when the bladder is filled with blood clots and is distended, pro- vided the patient can void urine still, and there is not retention, it is not necessary to interfere, for after a time the bleeding ceases, the blood clots cause catarrh of the bladder, the urine becomes alkaline and dissolves them. The patient should be kept perfectly quiet, narcotics being used together with ergot internally. If, however, the clots cause retention then the bladder must be emptied by an evacuation- catheter and astringents applied locally. If the bleeding still continue, a thick elastic catheter with large openings must be introduced and fastened, the open end dipping into a-5 per cent. carbolic acid solution. Every ten minutes injections of cold water are to be made. In long continuing hemorrhages, as in new growths, etc., daily injections of silver nitrate 1:500 should be used. When the patient be- comes less sensitive, 1:200.2 In all cases of intractable cystitis, bear in mind the possibility of stone in the bladder. 1Ultzmann, Krankheiten der Harnorgane, Vienna, 1888, p. 27. 2Ultzmann, op. cit. p. 28. SUPPl' RATION IX THE NECK OF THE BLADDER. 339 Failure to detect presence of stone by sounding should lead to the use of the cystoscope, if this instrument has not been thought of before. Post-mortem examinations often reveal stone in the bladder when the surgeon has during life been unable to detect it by sounding. SUPPURATION IN THE NECK OF THE BLADDER. Etiology:—Usually post-gonorrhceal, but also from unknown cause. It is of help in the diagnosis, if the urine during one micturition be voided into two glasses, and it be observed whether that in the first glass be more turbid than that in the sec- ond, etc. The albuminuria noted under " Suppuration in the Neck of the Bladder," Table X., disap- pears if the tenesmus be overcome by adminis- tration of narcotics. Inasmuch as the urine in cases of suppuration in the neck of the bladder (prostatic urethra) often contains more albumin than the pus accounts for, there is danger of mistaking the case for one of nephritis.1 More- over, the small, round epithelial cells from the neck of the bladder being swollen by inflamma- tion, are not easily told under the microscope from altered renal epithelium (Ultzmann). iUltzmann seeks to explain the albuminuria of this condition on the theory that there is hindrance to the outflow of urine from the ureters. 34° DISEASES OF THE KIDNEYS. Hence we cannot always rely on an examina- tion of the urine alone. First. Prove presence of pus in the urine, and find albumin more than a trace, often as much as one-tenth of one per cent, by weight. Prove absence of tube-casts and find none of the well-recognized symptoms of diseases of the kidney parenchyma. Second. Prove absence of chronic pyelitis by finding urine of 24 hours not increased. (Make as many 21-hour collections as possible, the patient beginning on an empty bladder in the morning, rejecting the urine voided on rising the first morning but including that voided the second morning, and ceasing to collect there- after.) Third. Take note of the micturitions of the patient, whether about normal or very frequent and painful. Fourth. Cause him to void the urine into two glasses. (See Table X.) Now, if after some or all of these precautions in observation we find: 1. Pus and possibly blood in the urine, or pus-shreds streaked with blood. 2. Albumin possibly more abundant than pus accounts for. 3. Quantity of urine in 24 hours not increased but less than normal, or very much decreased. 4. Micturitions frequent; every fifteen min- SUPPURATION IX THE NECK OF THE BLADDER. 341 utes or half hour not unusual. Intense pain at beginning and at end of micturition, and exceedingly painful tenesmus with perhaps a slight flow of blood at the close of micturition. 5. Urine in first glass more turbid and con- taining more pus than that in the second. 6. No discharge from urethra. The condition is due to inflammation of the neck of the bladder, and on exploration the max- imum pain will be felt just as the instrument enters the bladder. There may, however, be present in one case both catarrh of the vesical neck and that of the kidney-pelvis. In such a case the pyelitis must have been either primary or secondary, and we must inquire at once for history as follows: Pri- mary pyelitis: history of pus in the urine orig- inally teithout frequency of micturition, tenesmus, etc., followed by pus in the urine with fre- quency of micturition and tenesmus as the process invades the vesical neck; lastly, pus in the urine again without frequency of micturi- tion and tenesmus as the process ceases in the vesical neck but is still persisting in the kid- ney-pelvis. History of pain in the back and of fever. Secondary pyelitis: Acute, has his- tory usually of recent gonorrhoea, stricture, prostatitis, hypertrophy of prostate, or paresis of bladder; chronic, shows great increase of 342 DISEASES OF THE KIDNEYS. 24 hours7 urine, with absence of pain in back and of tenderness. If acute secondary pyelitis exist at the same time with catarrh of the vesical neck, the diagnosis may be difficult as regards the pyelitis, but the vesical catarrh will show itself by increased frequency of urination, tenesmus, and the like. If there is also pain in the back, fever, and the characteristic pus " plugs," short, thick, cylindrical aggregations of pus corpuscles, are found with the micro- scope, the presence of pyelitis may be inferred. Chronic secondary pyelitis in a patient suffer- ing from catarrh of the vesical neck may be suspected by the great increase in 24 hours' urine. Treatment:—In acute cases the hygienic pre- cautions and the remedies, Belladonna, Can- nabis, Cantharis, etc., mentioned under Cystitis, are to be used. Surgical interference not desirable. Chronic cases, as a rule, require surgical treatment, and often resist treatment altogether. Chronic catarrh of the vesical neck occurs in individuals who have practiced masturbation for a long time or are addicted to sexual excesses; it is also found in the early stages of tuberculosis of the prostate or elsewhere. Try warm sitz baths, and, also, full baths, SUPPURATION IN THE NECK OF THE BLADDER. 343 enemata of warm water (95° F.) or chamomile tea, twice or three times daily. In chronic inflammation of the bladder we must discriminate whether the trouble is primary and isolated, or whether, in addition to the bladder, the vesical neck, posterior urethra or prostate is affected. If the latter be the case, as in young men, who, from gonorrhoea, contract chronic vesical catarrh, the neck of the bladder and the posterior urethra must be included in the treatment. This is best accom- plished by introducing a soft catheter or small silver catheter in the bladder and then with- drawing it about an inch, so that the point of the catheter is in the neck of the bladder: with a small syringe the solution is slowly injected. The fluid enters the bladder but does not return into the catheter, as its fenestra is closed by the neck of the bladder. After all has been injected the catheter is withdrawn, and the patient empties the bladder spontaneously. If, on the other hand, the bladder itself is implicated, the fluid is injected through a catheter giving a double current and allowed to return. As the bladder is contracted, but a small portion of its mucous membrane will be reached by the fluid. It is best to inject the fluid through a soft cath- eter, using a syringe held in the hand. When irrigators are used too much fluid is introduced, and if the bladder is weak it may be dilated. 344 DISEASES OF THE KIDNEYS. Only in rare cases of contracted bladder inyoung persons is this method useful. The precaution must also be taken to empty the bladder thor- oughly after each injection. When possible, it is best if the patient stand during the irrigation. For irritable bladder Ultzmann advises luke- warm water with Tinct. Opii, cocaine one-fourth per cent., resorcin one-half per cent., carbolic acid one-sixth per cent. Ultzmann irrigates the neck of the bladder with a short metallic catheter, using various solutions, as carbolic acid, 1 in 500; or alum, zinc sulphate, and carbolic acid (equal parts) h to 1 in 500 of water; or potassium permanga- nate 1-10 to I, zinc sulphate 1 to 3 parts, in 500 of water; or fused silver nitrate 2-10 to 1 part in 500 of water. All solutions to be tepid. If no benefit is derived from irrigation, cauteriza- tion of the prostatic portion of the urethra may be necessary, for which purpose a solution of silver nitrate, 1 in 20, is used and applied by means of a drop-catheter (Ultzmann's urethral injector). Or a small suppository containing nitrate of silver may be deposited in the pros- tatic urethra by means of a porte remede, a catheter-shaped curved instrument, provided with an obturator. Ultzmann directs five sup- positories, to contain in all one-tenth of a gramme of silver nitrate, and begins the treat- ment with half a suppository. If there is annoy- FISSURE IX THE NECK OF THE BLADDER. ing tenesmus of the bladder, iodoform supposi- tories may be used. Finally, if no relief is obtained, the prostatic portion of the urethra may be cauterized with lapis in substance, either with Lallemand's Porte Canstiepie or by use of the endoscope. It must not be forgotten that pyuria occurring in feeble or neurotic individuals is best treated by letting the urethra, bladder, etc., entirely alone and trying change of climate, diet, and surroundings. FISSURE IN THE NECK OF THE BLADDER IN FEMALES. According to Morris,1 fissure of the neck of the bladder is apparently much more commonly met with than fissure of the anus, but seldom recognized. The fissure can be seen by gently distending the urethra with proper specula, and throwing in light with a head mirror. It is a narrow, grayish ulcer, similar to a narrow aph- thous spot in the mouth. The primary symptoms are pain on urination, lasting tenesmus after urination, and frequent urination. Secondarily come catarrhal cystitis and nervous derange- ments. The ulcer may be caused by the com- pression of folds of urethral mucous membrane by a uterus out of place, from a scratch by a passing bit of gravel, or it may be simply microbic, as the aphthae of the mouth are now known to be. xNew York Med. Jour., Feb. 15, 1890. 346 DISEASES OF THE KIDXEYS. Treatment consists in dilating the urethra slowly with the finger, to accomplish the same end as when we stretch the sphincter of the anus for fissure in that locality. Immediately after urination a few drops of a five per cent, cocaine solution injected at the neck of the bladder will at once control the painful tenesmus. The wool tampon for the vagina will give a feeling of great comfort and lessen tendency to spasm of the bladder. Absorbent cotton should never be used for the tampon, because when it became stony in a few hours it irritates the bladder just as it usually does the uterus. The above treatment failing to cure, the blad- der should be opened to give the urethra rest. This is best done by introducing a Sims uterine dilator through the urethra, pressing the blad- der-wall backward, and then slipping a scalpel through the wall between the blades, entering from the vaginal surface. In one aggravated case recently, Morris opened the bladder above the pubes and poured into it, twice daily, an ounce of a mixture of boroglyceride and gly- cerin. Boroglyceride and glycerin is the best thing for any sort of hypertrophic catarrh. Clots in the bladder should be digested out with pep- sin. If the bladder is acidulated with citric acid, pepsin will digest the thick tenacious muco-pus quickly, and give patients great relief. In old cases with contracted bladder, expansion HEMORRHAGE FROM NECK OF THE BLADDER. 347 daily with Davidson's syringe and warm boric acid solution will gradually enable the bladder to hold a pint or more of urine. HEMORRHAGES FROM NECK OF THE BLADDER AND PROSTATE. Acute inflammations, erosions, and fissures are the chief causes. The bleeding may also be due to concretions in the prostate; prostatitis, injuries, or wounds of the prostate and vesical neck, and new growths are sometimes the causes. Hemorrhage from prostate ami vesical neck is characterized by absence of pain, except when urinating, and of general symptoms, absence of vesical irritability and of urethral disease, lack of tenderness on pressure upon the hypogas- trium and perinseum, occurrence of hemorrhage chiefly in the morning, and after stool; absence of renal symptoms. Clots are fusiform, that is, wider in the middle than at the ends, and may escape with the first gush of urine. (Lydston.)1 Catarrhal ulcered ions of neck of the bladder: Usually after gonorrhoea; hsematuria shows itself toward the close of micturition. Varicose condition of neck of the bladder: Sud- den and profuse hsematuria, so that the patient in one or two days is quite ansemic. Hemorrhage from the prostatic urethra and vesical neck should be treated as follows: ^Medical Era, Dec., 1887, p. 364. 34& DISEASES OF THE KIDNEYS. If the hsematuria, as is often the case, is brought on by straining at stool, give Euony- mine or laxatives in general which act on the liver; if there is urethral stricture, this should be attended to; finally, such remedies as Hama- melis, Ergot. The diet should be simple, bread and milk alone being advisable. In some cases of hemorrhages from the vesical neck the spasm of the bladder is so great that narcotics may be required. If the hemorrhage is due to a fissure, astringent injections. In very profuse hemorrhages from the neck of the bladder, introduce a soft cath- eter and allow it to remain. PROSTATIC DISORDERS. Irritability and inflammation of the prostate are frequent between the ages of 25 and 50; 33 per cent, of all men over 55 have enlarge- ment. In all cases of chronic urinary trouble introduce the finger into the rectum, and at a distance of one and one-half inches from the anus the prostate, if healthy, is felt in the median line as a body about one and one-half inches long and as broad as it is long. Prostatic Hypertrophy:—-The symptoms are as follows: Difficulty in emptying the bladder, the urine escaping in driblets; there is frequent desire to pass water, especially nights and mornings; the character of the urine is usually PROSTATIC DISORDERS. 349 unchanged, and there may be slight pain before passing it, but usually none afterwards. These are the early or premonitory signs of hyper- trophy, and unless relieved increase in severity as the enlargement progresses. The patient reaches a stage where he finds it difficult to hold the water; the desire to pass it is impera- tive, and must be immediately attended to. This condition is produced by over-distention of the bladder, in which the urine accumulates on account of that viscus not being entirely emptied.1 Prostatic Congestion:—The symptoms are, complete retention of urine, accompanied by bloody urine, an increased temperature, quick pulse, and more or less pain and uneasiness in the region of the bladder. If the urine is not speedily evacuated through the catheter, putre- faction ensues, the tongue becomes dry and covered with a brown coat, the pulse becomes faster and weaker, and the patient sinks into a typhoid condition, which may end fatally. Old men are more liable to these attacks than young men. It is not improbable that suppurative nephritis may rapidly follow in con- gestion occurring suddenly in old urinary cases. Chronic Prostatitis:—The symptoms are: a frequent desire to urinate, with a feeling of 1 Therapeutic Gazette, 1889, p. 375. 35° DISEASES OF THE KIDNEYS. weight and heat in the perinseum, and a pain extending the whole length of the passage to the tip of the penis At times a few drops of blood will follow the water, and generally the patient suffers from frequent nocturnal emis- sions. The urine is cloudy, and deposits a muco-purulent mass after standing for a time. A rectal examination shows the prostate tender to the touch, and more or less enlarged. Berkeley Hill1 describes the use of the endo- scope in the diagnosis of prostatitis and tubercle of the prostate. His observations on tubercle of the prostate are of special interest. Prostatic Irritability:—In this condition there is always more or less complaint in regard to the urine, which feels hot, with a slight smart- ing or stinging sensation after passing; there is often a feeling as if the bladder was not entirely evacuated, which is true, as a very slight enlargement of the floor or middle por- tion of the gland, as previously remarked, inter- feres with the complete emptying of the bladder, and causes the last drops to dribble away after the stream of urine has ceased. This symptom is one indicative of the beginning of chronic hypertrophy. A still more frequent symptom of hyper- sesthesia of the prostate is the oozing out of a 1 Chronic Urethritis and Other Affections of the Urinary Organs. PROSTATIC DISORDERS. 351 thin, transparent discharge, which is increased by any sexual excitement. This discharge, mostly composed of prostatic mucus, is not only very annoying but often alarms the patient, who mistakes it for semen.1 The Urine:—As already shown in Table XY. there may be various alterations in the character of the urine. Presence of prostatic cylinders, amyloid bodies, and Bottcher's rhomboidal, transparent crystals may make the diagnosis plainer. Treatment:—Patient to be careful about excesses of all kinds and to live on simple nutritious diet, sometimes milk, avoiding highly spiced food, stimulants, etc., etc. Care must be taken in regard to exercise, which in irrita- ble prostate should be moderate only. Reme- dies internally as already described. Rectal suppositories are of value in prostatic hyper- trophy. Introduce every night at bedtime a rectal suppository containing potassium iodide, belladonna, iodoform, and mercuric nitrate. At the same time ointments containing various substances may be applied to the prostatic ure- thra by the instrument of Lallemande-^por/e caustique. The substances thus used are mer- curic chloride, iodoform, belladonna, ergotin, cocaine, etc., etc.2 1 Therapeutic Gazette, 1889, p. 371. 2Therapeutic Gazette, 1889, p. 377. 352 DISEASES OF THE KIDNEYS. McGill, of London, opens the bladder above the pubes, and removes with scissors and for- ceps that portion of the enlarged prostate which prevents the outflow of urine. URETHRITIS. If the suppuration is in the urethra anterior to the compressor urethrse, there is never tenes- mus or any uncontrollable desire to urinate, but merely a severe smarting sensation as the urine passes along the urethra. In acute urethritis the mouth of the urethra is usually swollen and reddened. Treatment:—Catarrhal urethritis is usually of but short duration and often disappears in a few days if the causes of it, as catheterizing, masturbation, etc., are removed. GONORRHEAL URETHRITIS. In cases of urethritis, obtain some of the pus which oozes from the meatus, and examine for the gonococcus (Fig. 22) in order to determine whether the condition be due to gonorrhoea or not. If the urine be examined for the micro- coccus, freshly voided urine must be obtained, quickly filtered, and the pus on the filter exam- ined as follows: A drop is pressed between two cover-glasses, spread out to a thin film upon a slide, and to it are added a few drops of a concentrated aqueous solution of methyl blue, GOXORRHCEAL URETHRITIS. 353 which is washed off in half a minute, and the cover-glass pressed between folds of filter paper dried over the alcohol flame and examined in Canada balsam (dissolved in turpentine) or in cedar oil. In examining with microscope re- move the diaphragm from the microscope stage and use condenser, thus causing colored objects to become more prominent. Figure 26. So called "clap-thread '"■ around a hair. X 150. The gonococcus shows unmistakable charac- teristics, such as tendency of the specific cocci to aggregate; to be present wholly within the pus and epithelial cells, or wholly without them, never half in and half out, nor ever in the nu- cleus. After being stained with methyl-blue, a 354 DISEASES OF THE KIDNEYS. solution of 5 minims of acetic acid in 6 drachms of water does not decolorize, whereas alcohol causes decoloration more rapidly than in case of other organisms. Subsequent to gonorrhoea the so-called "clap threads" may be found in the urine. Figs. 26 and 27. In cases where they are found and there is no history of gonorrhoea, prostatic irri- tation is said to be shown. Figure 27. So-called "clap-thread " and a hair. X 400. CHRONIC URETHRITIS. Inasmuch as this condition is usually dependent on gonor- rhoea it will not be considered here. Berkeley Hill makes observation of the pathological condition by use of the endoscope, treating granular areas with silver nitrate solu- tions and indurated areas by gradual dilatation. HOW TO EXAMINE A PYURIC PATIENT. EXAMINATION OF THE PATIENT WHEN PUS IS FOUND IN THE URINE. I. The examiner is to cause the patient to void urine into two glasses during one micturi- tion, and to have the last few drops caught in a third glass. Hints: Urine in first glass most turbid. Both glasses equally turbid. First glass turbid, second clear. Last few drops very turbid. Last few drops bloody. Urethritis or Prostato- Urethritis. Cystitis. Suppuration in the neck of the bladder. Cystitis. Suppuration zn the neck of the bladder. Tuberculosis. Chronic Prostatitis. II. The examiner is to note the manner in which the urine is voided. Hints: In driblets. Sudden stoppage. In spurts. Retention, in children. Prostatic hypertrophy. Stone in the bladder. Spasm of the bladder. Concretion in urethra. Look for swelling of the testicle (tuberculosis, when no gonorrhoeal history), prolapsus ani, priapism (uricamia in children). III. The examiner is to note if there is any ■pain, and if so where and when. 356 DISEASES OF THE KIDNEYS. Hints: Pain in the end of the penis. Pain in whole urethra as urine courses along. Pain in whole urethra with weight and heat in perineum. Pain when bladder is full, severe in middle of urination and increasing till bladder is ■^mpty, then relief. Pain at beginning and at end. Pain prolonged after urine is voided, tenesmus, etc. Pain paroxysmal and lanci- nating, but urine does not scald. Calculus. Urethritis or chronic pros- tatitis. Chronic prostatitis. Tuberculosis. Swppuration in the neck of the bladder. Cystitis. Spasms of the bladder. CHAPTER XII. Oliguria and Anuria. Incontinence of Urine. Motor Neuroses. Oliguria is the discharge of urine much less in quantity than the normal for 24 hours. If it is a manifestation of Bright's disease, treatment should be that already described, pp. 118 and 125. The quantity of urine is often much decreased, not in Bright's disease, in debilitated women and lithsemic men. In the former case the treatment must be purely general and in the way of supporting strength. In the latter case, the general treatment for uricsemia is to be adopted. Anuria (voiding of no urine at all) may be due either to suppression (arrest of secretion in the kidney) or to retention within the bladder. Suppression of urine occurs in children after " catching cold," in acute nephritis, and in any condition where there is renal hyper a- mia, as in poisoning by cantharides, turpen- tine, lead, mineral acids, and irritants. Sup- pression may follow introduction of the cath- eter for the first time. It occurs a few hours before death from acute inflammatory affec- 357 358 DISEASES OF THE KIDNEYS. tions, as typhus, small pox, etc. Also in con- ditions of shock or collapse. Treatment of suppression depends on the cause. If due to acute nephritis, see pages 118 and 125. In renal congestion, Terebinth should not be forgotten. If due to taking cold, Aconite. Digitalis in sudden suppression from cold or damp, or after scarlatina. Apocynum, Cantha- ris, Eupatorium, Hellebore, Nitric Acid may be indicated. Cantharis when there are inflamma- tory symptoms, etc. Apocynum and Hellebore when there is dropsy. Arnica when due to mechanical injuries. For diet, see page 114. Anuria due to retention is usually gradual. The symptoms are dragging and pain in the region of the bladder; there may be a high fever, and perspiration of urinous odor. The distended bladder is uniform in development and may be felt not only in the hypogastrium but also in the rectum or vagina. If a finger be introduced into the latter, while, with the other hand gentle percussion is made over the hypogastric region, an undulatory motion can be felt. Prognosis in retention:—If the urinary pass- ages are healthy and obstruction sudden, as when calculus blocks the ureter of a solitary kidney, the patient may live from several days to twenty-one days. If, however, there has OLIGURIA AND ANURIA. 359 been long-standing cystitis or pyelitis, suppur- ative nephritis will appear and the patient die in a few days, five or six at most. Death is indicated by typhoid uraemia, sub-normal tem- perature, etc. Hiccough is common. In partial retention from enlarged prostate the case may run a protracted course.1 Treatment of retention:—Except in hysterical cases, the treatment is surgical. In hysterical cases, the various remedies for the general con- dition, as Ignatia, the valerianates, bromides, etc., etc. In other cases the cause must be ascertained: impaction of calculus is a frequent cause. (See uRenal Calculus.") If due to stricture or enlarged prostate, instrumental relief must be given at once. The catheter must be promptly used. Vesical calculus to be removed as soon as detected. INCONTINENCE OF URINE. Inability to hold back the urine is a condi- tion which may occur in very different affec- tions of the urinary apparatus. According to Townseed the causes are as fol- lows :2 I. Reflex. (1.) Increased quantity of urine: (a) diabetes, (b) nephritis. 'Ralfe, op. cit. 2Ann. of the Univ. Med Sci., 1888, p. 489. 360 DISEASES OF THE KIDNEYS. (2.) Irritant quality of urine: (a) increased acidity, (b) uric acid crystals, (c) calcic oxalate crystals, (d) excess of phosphates. (3.) Vesical calculus. (4.) Hypersensitive state of external geni- tals from: (a) stricture of urethra, (b) phimosis, (c) balanitis or vulvitis. (5.) Anal irritation from: («-) pin-worms, (b) fissure, (c) eczema. (6.) Psychical. (7.) Increased irritability of bladder. II. Atony of sphincter vesicse: (1.) General debility. (2.) Spinal disease. (3.) Acute febrile disease. III. Malformations of bladder or urethra. To 1. 4 may be added hypersensitive condi- tions of the external genitals due to inflamma- tion of the vagina, vestibule, and urethra caused by masturbation. Small polypous excrescences about the meatus urinarius in girls. WHAT TO DO IN CASES OF INCONTINENCE OF URINE. First examine the urine as to its acidity, pres- ence of crystals, sugar, albumin, etc. Next examine the external genitals and anus. Lastly examine the hypogastric region for signs of retention. OLIGURIA AND ANURIA. 36l Beuiedies:—These must be given with an eye to the cause. If diabetes or nephritis be pres- ent, the treatment must be for these conditions. If due to over-acid urine, try Londonderry Lithia Water, Lithium Benzoate, or even Liquor Potassse in small doses (2 to 5 drops in water). If there is an uric acid diathesis, see u Uricao- mia." In cases where there are calcium oxalate crystals, see u Oxaluria." If due to phosphates, see u Phosphaturia." If vesical calculus be the cause (ascertained by sounding or use of cysto- scope), the stone should be removed. If there is urethral stricture, surgical treatment should be invoked: dilatation with sounds. In cases due to phimosis, circumcision, or when the prepuce is adherent, it is generally sufficient to break up the adhesions by stretch- ing the prepuce and removing the smegma. Cases due to balanitis will require Merc. Cor., Merc. Sol., Thuja, and local applications, as Cal- endula; in vulvitis, Arseniciim, Thuja, Mercurius. If there is a polypous excrescence about the meatus, snip it off. Cases due to anal irritation should receive the care of an orificialist. When there are psychical causes the treatment becomes general, with hygienic and dietetic precautions, rest from work, cheerful surroundings, change of air, etc., etc. Where there is increased irrit-. ability of the bladder, Belladonna or Atropine. Among the causes of incontinence of urine 362 DISEASES OF THE KIDNEYS. and of other phenomena of micturition are the various motor neuroses. MOTOR NEUROSES. The motor neuroses of the urinary system are either spasmodic contractions or paralysis. Dribbling of urine after micturition is probably due to spasmodic contraction of the organic muscular fibres of the urethra throughout its whole length. Spasm of the external sphincter shows itself by more or less inability on part of the patient to urinate, though the impulse is frequent. The treatment is the daily passing of large metallic sounds, allowed to remain in from 5 to 15 minutes. Spasm of the detrusors (cystospasmus) is shown by a frequent, though generally painless, impulse to urinate, for the most part only by day, but also during any sleepless nights. The urine is clear, pale, of low sp. gr., neutral or faintly acid, or even alkaline, and increased in quantity. The phosphates appear on heating. If the dis- order is the result of gonorrhoea, we find short, thick shreds from the prostatic urethra. The treatment is to decrease mental work, prohibit sexual excesses, advise change of air, travel, sea bathing, agreeable recreation, etc., etc. Internally, China, Ferrum, Arsenicum, in the lower decimals. In severe tenesmus, mor- phine suppositories. If due to gonorrhoea, sex- MOTOR NEUROSES. 363 ual excess or masturbation, then passage of sounds, use of short urethral catheter, warm rectal injections, and warm baths. Paresis of the bladder is shown by inability to empty the bladder completely. The diagnosis is made by passing catheter immediately after patient has urinated. The amount of urine then drawn off is a measure of the insufficiency of the bladder. Moreover patients complain that they have to wait long before urinating, pressing and straining; when the urine comesi it falls feebly down. There is no feeling of sat- isfaction after urinating. If the paresis pass gradually into paralysis, incontinence occurs, first at night but later becomes constant. The diagnosis between paresis of the sphincter and of the detrusor is made, according to Ultzmann,1 as follows: Paralysis of the Sphinc- ter. Incontinence of urine, early and in the day first. No retention. No distention. No dulness over symphy- sis. No resistance to catheter. Paralysis of the Detru- sor. Incontinence late and in the night first. Retention possible. Bladder distended. Several ringer breadths of dulness over symphysis. Powerful resistance. The urine:—In paresis of the bladder the urine may be normal or neutral, or feebly alka- line, with a sediment of earthy phosphates. lGenito-Urinary Neuroses. 364 DISEASES OF THE KIDNEYS. Diabetes decipiens is sometimes an accompan- iment. Gradually a purulent bladder catarrh comes about. The treatment of paresis is as follows: in light cases when in strong persons slow and infre- quent micturition is established, daily massage of the bladder, regular micturition at short intervals and with use of mineral waters con- taining salts of soda, as Carlsbad; regular exer- cise with cold rubbing of entire body, cold sitz-baths, douching of the perinseum and over the bladder and lumbar region, cold showers on the back immediately after coming out of a hot bath. [Internally, Ultzmann advises quinine, ergot, strychnine. The latter hypodermically, 5-100 of a gramme of strychnine nitrate in 10 c.c. of distilled water, one-half to a whole Pravaz syringeful daily, injected into the skin of the abdomen over the bladder; to be discontinued if muscular twitching, etc., appear.] A thoroughly carried out regular course of catheterization with vulcanized rubber catheters is advised by Ultzmann. After some weeks or months of catheterization electricity may be used, one pole as a catheter-formed electrode being passed into the bladder, and the other placed over the lumbar vertebrse, or introduced into the rectum. Electricity should not be used too early nor at all, if there is purulent pyelitis or nephritis. ENURESIS. 365 In paresis of the sphincter or when this pre- dominates, the electrode need be passed only into the prostatic urethra. Among motor neuroses, we find enuresis (invol- untary evacuation of normal urine in children) often very troublesome. In some cases the urine dribbles constantly night and day. Treatment:—The cause must be ascertained, but in children the following is, as a rule, of help: Cool sponge bath, with tablespoonful of sea salt added to the water every morning. Body briskly rubbed and especially in the region of the spine with a moderately coarse towel. Child to be clad in woollens next to skin and to have warm shoes; it should have as much fresh air as possible in fine weather and be allowed to exercise. But very little meat should be allowed and the quantity of drink should be restricted in the latter part of th3 day especially, no fluid being given after 4 or 5 o'clock in the afternoon. The child should be taken up to urinate late at night and early in the morning, and, if necessary, once during the nighty in each case being thoroughly awakened.1 Remedies:—When there is irritability of the bladder, Belladonna in 10 to 20 drop doses of th± tincture, or Atropine Sulphede, one grain in an ounce of water, given in doses of one drop for each year of the child at 4 and at 7, evenings, so 1W. M. Powell, Annals of Gynaecology and Pediatry, May 1, 1890. 366 DISEASES OF THE KIDNEYS. as to have the pupils dilated during hours of sleep. The dose at bed-time need not be given if the child's pupils are well dilated (Baruch). There are those1 who claim success from belladonna and the bromides in cases where belladonna alone fails. In the case of small, feeble children, great care must be taken in giving atropine. When the case would appear to be due to lack of tone in the sphincter due to general debility, try Rhus Aromatica, especially in nocturnal incontinence of urine in children. Dose, from 4 to 10 drops of the fluid extract four times daily, gradually increased to from 8 to 20 or 30 according to age of child. May be given in a little sweetened water. Or children 2 to 6 years old may take 10 drops night and morning: other children, 15 drops. Its favorable effects may not persist. Rhus Tox. has long been used. Equisetum, Eupatorium Purpureum, Pulsa- tilla and Gelsemium are credited with cures. Liquor Ferri Muriatici is recommended:2 2 drops in a wineglassful of water, tablespoonful every three hours during the day. Ergot and electricity are used in cases of atony of the sphincter. 1 Ann. Univ. Med. Sci., 1889. 2Homoeopathic Recorder, 1889. ENURESIS. 367 In spinal cases, try Strychnine, third decimal. In acute febrile disorders, the treatment should be directed to the febrile condition. If there is any reason for believing that there is congestion of the medulla oblongata, counter- irritation to the back of the neck, high up, in the form of dry cups, scarifications, or blisters. Clinical note: In the Homoeopathic Recorder a case is reported cured by Sulphur 30: patient was a little'girl, five years, with the fol- lowing symptoms: Nocturnal enuresis, agg. during the full of the moon. Craves sweets; fretful; changeable; appetite changeable; don't care for meat or potatoes; urine very strong, staining yellow. Blonde, rosy cheeks, nervous temperament. Ultzmann1 holds that the best treatment is indirect stimula- tion of the sphincter vesicae through the rectum. He uses the ordinary Dubois-Reymond sledge-battery, armed with one element. One pole of the induced current is a metallic pin size of a lead pencil and 7 c. m. long, with a wooden handle, which is well oiled and passed into the rectum. The other pole is an ordinary sponge-holder, which, in boys, is placed on the raphe of the perinaeum, but in girls in the crease of the buttock. The current at first must be very weak and gradu- ally increased. Sittings to be held daily, or every other day, and to last five or ten minutes. Treatment lasts 4 or 5 weeks. The omnipresent antipyrin in two doses of 10 or 15 grains one at 6 and one at 8 o'clock evenings, is said to cure enuresis in two or three days. EXAMINATION OF THE PATIENT IN MOTOR NEUROSES. Impulse to urinate frequent, but more or less 1 Neuroses of the Genito-Urinary System, translated by Gardner Allen, Boston, 1889. 368 DISEASES OF THE KIDNEYS. inability to urinate: suspect spasm of the external sphincter. Dribbling of the urine after micturition: sus- pect spasmodic contraction of the organic mus- cular fibres of the urethra throughout its whole length. Frequent painless impulse to urinate during day and also during any sleepless nights: sus- pect cystospasm (spasm of the detrusors). Long waiting necessary before urinating, with pressing and straining, urine falls feebly down, no satisfaction after urinating: suspect paresis of the bladder. Involuntary evacuation of normal urine in children: enuresis. * CHAPTER XIII. Diabetes Mellitus and Insipidus. Does the urine contain sugar? Try the tests (pages 21 and 22) or especially the following: 1. Haines's1 test:—Make the following test liquid: Pure sulphate of copper, gr. 30; pure water, fl. ounce, £; make a perfect solution and add pure glycerine, fl. ounce, h; mix thoroughly and add liquor potassse, fl. ounces, 5. A perfectly clear, transparent, dark blue liquid should result, which may be bottled and set aside for use. As usually made, it generally throws down a slight reddish deposit upon standing a week or two. This, however, does not affect its value as a test; in using, simply decant the clear liquid from the sediment. Directions for use.—Take about one fluid drachm of the test solution and gently boil it, when no change should take place; now add six or eight drops of the suspected urine and again bring to a boil. If sugar is present, an abundant yellow or yellowish red precipitate is thrown down; if no such precipitate appears, sugar is absent. 1 Practical Direction* for Clinical Urinalysis. 37° DISEASES OF THE KIDNEYS. N. B— The white flocculent deposit thrown down, when non-saccharine urine is used in the above test, consists of the phosphates of calcium and magnesium of the urine, which the alkaline character of the test liquid has precipitated, and it should not be mistaken for an indication of the presence of sugar. In applying the above test, never use more than eight or ten drops of the suspected urine; the use of a larger quantity is liable, at times, to lead to erroneous conclusions. Haines's test has been found to be more deli- cate than that with Fehling's solution. More- over the test liquid is perfectly stable, as Profes- sor Haines has proved by recent successful use of a sample which had been in his possession for thirteen years. The test is sufficiently delicate for clinical purposes and I will not here describe the phenyl-hydrazine test and hosts of others which are at present the subject of so much discussion pro and con. '2. Brucke's test:—freshly precipitated basic bismuth nitrate, 1.5 grams, mixed with 20 c.c. of water, heated to boiling and to it 7 grams of potassium iodide and 20 drops of hydrochloric acid added. This is known as Frohn's reagent. In order to test for sugar proceed as follows: put equal quantities of urine and of water into two separate test-tubes; to the one containing SUGAR TESTS. 371 water add hydrochloric acid till a drop of Frohn's reagent no longer produces cloudiness. Now add just as much hydrochloric acid to the urine as was added to the water, further add Frohn's reagent, and filter. The filtered liquid should not become cloudy on adding either hydrochloric acid or Frohn's reagent. Lastly boil the filtered liquid for a few minutes with excess of concentrated solution of caustic soda or potash, and, if a gray or black color results, sugar must be present. Precautions in testing for sugar with solutions containing copper:—The mixture of urine and reagent must not be boiled too long, or partial reduction may take place due to presence of uric acid, hipfmric acid, urates; much mucus, indican, hypoxanthin, glycuronic acid combina- tions, and much sugar in the urine of nursing mothers may sometimes render the test doubt- ful, especially if too much urine be added and the boiling kept up too long. The test may not succeed at all, especially if peptones be present in the urine. In all cases I set the tube aside for 24 hours before deciding. In urine contain- ing peptones and sugar, the precipitate may not take place till 24 hours have elapsed. Precautious in estimating the quantity of sugar by fermentation:—-The method given in Chapter I., may not prove to be accurate, if the patient have taken some of the newer remedies now in 372 DISEASES OF THE KIDNEYS. vogue. For example, saccharin, and other substances of antiseptic properties, if present in the urine, may retard fermentation in such a way as to render the estimation incorrect. Before making an estimation by the fermenta- tion process, see that the patient does not take antiseptics internally. WHEN TO TEST FOR SUGAR. Examine the urine voided two or three hours after a meal, preferably the principal meal of the day. In mild cases sugar in considerable quantity will be found in the urine voided after a meal, when examination of the 24 hours7 urine may give doubtful or negative results. In cor- pulent patients with lithsemic tendencies, watch the urine carefully for sugar. The onset of dia- betes is often sudden and may escape notice. Do not be too ready to blame a felloic practi- tioner for not detecting sugar. In one case under my observation the urine was that of lithse- mia for six months, except when under treat- ment. Suddenly sugar appeared in the urine. It was invariably found at a certain hour, but not always in the mixed 24 hours' urine. If sugar is found, distinguish between gly- cosuria (symptomatic of some morbid condi- tion other than diabetes) and true diabetes mellitus. Consult the following table: DIABETES mellitus. 373 TABLE XVI. Differential Diagnosis Between Glycosuria and Diabetes Mellitus. Symptomatic Glycosuria. Cases not very common. Sugar in the urine transient or intermit- tent. Very great fluctuations in amount of sugar and amount not heavy. Influence of diet not so marked. Attendant upon some other morbid con- diiion; functional derangement of the liver, result of plethora, gouty ten- dencies, conditions of debility or after diphtheria, blood poisoning, prolonged hi. tation, severe bodily and mental exh u-tion, in weakness of old age. In wonun at "change of life." Curable. Prognosis favorable in acute cases; unfavorable if tendency shown to become permanent and to pass over into confirmed diabetes mellitus. True Diabetes Mbllitus Common. Sugar persistent. Fluctuations not so great and amount of sugar excreted heavy. Diet exerts marked influence on amount of sugar. No other morbid condition necessarily present. Relapses when restrictions of diet are relaxed. Prognosis in general unfavorable; when uncontrolled by diet and medication. fatal within two years; mild forms may become suddenly aggravated and severe forms milder and stationary for a considerable period. Early recognition of diabetes mellitus: when- ever a patient passes more water than usual or is more thirsty than his fellows without apparent cause, the urine should be tested for sugar at once. If sugar is found in abundance and the quantity of urine ranges from six to twelve pints, the specific gravity from 1028 to 1045, the reaction highly acid and acidity increased by ex- posure to the air, the case should be at once re- ferred to the table just given. In cases where the urine has not been examined but bodily debil- 374 DISEASES OF THE KIDNEYS. ity is noted, the patient may notice whitish, sticky stains on his trousers, stockings, or boots which should direct his attention to his urine. The thirst of patients having diabetes mellitus is aggravated by starchy and saccharine food, and alleviated by repeated sippings of water, rather than by drinking large amounts at once. If sugar is found in the urine, but there is neither weakness, thirst, nor excessive micturi- tion, the disorder is probably glycosuria rather than diabetes mellitus, and especially in urines of specific gravity below 1020. "Cures" are most frequent in just such cases. Mild forms of true diabetes render the diagnosis often doubtful. Diabetes Decipiens:—This term has been applied to a certain form of diabetes mellitus in which the urine contains sugar, but the quan- tity of urine is normal or below normal. The following analyses illustrate cases of this nature: Case 1. Volume of urine in 24 hours, 625 c. c. Specific gravity, 1038. Urea per litre, 60 grammes. Urea per 24 hours, 38 grammes. Sugar per 24 hours, 13 grammes. In a second analysis I found urea 30 grammes in 24 hours, phosphoric acid, 2h grammes. Patient, male adult, in fairly good general health. DIABETES DECIPIENS. 375 2d. 3d. 4th. 5th. 1620 1530 1320 1125 1040 1040 1039 1034 .... 16 14 20 24^ 18 22^ Case 2: 1st analysis. Urine in 24 hours. 1080 c. c. Specific gravity.. . 1040 Urea, per litre......... Urea, per 24 hours --- Phosphoric acid per litre................ .... 1.45 1.37 2.15 Phosphoric acid per 24 hours............ ___ 2.21 1.7 2.41 Sugar, per litre.... 64 gram. 61 67 ............. Sugar, per 24 hours 76 gram. 100 92 82 35 Patient, female, adult, losing flesh slightly and complaining of debility. The first analysis shows that a considerable quantity of sugar may be present in urine below normal in 24 hours' volume. Case 3: Urine in 24 hours................. 1040 c. c. Specific gravity....................1023 Urea, per litre..................... 17 grammes. Urea, per 24 hours................. 18 a Phosphoric acid, per litre........... 1.10 Phosphoric acid, per 24 hours....... 1.16 Sugar, per litre..................... 10.5 Sugar, per 24 hours................. 11 Patient, a pregnant woman, who went to full term, but child was still-born; next pregnancy, sugar less, labor normal. What to do in case of diabetes mellitus:—The quantity of urine in 24 hours should be collected as often as possible and measured, the specific gravity taken from time to time, and the quan- tity of sugar voided estimated. The only accur- ate method by which we may judge correctly 376 DISEASES OF THE KIDNEYS. of the effect of our remedies, diet, and general treatment is by continued and systematic exami- nation of the urine, and especially for the quan- tity of sugar, together with frequent weighing of the patient. If the case is stationary, the patient not losing weight and the amount of sugar in the urine not increasing, the condition may be reckoned, in absence of distressing symptoms, fairly good. Two forms of diabetes are usually recognized—one, the severe, in which the amount of sugar may be large, even 4 per cent., but in which the sugar is reduced more or less by strict diet: another, in which the per- centage of sugar is less, and the sugar disap- pears entirely when the patient is put on a diet, but returns again when a mixed diet is resumed. The severe form may become milder, and the mild form much more severe. Clinical method of estimating sugar with Fai- ling's solution:—Tyson1 proceeds as follows:— One cubic centimeter of Fehling's solution is diluted in a large test-tube with four cubic cen- timeters of distilled water, and boiled as described for qualitative testing. Its purity being thus ascertained, 1-10 cubic centimeter of the sus- pected urine is added from a suitably graduated pipette. Heat is then reapplied, the precipitate watched, and then another 1-10 added, the 1 Practical Examination of Urine, Gth Edition. SUGAR TESTS. heat again reapplied, until it is found, after proper subsidence, that all the blue color is removed from the cubic centimeter of Fehling's solution. If, in doing this, 1 c. c. of urine has been added, it will have contained just half of one per cent, of sugar. If more than 1 c. c, it will have contained less than a half, but more than one-quarter per cent. If exactly 2 c. c. are used, it will have contained exactly one-quarter per cent. If, on the other hand, but half a cubic centimeter is used, it will have contained 1 per cent., one-quarter of a cubic centimeter, 2 per cent., and so on. If the proportion of sugar is large, as indi- cated by the specific gravity or qualitative test, the urine should be diluted with a definite pro- portion of water, and this regarded in the esti- mation. Fehling's solutionis made as follows:—(a) Take pure sul- phate of copper in crystals* (preferably prepared by recrystalli- zation a few days previously), roughly powder, press between folds of dry filter paper, and weigh ofF34.639 grammes. Dis- solve in moderately warm distilled water, and dilute the solution to 500 c.c. at the usual temperature, the solution being then kept in a well-stoppered flask. (b) 173 grammes of Rochelle salt—sodium potassium, tartrate—in pure crystals, are dissolved in 100 c. c. of a solu- tion of caustic soda of sp. gr. 1.34, and diluted to 500 c. c. with distilled water. This is preserved in a stoppered bottle, the stopper being smeared with paraffine so as to exclude the air. For using the solutions, exactly equal volumes of both are mixed and measured off with a pipette. On agitating, a 37§ DISEASES OF THE KIDNEYS. deep-blue liquid is obtained, of which 10 c. c.=0.05 gramme grape sugar.1 EELATION OF UKIC^MIA TO DIABETES MELLITUS. It has frequently been remarked that some mysterious rela- tion seems to exist between uricasmia and diabetes mellitus. In one of my cases there were the usual manifestations of uri- caemia in the urine for five or six months, when, suddenly, sugar appeared in the urine, during an indisposition, and since that time can be found persistently, but only at a certain time in the day, in the afternoon about four. THE PEOGNOSIS IN DIABETES MELLITUS. It is probable that there are three kinds of diabetes: First, "lean diabetes," so called, sudden, severe, and rapid, in which the prognosis is unfavorable. This form is thought to be accom- panied by lesion of the pancreas. Second, fatty, or constitutional, diabetes, which is an accompaniment of other patholog- ical states, and in which the prognosis is better. Lastly, traumatic, or nervous, diabetes, fol- lowing nervous perturbation, traumatism, or shock; prognosis fairly favorable. In general terms the prognosis is more unfav- orable in young people than in the old. Mild cases sometimes suddenly become severe, and cases severe in the onset may grow milder. If, on modified diet and appropriate therapeutic agents, the patient appears about as well as 'For volumetric determination of sugar .see auy of the various Manuals, as Tyson, MacMunn, etc. PROGNOSIS IN DIABETES MELLITUS. 379 ever, both mentally and physically, and, although the urine contain sugar, the 24 hours' volume is normal, the chances are in favor of some years of life—six or more. If there is only a tem- porary improvement from diet and therapeutic means, and the patient becomes both physically and mentally weak, the chances are that life will not be prolonged beyond a few years at most. Preynier claims that in diabetics in whom the tendon reflex is retained, surgical affections take a normal or slightly abnormal course, other- wise the prognosis is more unfavorable. Unfavorable conditions arising in the course of diabetes mellitus.—Sugar is not controlled per- ceptibly by diet and medication; extreme weak- ness; lower extremities oedematous; tongue red, raw, and glazed; mouth and throat covered with aphthous patches; uncontrollable diarrhoea; acute inflammatory affection of the lungs, or, earlier in disease, chronic pneumonia. Sudden death from diabetic coma possible. The urine, etc., in diabetic coma.—Examine the urine from time to time for extreme acidity, accompanied by sudden and unaccountable diminution in quantity of urine and in amount of sugar, especially if comatose symptoms have already set in. Odor of acetone (chloroform and acetic acid) in breath and urine of patient is noticed. Albumin in small quantity usually, but not invariably, found. ^8o DISEASES OF THE KIDNEYS. Early recognition of eliabetic comet.—This is very difficult, and, in some cases, impossible, but it may be said in general that any sudden improvement in objective signs not confirm eel by subjective sensations on part of patient should put the physician on his guard; reduction in the excessive appetite to below standard for healthy person; unexpected and unexplained loose movements when constipation has previously been the rule; peculiar acetone odor to breath already described; acid eructations and nausea, with or without vomiting; slave of general pros- tration and disinclination to exertion; tendency to drowsiness, during the day, and great despon- dency; attacks of intense vertigo, frontal head- ache, neuralgic pains; accelerated pulse, with or without decrease in volume. After variable period of indefinite symptoms like the above, the patient will complain of afeeling of depression, is restless at night, eats nothing, has colicky pains, vomits matters sometimes having acetone odor, has sense of constriction about thorax, causing deeper breathing than usual; mental condition varies from excitability to mild, talk- ative delirium, alternating with drowsy or stupid intervals. [Gastro-intestinal derangements seem to stand in causal relation, and coma may follow any unusual strain on the digestion, as also after great fatigue, as of a railroad journey. If a PROGNOSIS IN DIABETES MELLITUS. 3§I sudden onset of nervous symptoms is noticed when the patient has been put on a diet, it should be relaxed.] Whether or not sugar has been found, try the ferric chloride reaction, as follows : Add a few drops of a solution of ferric chloride to the urine in a test-tube, and, if from excess of phos- phates, the iron is precipitated in sufficient quantity to obscure the reaction, filter the con- tents of the tube and add a few more drops of the reagent to the clear fluid; if diacetic acid be present, a coloration results varying from a light claret to an opaque reddish brown, and dissi- pated by heating. When the above reaction is obtained, further test the urine for acetone. Ralfe's test for acetone is as follows: Boil 20 grains of potassium iodide in a fluidrachm of liquor potassse; then float a fluidrachm of the suspected urine on the former. Where the urine comes into contact with the hot alkaline solution a ring of phosphates is formed, and, after a few minutes, if acetone or its allies are present, the ring will become yellow and studded with yellow points of iodoform; these in time will sink through the ring of phosphates, and become deposited at the bottom of the test-tube. Freshly-voided urine to be used. In general, if the ferric chloride reaction is obtained, it is a sign that the diet is too strict, and that it should be relaxed. In one class of 3^ DISEASES OF THE KIDNEYS. cases no evidence of acetone is to be had, but in another acetonsemia is plainly marked. There may be acetone in the urine without diabetes, and the case is not necessarily fatal, but no operation should be hazarded (Churton). Many of the drugs now given internally yield reactions in the urine with ferric chloride, which should not be mistaken for the diacetic acid reaction: for example, antipyrine gives a reddish color, salicylic acid a violet, thallin a purple, kairin a brownish-red, tannin a bluish-black. SYSTEMATIC METHOD FOE THE CUEE OF DIABETES MELLITUS. I regard it as not now (1890) impossible that certain mild cases of diabetes may be cured, provided the patient be willing to go into "train- ing for it "—to use a sporting phrase. There is very little hope, however, of anything beyond amelioration if the patient, "hasn't time" to attend to the particulars of diet, regimen, etc., which I shall specify. I. Diet:—I have reduced the daily quantity of urine from 12 pints to 6 in three weeks by the following diet1 alone, without other measures or use of remedies: [TJie diet should be adopted gradually, not too suddenly, for fear of albuminuria and serious ursemic symptoms. The patient may begin, for example, by cutting off potatoes first; then, hi a tTliat of Austin Flint, Jr., as modified by the author. CURE OF DIABETES MELLITUS. 3§3 week or so, desserts made of flour and sugar and sweet fruits; next, all bread and cake made with ordinary flour and sugar.] Shell-fish and fish:—Oysters cooked in any way without milk or flour. Clam water. All kinds of fish, but sauces should contain no flour. Soft-shell crabs and fish roe for those with whom they agree; the same may be said of fish balls (made without potatoes or flour), shrimps and craw-fish. Soups:—Consomme (beef, veal, chicken or turtle), with asparagus points, okra, ox-tail, turtle, terrapin, oyster or clam, but all without flour or milk; mock turtle soup, mullagataw- ny, tomato, gumbo fillet. Beef-tea. Meats:—Beefsteak (with or without fried onions, according to digestion), broiled chicken, lamb chops, tender mutton chops, roast beef, roast mutton, game (for those with whom it agrees). Tongue, sweetbreads, lamb fries. Poultry should not contain dressing made of bread or flour; currie should not be thickened with flour. No liver allowed. Vegetables: — Lettuce, spinach, cauliflower, cabbage, tomatoes, radishes, oyster plant, celery, onions, string beans, water cresses, mushrooms, asparagus tops. (Those in italics should not be given to patients whose digestion is weak.) Relishes:—Pickles, sardines,anchovies, olives. 384 DISEASES OF THE KIDNEYS. (Not to every patient, but according as they agree.) Eggs:—Poached, scrambled with a little chipped beef, soft boiled; carefully made ome- let or ham omelet in small quantity, eaten when warm. (In some cases omelets do not agree.) Substitutes for siveets:—Brandy peaches, with- out sugar; wine jelly, without sugar; kirsch and rum jellies, without sugar; glycerin, saccharin. If saccharin is used with tea or coffee, add it before milk. A single grain suffices for a cup of coffee. Too much saccharin should be avoided. Many do not like it, and in some it causes serious gastric troubles.1 Miscellaneous:—Butter; cheese, if not too con- stipating; salads, except potato; lean patients, whose digestion is good, may take consider- able fat. Sauces to be made without flour or sugar; if to be thickened, use gluten flour. Desserts:—Blanc-mange, made of white of eggs, beaten up and flavored with vanilla, sweetened with a little saccharin. One apple, not sweet. A few almonds, hazelnuts, wal- nuts. Cheese, cranberries, strawberries, plums, cherries, lemons ; if stewed, add a little sodium bicarbonate. Bread:—Gluten bread, sparingly used. In cases where the patient is grievously disap- *Ann. of the Univ. Med. Sci., 1889. CURE OF DIABETES MELLITUS. 38 pointed at giving up bread, allow him ordinary bread in small quantity, as a psychical measure. But if the loss in sugar overbalances the psy- chical gain, be sure to cut off the ordinary bread at once. The various gluten and diabetic flours usually contain more or less starch and should be sparingly used but can be allowed in greater (luantity than ordinary flour. (Hoffmeister al- lows at first 100 grammes (2 oz. 3 dr.) of bread daily, gradually reduced to 60 grammes (2 oz.), but no bread substitutes. He recommends 100 to 150 grammes of fat and fat meats daily.) All food should be masticated thoroughly. Drinks:—-Tea, coffee without sugar but with a little cream. If thirst excessive, weak warm tea (with a slice of lemon), to be drunk little at a time. Immediately after meals, dry old claret, Burgundy, dry sherry, Bass' ale or bitter beer, (but no soda water, ordinary beer or sweet drinks) brandy and seltzer, koumis, cream with raw eggs, good spring water not iced. In cases of constipation, sour milk. Tobacco:—One or two light good cigars a day for those who are unable to give up smoking. Effect of the Diet:—If the patient's urine de- creases gradually in quantity and he loses the feeling of languor so often complained of, if his weight remains the same and there are, in gen- eral, no distressing symptoms, the diet is doing him good. If on the other hand the urine 386 DISEASES OF THE KIDNEYS. rapidly diminishes in quantity and albumin and casts appear, the diet should be relaxed for fear of uraemia. Diet for gouty diabetics:—Corpulent plethoric patients with tendency to piles and uric acid gravel and without the usual symptoms of dia- betes may not, though their urine is saccharine, be benefited by the diabetic diet. In such cases the skim milk diet may be used, chiefly for the reason that it keeps the patient in a state of semi-starvation, the natural cure for the effects of habits of gross feeding. II. Rest and Exercise:—After every meal, rest from half an hour to an hour. For exercise, light work in a garden, billiard playing, use of light dumb-bells, moderate rowing, splitting wood, moderate walking, especially up hill, and horse-back riding; in hot weather, driving. All exercise should be gentle, and, in the beginning, even cautious. Passive exercise may be used at first. III. Baths:—I have found the Turkish bath useful especially for fat diabetics. Schnee ad- vises first a Turkish bath, followed by a short stay in a Russian vapor-bath at a temperature not above 100° F. after which the skin is cooled off by a lukewarm shower. The patient is finally allowed to have a secondary perspira- tion on a couch and to rest for upwards of an hour. After twelve baths of this kind he CURE OF DIABKTES MELLITUS. 3,S7 claims that the thirst begins to cease. The patient should drink a cup of beef tea an hour before entering the bath. At home, sponge bathing daily with lukewarm water, quickly followed by rubbing. IV. Residence:—Sleeping rooms should be well aired and ventilated. Houses on high grounds to be selected. Hot, stuffy rooms to be avoided. Open fire-places a desideratum. Temperature of dwelling rooms never below 60° nor above 72" F. Patient should, if possible, sleep in a room adjoining another in which the window is open, the door between being open. The air in dwelling rooms should not be too dry in winter. Water should be evaporated. In the winter, if the patient go abroad he should seek the Riviera, in the summer Carls- bad. The sea shore is better than high alti- tudes. In traveling, caution should be taken about fatiguing journeys. Frequent stops should be made and rests taken. Vestibuled trains to be preferred to the old fashioned coaches. V. Massage and Electricity:—Massage, not too vigorous, may be employed daily between breakfast and dinner. Sclmee advises a weak solution of mercuric chloride in alcohol with a little vaseline to be used in rubbing. In some cases, muscular tone is influenced by ap- plications of electricity. 388 DISEASES OF THE KIDNEYS. VI. Respirations:—Delicate patients to use pneumatic apparatus. In ordinary cases gentle and progressive hill-climbing, with great pre- cautions, is of undoubted benefit. VII. Miscellaneous:—The mouth and teeth should be well cleaned daily, with a solution of chlorate of potassium, 1 in 19, one teaspoon- ful in a pint of water to which a little alcoholic solution of thymol is added. The patient should take extreme care to void all the urine and even to remove any drops that may adhere by use of a soft handkerchief. The skin, if ir- ritated by the last drops of urine, should be pro- tected by vaseline or cold cream. Out-of-door occupations are preferable. Mental strain and business anxiety to be avoid- ed. "Early to bed and late to rise" should be the motto. In case of accidents involving concussion of the brain and followed for considerable time by notable slowness of the pulse, all mental excitement and exposure to excessive heat of the sun should be avoided for a year.1 The patient should if in a warm enough cli- mate, attend out-of-door concerts or places of amusement to keep him as cheerful as possible. Enemata of oxygen gas may prove of service and are certainly worth a trial for the effect of 1A. H. Smith. CUKE OF DIA.RETES MELLITUS. 389 excess of oxygen in the portal blood in prevent- ing excessive formation of sugar. VIII. Mineral waters:—The hot alkaline waters of Carlsbad have, on the whole, the high- est i'eputation in cases of glycosuria. They will not alone, however, cure the disease. Hughes thinks Silica, as found in certain min- eral waters, valuable. Andrew H. Smith thinks the natural Chalybeate waters of value. Aerated water, charged with oxygen gas, is advocated by Le Blond. IX. Remedies:—There is no specific for dia- betes, but remedies are useful for alleviation of the sufferings of the patient. The following are often prescribed: Arsenicum:—In emaciated patients, with great hunger and thirst, pallor, loss of strength, tend- ing to gangrene, dryness of the mouth and throat, watery diarrhoea, dyspnoea on slight exertion. Kreasote:—Heaviness, drowsiness, depression of spirits, head confused and dull; very severe chronic neuralgic troubles. Phosphoric Acid:—Of value when the case is evidently of nervous origin; when there is loss of fluids, particularly seminal; patient is indif- ferent to all tilings; long-lasting diarrhoea. Uranium Nitrate:—Languor marked and gen- eral. Excessive thirst. In cases originating in dyspepsia or digestive derangement. 39O DISEASES OF THE KIDNEYS. Bryonia:—Dryness of the lips and tongue, persistent marked bitter taste in the mouth, invariably aggravated shortly after eating, or even drinking. Quantity of urine not so great, but specific gravity high. Pruritus vulvae. Sleep disturbed and unrestful. Often loss of appetite and marked debility. lactic Acid:—Immense quantities of urine, inordinate thirst and hunger, gastric symptoms marked (acidity, sour burning risings), marked intermittent protrusion of the eye-ball, and great dilatation of the pupil. Morning urine contains but little sugar; after- noon and evening, much. Leptandra:—A case is reported by Laning,1 in which five grain doses of Eeptandra, 3d deci- mal, was found useful. The symptoms were those of portal stasis. The patient complained of an almost constant feeling of emptiness or goneness in the stomach, which seemed to be relieved by food only for a short time, if at all. After eating, he almost immediately was un- comfortable, and at times had a distressing full- ness, which might be present even though he felt the need of food, so that, as he expressed it, he " felt full and empty at the same time." There was a frequent desire to drink, which he resisted as much as possible, for the reason 1Clinique, 1890, p. 227. CURE OF DIABETES MELLITUS. 39I that it also produced the disagreeable sense of repletion. The skin was dry all over the body, and particularly of the face, it being rough and scaly, numerous bran-like flakes coming off on slight rubbing. The nose was red, swollen, and sore, especially on the alae. This symptom was better or worse according as he ate much or little; indeed, it was made worse even by the free drinking of water, a condition that evidently was due to the degree of portal stasis. Heyberger reports a case of diabetes mellitus in a woman 68, cured by Kali Bromatum, second decimal. In cases of venereal origin, especially if hereditary, try Kali BichromicuiueLn&Mere. Cor. Von Mering has recently shown that Phlor- idztn (a glucoside found in the bark of the root of apple trees) causes sugar to appear in the urine. Laning in the Clinique for June, 1890, speaks of the following :— Podophyllum■; — Head dull and heavy, with occasional sharp pains; tongue dry and foul in morning, at other times quite moist; urine vari- able in quantity; stools light colored; limbs often swollen from venous stasis. Aurum Muriaticiim .-—Exceeding depression of spirits; intestinal and vesical catarrh; urine at times turbid from mucus, and of ammo- 392 DISEASES OF THE KIDNEYS. niacal odor. Patient craves sour things and dislikes meat. Hands and feet icy cold. Pal- pitation of the heart common. Mercurius SolnlnUs :—In early stages when there is coldness and clamminess of the thighs, (rest of skin dry) with increased urination. For the gastric symptoms and constipation; much debility. Nitric Acid.—Patient craves fat meat. In early or prodromal stages of diabetes, when there are crops of boils, etc. Graphites : — ltching eruption in the bends of the elbows, and in the popliteal spaces, fre- quent attacks of vertigo; hang nails and brittle- ness of the finger nails. Miscellaneous:—The sands of the sea are hardly more numerous than the various remedies which have been pre- scribed for diabetes mellitus. Among the more modern are the following: pilocarpine, chromate of potassium and corrosive sublimate albuminate, iodoform, sulphocarbolate of .sodium, ergot, arsenic bromide, arsenic and lithia, alkalies, jumbul seeds, iodides of sodium and potassium, antipyrine, thymol, cocaine, morphine, codeine, salicylic acid, phenol, sodium salicylate. Clinical notes • — Pavy gives 5 grains of codeine daily. VOUemin gives belladonna and opium together; \y2 grains extract of belladonna and l/x grain of opium at first. Robin gives 45 grains of antipyrine daily, in 3 doses at 4 hour intervals, as far apart from meals as possible, except when there is albuminuria, then 30 grains in all, without restricting the diet. Then, after a week, discontinues anti- CURE OF DIABETES MELLITUS. 393 pynne and restricts the diet, and so on. If the amount of sugar is not at once reduced, it is useless to continue the anti- pyrine. He associates bi-carbonate of soda with anti- pyine, in proportion of half a gramme of the latter to one of the former. Tyson gives ergot in doses of half a drachm to a drachm three times daily. Dujardin-Beaumetz uses Martineau's remedy (arsenic and lithia), as follows* Before each meal take in a tumblerful of Vichy or Vals water, one of the following powders, adding to the mixture two drops of Fowler's solution: Carbonate of lithia, 3 iiss, divide in chart., No. XX. Saundby gives 5 grain doses of jumbul seeds 3 or 4 times daily. In gouty cases, Ralfe gives 20 grains bi-carbonate of soda, 10 grains phosphate of soda, 5 grains of carbonate of ammo- nia, all taken in a draught 2 hours after food. Waring gives phosphoric acid, largely diluted, for the thirst. Duchenne, for the thirst, gives the following mixture: Potassium phosphate, 2 parts; water, 75 parts. A tea- spoonful three times a day in a little wine or hot tea. Saundby gives opium and potassium bromide. Gardner has used pepsin. Wilson gives 15 grains of sodium salicylate and 5 drops of Fowler's solution, 4 times daily. J. Mitchell Bruce, in very complete and laborious obser- vations, has shown that, after the sugar has been reduced, to the minimum which diet brings about, the best effects are produced bv 6 grains in all per diem of morphine acetate by the mouth, the dose being small at first and gradually increased. Bruce suggests that morphine be given in smaller doses till the amount of sugar daily is but 167 grains, a comparatively safe excretion, (The dangers of the opium habit and the fact that the 394 DISEASES OF THE KIDNEYS, beneficial effects do not last long, are great objections to opium in any form ) Korjensky cured a case by use of strychnine in l-60th to l-16th grain doses. Wolkow gives salol, 25 grains, four times a day. De Heune uses 6 to 10 drops of ergotin, subcutane- ously, daily, to prepare diabetics for cataract operation. Per- manent disappearance of sugar after 6 to 8 weeks' treatment. Jacobi treats diabetes of infants and children by milk diet, salicylate of sodium, 5 to 8 grains, 3 times a day, in Seltzer or Vichy, and one drop or more of Fowler's solu- tion, largely diluted, after meals, dose increased till 2 to 4 drops. Valentine gives kreasote in 10 drop dose-**, three times a day. Phosphorus in doses of l-30th grain, three times a day, is recommended by Squire. Empirical treatment of diabetes mellitus by administration of powerful drugs, is the Louis- iana lottery of modern medicine. We hear of many who draw prizes, but no one can name the lucky combination which will win even in a scanty percentage of cases. COMPLICATIONS OF DIABETES. The symptoms of diabetic coma have already been mentioned in part. Dyspnoea, great excite- ment and wildness, benumbing of the senses, followed by coma, is often the order of symptoms.1 The prognosis is grave. Treat- ment: administration of alkalies. Intravenous 1Ueber Coma Diabeticum, Kirstein COMPLICATIONS OF DIABETES. 395 injection of 8 ounces of a four per cent, solu- tion of sodium carbonate has prolonged life.1 Other complications are albuminuria, phleg- monous and gangrenous processes, erysipelas, pruritus, eczema; various other complications are sometimes noted. Pregnancy and diabetes:—J.G. Brooks2reports a case in which glycosuria (quantity of sugar not given) complicated pregnancy. After induc- tion of labor patient recovered. Dr. Brooks found the diet treatment u worse than useless," and the patient recovered on generous mixed diet. In several cases of pregnancy I have found 150 grains daily of sugar. In one case only have I subsequent history: patient went to full term, and was safely delivered, though of a still-born child. The child in Dr. Brooks' case survived. Furuncles:—An cases of crops of boils exam- ine the urine for sugar. Boils are often found in the initial stage of diabetes. Dr. R. Lud- lam, Jr., reports several cases.3 The treat- ment was diet and Uranium Nitrate, in one case Hepar Sulphur and Phosphoric acid. DIABETES INSIPIDUS. Diagnosis:—Suppose, now, that the patient iDeutsch. Med. Woch., No. 15, 1889. Berlin. Klin. Woch., No. 19, 1888. -Amer. Pract. and News, 1889. *Chnique, 1890, p. 253. 396 DISEASES OF THE KIDNEYS. is voiding much more urine than normal in 24 hours, but that both albumin and sugar are absent (or, if albumin is present in small quantity, there are no casts, and the quantity of urea, phosphoric acid, etc., is normal or above normal): suspect diabetes insipidus. To make the diagnosis certain, find first whether the condition is temporary or perma- nent. Intermittent copious discharge of pale, watery urine, may be due to hydro-nephrosis. Be sure that there are no cardio-vascular changes as in renal sclerosis. Absence of sugar rules out diabetes mellitus. The differential diag- nosis between diabetes insipidus and renal dis- eases depends largely on estimation of phosphoric acid, which, as I have shown, is decreased in Bright's disease, but is normal or increased in diabetes insipidus, form polyuria. There may be phosphatic diabetes, and chlor- ine diabetes. Peptonuria is sometimes an associated condition. Symptoms:—In hydruria the patient feels in poor health, is easily chilled, appetite capri- cious, sinking, gnawing sensation. As a rule alcohol increases the amount of urine. In poly- uria we find debility, languor, loss of weight, neuralgic and rheumatic pains, and moderate thirst. Boils and cataract have been noted. In some cases serum-albumin is found, but no casts at first. I hold that the appearance of DIABETES INSIPIDUS. 397 albumin is an unfavorable sign. In one case, after two years of great debility, in a young patient, with excessive flow of urine and one- tenth albumin, casts appeared and the patient became more or less oedematous, and died. Prognosis:—If the urine is of very low spe- cific gravity (hydruria) and there is no exces- sive discharge of solids, it is possible that the patient may live as long as otherwise, but if there is a large amount of solids (poly- uria) suspect the condition to be a prelude of serious constitutional disturbance, as cancer, tubercle, syphilis. In some cases marked ner- vous disorder or phthisis appears; in others, true diabetes mellitus. Treatment:—In hydruria give nourishing food liberally, and allow patient to relieve thirst at pleasure, taking care to warm the fluids in- gested in cold weather. Thicken the various drinks, as, for example, with a handful of raw oat-meal to a quart of boiling water, with a lemon sliced into it. Warm clothing, woollen preferable. Dry soil. Russian vapor baths, salt water douches. Winter, if possible, in South. In polyuria the diet should be light, and, if urea is in excess, the nitrogenous articles should be limited. Alcohol particularly to be avoided, as also coffee. Vapor baths, followed by salt water tepid douches. Change to dry, bracing climate. 398 DISEASES OF THE KIDNEYS. Warm clothing, early hours, avoidance of fatigue and excitement. Remedies:—Those already mentioned under Diabetes Mellitus. Helonias is of value in polyuria. Apocy- num Cannabinum has been used where there is the u sinking sensation " in the stomach. Citrate of iron, quinine, and strychnine is of use. With those who believe in using powerful drugs, antipyrin is the favorite remedy. Many cures are reported. Dose, 45 to 95 grains daily. Jumbul is also said to be efficacious. Ergot, atropine, and strychnine are also recommended. In children, with hydruria, cod liver oil and iron in some form, as syrup of the iodide. In polyuria, cod liver oil, phosphorus, nux vomica, etc. When there is history of syphilis, iodide of sodium, hydri- odic acid, etc. CHAPTER XIV. Miscellaneous:—Peptonuria.—The Urine in Diseases of the Liver.—The Urine in Dis- eases of the Nervous System.—The Typhoid Fever Reaction.—Aromatic Compounds in the Urine.—Diseases of the Upper Air Pass- ages.—The Urine in Cancer.—Poisons in the Urine. Suppose, now, that neither serum-albumin nor sugar has been found in the urine. Test for paraglobulin, hemi-albumose, and pep- tone. 1. Paraglobulin is found either alone or in excess of serum-albumin; if the latter, the con- dition is probably one of the following: (a) long-standing cases of chronic nephritis, com- plicated with lardaceous degeneration; (b) early stages of scarlet fever nephritis, especially in children; (c) functional albuminuria, associ- ated with marked disturbance of the digestive organs. This condition is also noted in the intense hypersemia following cautharides poison- ing. In rare cases paraglobulin without serum- albumin may be found. 399 400 DISEASES OF THE KIDNEYS. 2. Hemi-albumose is found. This substance has been found in a case of osteo-malacia. 3. Peptones are found: either pus or inflam- matory exudations are being absorbed some- where or young cell forms are being formed in excess along some portion of the genito-urin- ary tract, or albumin is decomposing some- where in the urinary passages. It is well known that peptone is formed as an early pro- duct of the decomposition of proteid matter by bacteria, so that cases of peptonuria cannot always be so easily understood as some authors would have us think. Peptonuria is present in inflammation of the lungs before the crisis, in empyema, pneumonia, suppurative peritonitis, pleural exudations, cancer of the stomach, etc., etc. The tests for the peptones are as follows: Biuret test:—The urine is first to be made alkaline with caustic potash, and then 1-3 drops of a diluted solution of sul- phate of copper are to be added, and if albumin, hemi-albu- mose. or peptone be present, a reddish violet solution is formed. To test for hemi-albumose it is necessary, first, to remove the albumin. For this purpose, to the urine (or to any other fluid to be examined, as the contents of the stomach) 5 to 10 drops of acetic acid and y§ of its volume of a concen- trated salt solution are added, and the whole heated. Then the albumin will be precipitated and should be removed while hot by filtration, while the filtrate is allowed to cool off. If a cloudiness now arise, on the addition of salt solu- tion to the filtrate, then hemi-albumose is present. If too much salt solution be added, the precipitate of hemi-albumose cannot be redissolved by heat. PEPTONURIA. 40I To test iox peptone, 10 c. c. m. [2^ drachms] of a concen- trated solution of sodium acetate and a few drops of a solu- tion of iron chloride are added to 500 c. c. m. [1 pint] of urine until there results a permanent red color, then a caustic potash solution is dropped carefully into this mixture until it is slightly acid or neutral, and the mixture heated. After it has cooled off and been filtered, the filtrate, which, ought to be entirely free from albumin, is subjected to the biuret test. (Peptone, in considerable amount, gives a pink color in the cold with Fehling's solution diluted with one-half water.) DISEASES OF THE LIVER. Bile pigment is found in the urine, or (using Oliver's test) great excess of bile-acid salts is found; some disorder of the liver is prob- ably present. TABLE XVII The Urine in Diseases of the Liver. Disease. Acute Yellow Atrophy. Functional Disorders of the Liver. Carcinoma. Amyloid Disease, Cirrhosis, Tumors Probably Hepatic. Character of Urine. Bile-acid salts increased in quantity before appearance of bile pigment and persist for some weeks after urine is free from pigment. Bile pigment if present gives urine a deep color—dark yellow or dark brown — and urine stains linen rag yellow. Urine contains both pigment and bile acid salts early. As bile diminishes urea diminishes to even as low as one-fourth Lhe normal figure. Urine contains Jeucin, tyrosin, urates in great excess. Color dark. Albumin may or may uot be present. Excess of bile-acid salts during bilious attacks and in chronic biliousness. Excess of bile-acid salts. Urates in excess. Urea di- minishes in malignant disease. Note. The distinction between hematogenous and heptogenous jaundice is no longei made, as all jaundice is more or less heptogenous in character. 402 DISEASES of the kidneys. In certain forms of renal degeneration during pregnancy the liver is at fault and imperfectly performs its functions, and we have high colored urine loaded with excrementitious material. In pernicious aneemia William Hunter has found large excess of iron in the liver. In such cases the urine is of remarkably high color, though neither nitrogenous diet nor febrile condition accounts for it. The coloring matter has all the characteristics, as regards its spec- trum and chemical behavior, of -pathological uro- bilin. He also finds blood pigment, and an in- creased excretion of iron. CERTAIN NERVOUS DISOEDEES. Neurasthenia:—C L. Dana1 has shown that in this disorder we may have lithsemia, glyco- suria, phosphaturia, or oliguria, polyuria, etc. Hydruria he finds in spinal irritation, ner- vous old people, nervous disturbance of cli- macteric with angiopathic changes. Neuras- thenic young people with ansemia. In these cases there is considerable urine of low spe- cific gravity, but the total solids are deficient. On the other hand, watery urine not abund- ant, but less than normal in 21 hours, he finds in certain neurasthenics who require simple and not very abundant diet. In one case of a depressive form of cerebro-spinal neurasthenia ^Dietetic Gazette. CERTAIN NERVOUS DISORDERS. 403 with some anaemia, the urine averaged 1016 in sp. gr., and less than 960 c. c. in 24 hours, the solids being only about 37 grammes. Neurasthenics of middle age sometimes pass enormous amounts of urine of low specific grav- ity. Urine of high specific gravity he finds most often in those forms of neurasthenia occurring in adult life, associated with gastric disturban- ces, and due to overwork or mental strain. More specifically, they are the cerebral and gas- tric neurasthenias, irritative in character and associated icith lithemuiaor a transient glycosuria. Many such cases go by the name of cere- bral hypersemia. Haslett calls them neuroses of encephalic origin. One often finds specific gravities of 1028 and 1030, without albumin or sugar. The phosphates and urates are in some excess, but the real cause of the heavy urine is the excessive amount of urea. In those cases in which Dana has measured the urine, its amount has not been very small— 35 to 45 oz. daily. In one patient whose urine averaged 1026 the daily amount was 1200 c. c. in seven differ- ent tests, giving a daily discharge of about 75 grammes (Haeser's coefficient) of solids. The man was of average weight and build, with a fair appetite, and took a moderate amount of exercise. 4°4 DISEASES OF THE KIDNEYS. Such cases have been classed as examples of lithsemia, but they are not always such, and often do not respond to any kind of anti-lithse- mic or anti-rheumatic treatment. In neuras- thenia, with heavy urines, we however, look for diathetic taints and for functional trouble in the stomach and liver. Such cases require, more than any other, careful attention to diet, and to the regulation of the bowels and the liver. Milk and bread or meat and bread form a good basis for the diet, with a plentiful sup- ply of water between meals. Insanity and Epilepsy:—According to Mairet, confirmed by Lailler, in acute delirium phos- phoric acid and urea are eliminated in notable excess; in excitable mania the phosphoric acid is in slight excess, whilst the amount of urea is normal; and in simple insanity the urine has the normal composition. In acute or excitable lypemania, the amount of urea eliminated is abnormally high, whilst that of phosphoric acid is abnormally low. In simple lypemania the composition of the urine is normal. In general paralysis the elimination of both phosphoric acid and urea is related to the gen- eral morbid conditions of the patient. At, or immediately after, epileptic seizures, the urine contains a high proportion of phosphoric acid and a low proportion of urea. If the seizures succeed one another rapidly, the proportion of TYPHOID FEVER REACTION. 405 both phosphoric acid and urea is increased; in the interval between seizures the urine has the normal composition. THE TYPHOID FEVER EEACTION. The diazo-reaction (Ehrlich) so-called, de- pends upon the fact that sulpho-diazo-benzole unites with different kinds of unknown aro- matic substances of the urine to form colored compounds. The solutions required in making the test are: First, hydrochloric acid in water (five cubic centimeters of hydrochloric acid and one hun- dred of distilled water) to which a sufficient amount of sulphanilic acid is added to satur- ate it. (Add, therefore, sulphanilic acid, which conies in the form of crystals, little by little to the hydrochloric acid solution, shaking well each time, until finally no more is dissolved.) Second, dissolve one gramme of sodium nitr/fr (not niti-ate) in 200 cubic centimeters of dis- tilled water. (Sodium nitrite comes in the form of sticks. Cut off from one of the sticks a piece little less than half an inch long, and this will weigh a gramme, roughly speaking.) In order to perform the test proceed as fol- lows: Take 25 cubic centimeters of the solution first described, viz.: sulphanilic acid in dilute 406 DISEASES OF THE KIDNEYS. hydrochloric acid; add to it one cubic centi- meter of the sodium nitrite solution; mix well, and add to the whole about an equal bulk of the urine to be examined. Then further add i the volume strong ammonia, mixing well, until the mixture turns red litmus-paper noticeably blue. When the freshly-prepared solutions are added to the urine of typhoid-fever patients in the proper proportions, the mixture of urine and chemicals turns red, the color varying from yellow-red to ruby-red or darker. In severe cases of typhoid the red color appears quickly and is rich in hue. In severe cases in the second or third week the precipitate of phosphates has a very marked dark-greenish tint. In milder cases and in those convalescing this green tint is wanting. In severe cases the froth, on shaking the mixture, is pinkish The same chemical action is found in certain other diseases (pneumonia, phthisis, puerperal fever, measles) but none which can be con- founded with typhoid fever. In cerebro-spinal fever the reaction does not take place. If the reaction is found in puerperal cases, there is danger of puerperal fever. Disappearance of the reaction in cases where it has been found is a good sign. AROMATIC COMPOUNDS IN THE URINE. 407 AROMATIC COMPOUNDS IN THE UEINE. Much interest is taken in the study of these substances. The most important at present are indie -an, phenol, cresol-sulphuric acid, proto- eatecliuic acid, and skatol. Their presence in the urine in greater quantity is due to increase of putrefaction in the intestine. They are also increased in other conditions. Iudican in larger amount than normal is shown in the nitric acid test for albumin by a narrow blue or bluish zone resting on the ring of brown coloring matter on the border between the colorless acid and the urine. In such cases try Jaffe's test: to 10 c. c. of urine and an equal quantity of strong hydrochloric acid, well mixed, add one or two drops of a cold saturated solution of chlorinated lime, The mixture becomes bluish-black or violet, and, on adding a few c. c. of chloroform and shaking, the latter is colored blue. Large q uan- tities of indican are found in the urine in dis- eases of the abdomen, in the urine of mastur- bators, after sexual excess or excitement, and the urine of nervous and hysterical women. Also in diseases of the central nervous system, as cerebro-spinal meningitis. After taking certain drugs, as turpentine, oil of bitter al- monds, nux vomica, creasote. 408 DISEASES OF THE KIDNEYS. DISEASES OF THE UPPEE AIE PASSAGES Examine the urine for evidences of lithsemia in diseases of the upper air passages. One of the most characteristic manifestations is a patchy or streaky irregular congestion of the mucous membrane of the larynx and pharynx. In the former case a dry, explosive cough accompanies; in the latter, uneasiness or positive pain is referred to the sides of the throat, occasionally extending to the ears. These cases are notably irritated and made worse by stimulant applications. Local seda- tives and general antilithic treatment give the best results. Occasionally, acute nasopharyn- geal catarrh is a manifestation of an exacerba- tion of the lithsemic tendency. Alkaline and diluent medication, with proper diet, give more relief than local treatment. Obstinate relaxa- tion of the nervous plexuses of the turbinated bodies in some individuals appears associated with lithiasis. Such cases stand operative— caustic—applications badly, and receive little or no benefit from them. Some of these cases are much improved by antilithics and general hygiene. Others are intractable on account of uncontrollable lithsemic tendencies. Acute coryza, incessant sneezing, and symp- toms such as seen in so-called " hay-fever," are often relieved by the diet and treatment usual in lithsemia. Spasm of the glottis and THE URINE IN CASES OF CANCER. 409 many affections of the tonsils yield to the same treatment as do some cases of asthenopia and relapsing episcleritis.1 THE UEINE IN CASES OF CANCEE. In cases where cancer is suspected, estimate the quantity of urea and of phosphoric acid. If these are found to be notably diminished while at the same time renal lesion is excluded, cancer may be suspected, if there are other and reason- able grounds for belief in its presence. Diag- nosis of cancer from mere observation of a marked deficiency in phosphoric acid is absurd, since I have shown by scores of analyses that a deficiency in phosphoric acid is found in nearly all renal lesions of the diffuse or scle- rotic type, and in suppurative lesions. If cancer of the stomach be suspected, decrease in urea and phosphoric acid, together with pres- ence of peptone, may help to make the diagnosis more certain. If sugar is found in the urine in connection with symptoms of pyloric cancer, it may be assumed that the pancreas has become involved. A marked indican reaction is often found in the urine of the cancerous, and also the Bur- gundy-red reaction with ferric chloride. What to do in cases where cancer is suspected : Estimate urea and phosphoric acid. Test for "-W. Cheatham, in Amer. Pract. and News, 1890, p. 333. 410 DISEASES OF THE KIDNEYS. peptone. Observe whether the indican reaction is marked, and whether any red coloration is obtained with a dilute solution of ferric chloride. POISONS IN THE UEINE. Iodoform: — Bruce1 finds the following test for Iodine in the urine more readily performed than the tests usually described:—to about 10 c. c. of urine add 1 c. c. of hydrochloric acid and about the same amount of a 10 per cent solution of ferric chloride (Fe2Cl6); shake vigorously, add 2 c. c. of carbon disulphide and shake again. The carbon disulphide gathers in a layer at the bottom of the test tube, and is colored a pinkish tint if traces only of iodine are present, but violet if iodine in noteworthy amount is present. Carbolic Acid: — In poisoning by this agent the urine has a characteristic dark color. Morphine:—I am skeptical in regard to the value of some of the " simple" tests for mor- phine in the urine which have appeared lately. To obtain morphine or other alkaloids from the urine, use the method of Dragendorff and Wis- licenus, which is described by MacMunn in his " Clinical Chemistry of the Urine," 1890, p. 239. 1 Clinique, June 15, 1890. APPENDIX. Tables for reference :— I have constructed some tables for the purpose of showing at a glance what per cent of the normal average any quantity of urine urea, etc., is. For example: Suppose, on analysis, we find a female patient voiding a total of 10 grammes of urea in 24 hours. Turning to Table III, Total Urea in 24 Hours, under Female Patients, we find 10 grammes the eleventh figure from the top. To the right of it is the figure 50, which means that if a female patient is voiding 10 grammes of urea in 24 hours, she is voiding 50 per cent of the normal average. Inasmuch as the normal averages vary according to nationality, I have adopted those of Yvon-Berlioz for the minimum (descending scale), and those of Parkes for the maximum (ascending scale). (411 412 DISEASES OF THE KIDNEYS. TABLE I. («•) URINE IN 24 HOURS. DESCENDING SCALE, Male patients, Female patients. Fluid Cubic normal Fluid Cubic 70 normal ounces. centimeters av'ge. ounces. centimeters. av'ge. f 45.33 1360 100 36.66 1100 100 | 43. 1290 95 34.83 1U45 95 A i 40.83 ■1 ^*5 1225 90 33. 990 90 1155 85 31.16 935 S3 | 36.33 1090 80 29.33 880 S I { 34. 1020 75 27.5 825 75 f 31.06 950 70 25.66 770 70 | 29.5 885 65 23.83 715 65 B -1 27.16 815 60 22. 660 60 25. 750 55 20.16 605 55 1 22.66 680 50 18.33 550 50 f 20.33 610 45 165 495 45 | 18 16 545 40 14.66 440 40 C -1 15 83 475 35 12.83 385 35 13.66 410 30 11. 330 30 I 11.33 340 25 9.16 275 25 r 9. 270 20 7.33 220 20 | 6.8S 205 15 5.5 165 15 D -{ 4.5 135 10 3.66 110 10 2.33 70 5 1.83 55 5 L 1.16 35 2^ 0.83 25 2V4 0 0 0 (b.) 0 0 0 ASCENDING SCALE. r so 1500 100 40 1200 100 Ai 55 1650 110 44 1320 110 J 60 2S 1800 120 48 1440 120 1950 130 52 1560 130 An 70 2100 140 56 1680 140 I 75 2250 150 60 1800 150 \ o° 2400 160 64 1920 160 Am 85 2550 170 68 2040 170 J 87 2625 175 70 2100 175 1 90 2700 180 72 2160 180 Aiv 95 2850 190 76 2280 190 I 100 3000 200 80 2400 200 125 3750 250 100 3000 250 Etc. 150 4500 300 120 3600 300 175 5250 350 140 4200 350 200 6000 400 160 4800 400 225 6750 450 180 5400 450 250 7500 500 200 6000 500 275 8250 550 220 6600 550 Etc. 300 9000 600 240 7200 600 325 9750 650 360 7800 650 350 10500 700 280 8400 700 375 11250 750 300 9000 750 400 1200U 800 320 9600 800 425 12750 850 340 10200 850 450 13500 900 360 10800 900 475 14250 950 380 11400 950 500 15000 1000 400 12000 1000 APPENDIX. 4r3 TABLE II. (a.) UREA RELATIVE TO WATER. DESCENDING SCALE. Male patients. Female patients. Grains % of Grains % of ■ per fluid Grammes normal per fluid Grammes normal ounce. per liter. av'ge, ounce. per liter. av'ge. r 10.09 21.50 100 8.924 1900 100 9.56 20.42 95 8.478 18.05 95 A 9 008 19.35 90 8.003 17.10 90 1 8.589 18.28 85 7.585 16.15 85 8.007 17.20 80 7.139 15.20 80 I 7.571 16.12 75 6.692 14.25 75 r 7.068 15.05 70 6.246 13.30 70 ] 6.566 13.98 65 5.800 12.35 65 B 6.059 12.90 60 5.354 11.40 60 5.556 11.83 55 4.908 10.45 55 5.049 10.75 50 4.462 9.50 50 r 4.546 9.68 45 4.015 8.55 45 i 4.036 8 60 40 3.569 7.60 40 C 3.532 7.52 35 3.123 6.65 35 j 3.332 6.45 30 2.919 5.70 30 i 2.527 5.38 25 2.231 4.75 25 f 2.019 4.30 20 1.784 3.80 20 1.517 3.23 15 1.338 2.85 15 D -i 1.009 2.15 10 0.892 1.90 10 i 0.507 1.08 5 0.445 0.95 5 0.256 0.54 2'/2 0.225 0.48 w% (&•) ASCENDING SCALE. f 10.821 23.04 100 10.427 22.2 100 i 11.362 24.192 105 10.948 23.31 105 j 11.904 25.344 110 11.47 24.42 110 Ai 12 445 26.496 115 11.991 25.53 115 12.986 27.648 120 12.512 26.64 120 i. 13.527 28 8 125 13.034 27.75 125 r 14.068 29.952 130 13.555 28.86 130 14.609 31.104 135 14.076 29.97 135 An -i 15.150 32.256 140 14.598 31.08 140 15.691 33.408 145 15.119 32.19 145 16. "-'32 34.56 150 15.640 33.3 150 16.773 35.712 155 16.162 31.41 155 17.314 36.864 160 16.683 35.52 160 Am ■i 17.856 38.016 165 17.205 36.63 165 18.397 39.168 170 17 726 37.74 170 I 18.938 40.32 175 18.247 38.85 175 r 19.479 41.472 180 18.761) 39 96 180 20 020 42.624 185 19.290 41.07 185 i 20.561 43.776 190 19.811 42 18 190 Aiv -! 21.1H2 44.928 195 ■in.:;::;; 43 29 195 21.643 46.08 200 20.854 44 4 200 [ 24.349 51.84 225 23.461 49.'.!.") 225 Etc. 27 054 57.6 250 -'6.068 55.5 250 29.760 63.36 275 28.675 61.05 275 32.405 69.12 300 31.281 66.6 300 35.171 74.88 325 33 888 72.15 325 Etc. 37.876 80.04 350 36.495 77.7 350 40.582 86.4 375 49.102 83.25 375 13.2S7 92.16 400 51.709 88.8 400 414 DISEASES OF THE KIDNEYS. TABLE III. (a.) TOTAL UREA IN 24 HOURS. DESCENDING SCALE. Male patients. Female patients. Grains. Gram's. Approx. % Grains. Gram's. Approx. % 410.75 26.50 27 100 312.75 20.50 21 10C 390.29 25.18 25 95 301.94 19.48 19 95 369 675 23.85 24 90 285.975 18.45 18 90 349.215 22.53 23 85 270 165 17.43 17 85 328.60 21.20 21 80 254.20 16 40 16 80 307.83 19.88 20 75 238.39 1538 15 75 287.525 18 55 19 70 222.425 14.35 14 70 267.065 17.23 17 65 206.615 13.33 13 65 246.45 15.90 16 60 190.65 12 30 12 60 225.99 14.58 15 55 174.84 11.28 11 55 204.875 13.25 13 50 158.875 10.25 10 50 184.915 11.98 12 45 143.065 9.23 9 45 164.30 10.60 11 40 127.10 8.20 8 40 143.84 9.28 9 35 111.29 7.18 7 35 123.225 7.95 8 3o 95.325 6.15 6 30 102.765 6.63 7 25 79.515 5.13 5 25 82.15 5.30 5 2U 63.55 4 10 4 20 61 69 3.98 4 15 47.74 3.08 3 15 41.075 2.65 3 10 31.775 2.05 2 10 20.46 1.32 1 5 15.965 1.03 1 5 10.23 0.66 % 2l/2 8.215 0.53 a 2i/ (b.) ASCENDING SCALE. Grains. Grammes. Per cent. Grains. 514.6 33.2 100 412.3 540.33 34.86 105 432.915 566.06 36.52 110 453.53 591.79 38.18 115 474.145 617.52 39.84 120 494.76 643.25 41.5 125 515.375 668.98 43.16 130 535.99 694.71 44.82 135 556 605 720.44 46 48 140 577.22 746.17 48.14 145 597.835 771.9 49.80 150 618.45 797 63 51.46 155 639.065 823.36 53.12 160 659 68 849.09 54.78 165 680 295 874.82 56 44 170 700.91 900.65 58.10 175 721.525 926.28 59.76 180 742.14 952 01 61.42 185 762 755 977.74 63.08 190 783.37 1003 47 61.74 195 803 985 10292 66.40 200 824 6 1157.85 74.7 225 927.675 1286.50 83. 250 1030.75 1415.15 91.3 275 1134.825 1543.80 99.6 300 1236.9 Grammes. Percent. 26.6 100 27.93 105 29.26 110 30.59 115 31.92 120 33.25 125 34.58 130 35.91 135 37.24 140 38.57 145 39.90 150 41.23 155 42.56 160 43.89 165 45.22 170 46.55 175 47.88 180 49.21 185 50 54 190 51.87 195 53.2 200 59.85 225 66.5 250 73.15 275 79.8 300 APPENDIX. 415 TABLE IV. (a.) PHOSPHORIC ACID RELATIVE TO WATER. DESCENDING SCALE. Mai Grains per fluid ounce. ( 1.174 Ai 1 1.117 ( 1.056 [ 1.004 A J. 0.939 ( 0.883 f 0.821 0 765 B i <'.704 I 1 .648 I 0.587 f 0.530 0.469 C -I 0.413 | 0.352 L 0 295 f 0.234 0.178 D -* 0.117 | 0.061 I 0.032 0 An -! I I f Am -! I I [ Aiv -i Etc. Etc. ients, Female Grains i patients Grammes per fluid Grammes per liter. Per cent ounce. per liter. Per cent. 2.5 100 1.127 2.40 100 2.38 95 1.070 2.28 95 2.25 90 1.014 2.16 90 2.13 85 0.958 2.04 85 2.00 80 0.901 1.92 80 1.88 75 0.845 1.80 75 1.75 70 0.789 1.68 70 1 63 65 0.732 1.56 65 1.50 60 0.676 1.44 60 1.38 55 0.66 1.32 55 1 25 50 0 5«3 1.20 ' 50 1 13 45 0.507 1.08 45 1.00 40 0.450 0.90 40 0.88 35 0.394 0.84 35 0.75 30 0.33S 0.72 30 0.63 25 0.281 0.60 25 0.50 20 0.225 0.48 20 0.38 15 0169 0.36 15 0.25 10 0.112 0.24 10 0.13 5 0.059 0.12 5 0.07 2V2 0.028 0.06 2J4 0 0 0 0 0 (6-) ASCENDING SCALE. 0.986 2.1 100 0.939 2.0 100 1.035 2 205 105 0.986 2.1 105 1.083 2.31 110 1.030 2.2 110 1.134 2.415 115 1 080 2.3 115 1.183 2.52 120 1.127 2.4 120 1.233 2 625 125 1.174 2.5 125 1.282 2.73 130 1.221 2.6 130 1.331 2.835 135 1.268 2 7 135 1.380 2.94 140 1.315 2.N 140 1.430 3.045 145 1.362 2.9 145 1.479 3.15 150 1.409 3.0 150 1.528 3.255 155 1.456 3.1 155 1.578 3.36 160 1.503 3.2 160 1.627 3.465 165 1.55 3.3 165 1.676 3.57 170 1.596 3.4 170 1.726 3.675 175 1.643 3.5 175 1.775 3.78 180 1690 3.6 180 1.824 3.885 185 1.737 3.7 185 1.874 3.99 190 1.784 3.8 190 1.921 4.095 195 1.831 3.9 195 2 003 4.2 200 1.878 4.0 200 2.220 4.725 ■ ;•)-, 2.113 4.5. 225 2.465 5.25 250 2.348 5.0 250 2.712 5.775 275 2.583 5.5 275 2.950 6.3 300 2.S18 6.0 300 3.205 3.452 6.825 7.35 325 350 3.053 3.287 6.5 7.0 325 350 3.698 7.875 375 3.522 7.5 375 3.90 8.4 400 3.757 8.0 400 416 DISEASES OF THE KIDNEYS. TABLE V. (a.) TOTAL PHOSPHORIC ACID IN 24 HOURS. DESCENDING SCALE. Male patients. Female patients. Grains. Grammes. Per cent. Grains. Grammes. Per cent, | 49.60 3.20 100 40.30 2.60 100 47.12 3.04 95 38.285 2.47 95 ! 44.64 2.88 90 36.27 2.34 90 1 42.16 2.72 85 34.255 2.21 85 | 39.68 2.56 80 32.24 2.08 80 [ 37 20 2.40 75 30 225 1.95 75 f 35.72 2.24 70 28.21 1.82 70 32.24 2.08 65 26.195 1.69 65 -i 29.76 1.92 60 24.18 1.56 60 27.28 1.76 55 22.165 1.43 55 I 24.80 1.60 50 20.15 1.30 50 f 22.32 1.44 45 18.135 1.17 45 19.84 1.28 40 16.12 1.04 40 -I 17.36 1.12 35 14.105 0.91 35 | 14.88 0.96 30 12.09 0.78 30 I 12.40 0.80 25 10.075 0.65 25 f 9.92 0.64 20 8.06 0.52 20 7.44 0.48 15 6.045 0.39 15 i 4.96 0.32 10 4.03 0.26 10 I 2.58 0.16 5 2.015 0.13 5 I 1.24 0.08 2V2 1.085 0.07 2yt cb.) ASCENDING SCALE. f 49 6 3.2 100 40.3 52.08 3.36 105 42.315 j 54.56 3.52 110 44.33 1 57.04 3.68 115 46.345 | 59.52 3.84 120 48.36 L 62.00 4.00 125 50.375 f 64.48 4.16 130 52.39 I 66.96 4.32 135 54.405 An -j 69.44 4.48 140 56.42 71.92 4.64 145 58.435 [ 74.4 4.80 150 60.45 f 76.88 4.96 155 62 465 | 79.36 5.12 160 64.48 Am -I 81.84 5.28 165 66.495 | 84.32 5.44 170 68.51 I 86.80 5.6 175 70.525 f 89.28 5.76 180 72 54 I 91.76 5.92 185 74.555 Aiv -j 94.24 6.08 190 76.57 I 96.72 6.24 195 78.585 t 99.20 6.40 200 80.6 111.60 720 225 90.675 Etc. 134.00 8.00 250 100.75 136.40 8.80 275 110.825 148.80 9.60 300 120.9 Etc. 16120 10.40 325 130.975 173.60 11.20 350 141.05 186.00 12.00 375 151.125 198.40 12.80 400 161 2 Ai 2.6 100 2.73 105 2.86 110 2.99 115 3.12 120 3.25 125 3.38 130 3.51 135 3.64 140 3.77 145 3.9 150 4.03 155 4.16 160 4.29 165 4.42 170 4.55 175 4.68 180 4.81 185 4.94 190 5.07 195 5.2 200 5.85 225 6.50 250 7.15 275 7.80 300 8.45 325 9.10 350 9.75 375 10.40 400 APPENDIX. 4lC.\ TABLE VI. (a.) URIC ACID RELATIVE TO WATER. DESCENDING SCALE. M ale patients. Female patients. Grains per Grammes Grains per Grammes fluid oz. per liter. Per cent. fluid oz. per liter. Per cent. 0.173 0.37 100 0.191 0.407 100 0.164 0.35 95 0.181 0.386 93 0.155 0.33 90 0.172 0.366 90 0.147 0.31 85 0.162 0.345 85 0.138 0.296 80 0.153 0.325 80 0.129 0.277 75 0.143 0.305 75 0.121 0.259 70 0.133 0.285 70 0.112 0.24 65 0 124 0.264 65 0.103 0.22 . 60 0.115 0.244 60 0.095 0.20 55 0.105 0.224 55 0.086 0.185 50 0.095 0.203 50 0.077 0.166 45 0 086 0.183 45 0.069 0.148 40 0.764 0.163 40 0.060 0.129 35 0.668 0.142 35 0.052 0.111 30 0.573 0.122 30 0.042 0 092 25 0.477 0.102 'J 5 0.034 0.074 20 0.382 0.008 20 0.026 0.055 15 0.286 0.006 15 0.017 0.037 10 0.191 0.004 13 0.008 0.018 5 0.095 0.002 5 0.004 0.009 2*4 0.047 0.001 254 In this table the average of Parkes is chosen, since it is lower than that of Yvon- Berlioz. But in order to make the avera ge for female patients, the ratio of male to female in the Yvon-Berlioz average is taken. (b.) ASCENDING SCALE. 0.232 0.500 100 0.255 0.244 0.525 105 0.267 0.255 0.556 110 0.280 0.267 0.575 115 0.293 0.278 0.600 120 0.306 0.290 0.625 125 0.319 0.302 0.650 130 0.331 0.313 0.675 135 0.344 0.325 0.700 140 0.357 0.336 0.725 145 0.369 0.348 0.750 150 0.382 0.359 0.775 155 0.395 0.371 0.800 160 0.408 0.383 0.825 165 0.420 0.394 0.850 170 0.433 0.406 0.875 175 0.446 0.418 0.900 180 0.459 0.429 0.925 185 0.472 0.441 0.950 190 0.484 0.452 0.975 195 0.497 0.464 1.000 200 0.510 0.522 1.125 225 0.573 0.580 1.250 250 0.637 0.638 1.375 275 0.701 0.696 1.500 300 0.765 0.754 1.625 325 0.828 0.812 1.750 350 0.892 0.870 1.875 375 0.956 0.928 2.000 400 1.020 0.550 100 0.577 105 0.605 110 0.632 115 0.660 120 0.687 125 0.715 130 0.742 135 0.770 140 0.797 145 0.825 150 0.852 155 O.S80 160 (1.907 165 0.935 171) 0.962 175 0.990 180 1.017 183 1.045 190 1.072 195 1.100 200 1.237 225 1.375 250 1.512 275 1.650 300 1.787 325 1.925 350 2.062 375 2.200 400 016b DISEASES OF THE KIDNEYS. TABLE VII. [a.) TOTAL URIC ACID IN 24 HOURS. DESCENDING SCALE. Male patients. rains. Grammes. . Per cent. 8.600 0.555 100 8.170 0.527 95 7.740 0.499 90 7.310 0.472 85 6.880 0.444 80 6.450 0.416 75 6.020 0.388 70 5.590 0.361 65 5.160 0.333 60 4.730 0.305 55 4.300 0.277 50 3.870 0.250 45 3.440 0.222 40 3.010 0.194 35 2.580 0.166 30 2.150 0.139 25 1.720 0.111 20 1.290 0.083 15 0.860 0.055 10 0.430 0.028 5 0.021 0.014 VA Female patients. 0.817 0.776 0.735 0.694 0.654 0.613 0.572 0.531 0.490 0.449 0.408 0.367 0.327 0.286 0.245 0.204 0.163 0.123 0.082 0.040 0.002 (60 ASCENDING SCALE. Grammes. Per cent. 0.527 100 0.501 95 0.474 90 0.448 85 0.422 80 0.396 75 0.370 70 0.343 65 0.316 60 0.290 55 0.263 50 0.237 45 0.211 40 0.184 35 0.158 80 0.132 25 0.105 20 0.079 15 0.053 10 0.026 5 0.001 2l/2 9.30 0.60 100 8.80 0.57 100 9.76 0.63 105 9.24 0.59 105 10.23 0.66 110 9.68 0.62 110 10.69 0.69 115 10.12 0.65 115 11.16 0.72 120 10.56 0.68 120 11.62 0.75 125 11.00 0.71 125 12.09 0.78 130 11.44 0.74 130 12.55 0.81 135 11.88 0.77 135 13.02 0.84 140 12.32 0.79 140 13.48 0.87 145 12.76 0.82 145 13.95 0.90 150 13.20 0.85 150 14.41 0.93 155 13.64 0.88 155 14.88 0.96 160 14.08 0.91 160 15.34 0.99 165 14.52 0.94 165 15.81 1.02 170 14.96 0.97 170 16.27 1.05 175 15.40 1.00 175 16.74 1.08 180 15.84 1.03 180 17.20 1.11 185 16.28 1.05 185 17.67 1.14 190 16.72 1.08 190 18.13 1.17 195 17.17 1.11 195 18.60 1.20 200 17.60 1.14 200 APPENDIX. 416c TABLE VIII. TOTAL SOLIDS IN 24 HOURS BY TRAPP'S COEFFICIENT. DESCENDING SCALE. ASCENDING SCALE. Grains. Grammes. Per cent. Grains. Grammes. Per cent 899. 58. 100 899. 58. 100 854.05 55.1 95 943.95 60.9 105 809.10 52.2 90 988.9 63.8 110 764.15 49.3 85 1033.85 66.7 115 719.2 46.4 80 1078.8 69.6 120 674.25 43.5 75 1123.75 72.5 125 629.30 40.6 70 1168.7 75.4 130 584.35 37.7 65 1213.65 78.3 135 539.4 34.8 60 1258.6 81.2 140 494.45 31.9 55 1303.55 84.1 145 449.5 29. 50 1348.5 87. 150 404.55 26.1 45 1393.45 89.9 155 359.6 23.2 40 1438.4 92.8 160 314.65 20.3 35 1483.35 95.7 165 269.7 17.4 30 1528.3 98.6 170 224.75 14.5 25 1573.25 101.5 175 179.8 11.6 20 1618.2 104.4 180 134.S3 8.7 15 1663.15 107.3 185 89.9 5.8 10 1708.1 110.2 190 44.95 2.9 5 1753.05 113.1 195 22.475 1.45 2% 1798. 116. 200 2022.75 130.5 225 TABLE IX. RATIO OF UREA TO SALTS. Urea. Salts. Per cent. Urea. Salts. Per cent 0.85 I 100 1.33 1 100 0.8075 95 1.396+ 105 0.765 90 1.463 110 0.7225 85 1.529+ 115 0.68 80 1.596 120 0.6375 75 1.662+ 125 0.595 70 1.729 130 0.5525 65 1.795+ 135 0.51 60 1.862 140 0.4675 55 1.928+ 145 0.425 50 1.995 150 0.3825 45 2.061+ 155 0.34 40 2.128 160 0.2975 35 2.194+ 165 0.255 30 2.261 170 0.2125 25 2.327+ 175 0.17 20 2.394 180 0.1275 15 2.46+ 185 0 085 10 2.527 190 0.0425 5 2.593+ 195 0.02125 25s 2.66 2.992+ 3.325+ 3.657+ 3.99 200 225 250 275 300 416d DISEASES OF THE KIDNEYS. TABLE X. RATIO OF UREA TO PHOSPHORIC ACID. DESCENDING SCALE. ASCENDING SCALE. (Yvon-Berlioz.) Per cent. 8 to 1..................______inn 7.6 to 1............ ................ 95 7.2 to 1............ ................ 90 6.8 to 1........ ... ................ 85 6.4 to 1............ ............... 80 6.0 to 1............ ............... 75 S.6 to 1............ ................ 70 5.2 to 1........... ................ 65 4.8 to 1............ ..............60 4.4 to 1............ ___............. 55 4.0 tol............ ................ 50 3.6 to 1............ ............... 45 3.2 tol........... ................ 40 2.8 to 1.......... ................ 35 2.4 tol......... ................ 30 2.0 tol........... ................ 25 1.6 tol............ ............... 20 1.2 tol............ ................ 15 0.8 tol............ ................ 10 0.4 tol............ ............... 5 0.2 tol............ ................ iVi (Parkes.) 10 10.5 11.0 11.5 12.0 12.5 13.0 13.5 14.0 14.5 15.0 15.5 16.0 16.5 17.0 17.5 18.0 18.5 19.0 19.5 20.0 22.5 25.0 tol. tol. tol. tol. tol. tol. tol. tol. tol. tol. tol. to 1. tol. tol. tol. tol. tol. tol. tol. tol. tol. tol. tol. Per cent. .....100 .....105 .....110 .....115 .....120 .....125 .....130 .....135 .....140 .....145 .....150 .....155- .....160 .....165 .....170 .....175 ... .180 .....1S5 .....190 .....195 .....200 .....225 .....250 TABLE XI. RATIO OF UREA TO URIC ACID. DESCENDING SCALE. (Yvon-Berlioz.) Per cent. 40 to 1............................100 38 to 1............................ 95 36 to 1............................ 90 34 to 1............................ 85 32 to 1............................ 80 30 to 1............................ 75 28 to 1............................ 70 26 to 1............................ 65 24 to 1............................ 60 22 to 1............................ 55 20 to 1............................ 50 18 to 1............................ 45 16 to 1............................ 40 14 to 1............................ 35 12 to 1............................ 30 10 to 1............................ 25 8 to 1............................ 20 6 to 1............................ 15 4 to 1............................ 10 2 to 1............................ 5 1 to 1............................ 2*4 DESCENDING SCALE. (Parkes.) Per cent.. 60 to 1.........................100 57 to 1......................... 95 54 to 1......................... 90 51 to 1......................... 85 48 to 1........................ 80 45 to 1........................ 75 42 to 1......................... 70 39 to 1......................... 65 36 to 1......................... 60 33 to 1......................... 55 30 to 1......................... 50 27 to 1......................... 45 24 to 1......................... 40 21 to 1......................... 35 18 to 1......................... 30 15 to 1........................ 25 12 to 1......................... 20 9 to 1......................... 15 6 to 1......................... 10 3 to 1........................ 5 1. to 1......................... 2*4 APPENDIX. 41 Oe TABLE XII. RATIO OF DAY URINE TO NIGHT URINE. The author having collected his urine for the 24 hours, day and night, separately, during 28 successive days, found the lowest ratio of day to night to be 1.7 to 1, the highest 7 to 1. On 12 days out of the 28 the ratio was 3 to 1. On 1 days the ratio was between 2 and 3 to 1. On only 3 days was it below 2 to 1, and on 8 days it was from 4 up to 7 to 1. I have, there- fore, adopted 3 to 1 as a basis on which to reckon percentages. DESCENDING SCALE. Per cent. Per cent. 3 to 1 2.85 to 1 2.70 to 1 2.55 to 1 2.40 to 1 2.25 to 1 2.10 to 1 1.95 to 1 1.80 to 1 1.65 to 1 100 95 90 85 GO 75 70 65 , 60 . 55 1.50 to 1, 1.35 to 1 1.20 to 1 1.05 tol 0.90 to 1 0.75 to 1 0.60 to 1 0.45 to 1 0.30 to 1 0.15 to 1 50 45 40 35 30 25 20 15 10 5 416f DISEASES OF THE KIDNEYS. Examples for Practice. 1. Urine of 24 hours, 1,800 cubic centi- meters, sp. gr. 1010, urea per liter 6.50 grammes: calculate total solids and total urea in both French and American measures, and compare with normal averages for female patient. 2. Totax urine 780 c.c, sp. gr. 1020, urea per liter 27 grammes, phosphoric acid per liter 1.50 gramme. Albumin half-way between first and second mark on Esbach tube: calculate total urea, total phosphoric acid, total solids, ratio of urea to salts, total salts, ratio of urea to phos- phoric acid, total albumin. Compare with normal averages for male. 3. Day urine 1800 c.c, night urine 1620 c.c; sp. gr. before fermenting 1033, after, 1012; urea per liter 15.50 grammes: calculate total urine, ratio of day urine to night urine, total urea, total salts, total solids, ratio of urea to salts, sugar per liter, sugar per fluidounce, sugar per 24 hours in grammes and grains, sugar per cent. 4. Urine of 24 hours 1500 c.c; specific gravity before fermenting 1035, after, 1007: calculate as above, in third example, all you can. 5. Urine of 24 hours 3000 c.c, sp. gr. before fermentation 1029, after, 1013. Calculate as above. APPENDIX. 416G 6. Urine per 24 hours, 84 fluidounces. Ratio of day to night 1.2 to 1. Sp. gr. 1010. Urea per fluidounce 5 grains. Calculate volume of urine in cubic centimeters, volume of day urine, volume of night urine, urea per liter, urea per 24 hours, total solids, total salts, ratio of urea to salts, all in metric system. 7. Urine per 24 hours 30 c.c, urea per liter 11 grammes, phosphoric acid per liter 2 grammes. Calculate urea per 24 hours, phosphoric acid per 24 hours, ratio of urea to phosphoric acid. Is there anything remarkable about these figures? Strophanthus increased the volume of the urine after failure of alkaline waters, lith- ium benzoate, and diuretin. What inference? 8. Urine per 24 hours, 780 c.c. Sp. gr. 1020. Urea per liter, 27 grammes. Albumin, H tenths; no casts; sediment, pus streaked with blood. Frequent micturition, pain at end of urination, urine acid, great sensitiveness on passage of sound just as it enters bladder. Diagnosis and suggestions as to treatment? 9. Urine per 24 hours, 2000 c.c. Urea per liter, 17 grammes. Phosphoric acid per liter 1.38 gramme. Sp. gr. 1016. Albumin, -^th. Sediment: pus, single corpuscles and plugs, a few hyaline casts. Calculate as above and give probable diagnosis. 416h diseases of the kidneys. EXAMINATION OF THE PATIENT IN CHRONIC DISEASES OF THE KIDNEYS. (a) Age, sex, and weight of patient ? (6) History? (Ascertain particularly whether there has been previous acute nephritis; ask for history of alcoholism, gout, lead poisoning, apoplexy, syphilis, phthisis, scrofula, chronic suppurative processes.) (c) General condition? (1) Head.—Observe appearance of face; note if features are puffy and pallid or whether the skin is sallow and cachectic in hue, or cyanotic. If headache, ascertain particularly whether it be occipital and extending to back of the neck. Note dis- turbances of hearing or vision, insomnia, mental depression, and hypochondria. Inquire for presence of epistaxis. (2) Chest.—Notice whether the patient is suffering (or has suffered) from dyspnoea; whether the area of cardiac dullness is increased or whether there are signs of cardiac changes in general. (3) Abdomen.—Inquire for gastro-intestinal symptoms, nausea, vomiting, flatulent dyspepsia, diarrhoea; look for en- largement of liver or spleen; note any symptoms connected with the urinary organs, as total number of micturitions, micturitions at night, if any, pain (on voiding urine), whether absent, renal colic, clots of blood voided, etc., etc. (4) Notice whether the pulse is hard, resistant, rolling like a cord, or small, compressible, rapid. Observe whether the larger veins are prominent, especially over the abdomen and lower extremities. (5) Dropsy.—If there is or has been dropsy, where first noticed, and whether general or confined to special localities. (6) Miscellaneous.—Inquire for muscular weakness, lassi- tude, vertigo, loss of sexual desire. Ascertain whether there have been convulsions, coma, or other symptoms of ursemia. APPENDIX. 416i Summary of Therapeutic Progress. The Bright7s Disease of Pregnancy:—The urine of girls should be examined before mar- riage, and, if they are found to have Bright's disease, they should be dissuaded from mar- riage; if, in spite of advice, they marry, prema- ture labor should be induced as soon as conclusive symptoms, such as increased albu- minuria, tube casts, marked dropsy, or severe headache appear. In cases of Bright's disease complicating pregnancy, when grave accidents, as paralysis of speech, and paraplegia, followed by slow return of motor power, were noticed in a pre- vious pregnancy, premature labor should be induced as soon as albuminuria appears. When signs of a renal affection complicating a previous labor persist after such labor, pre- mature labor may with propriety be induced during the next pregnancy.* Treatment of Chronic Bright1 s Disease:—The milk diet is growing in favor. Koumiss, kephir, matzoon are recommended. Milk of almonds,' white meats, fish, and eggs, the latter in small quantities, are allowed. Smoking for- bidden. In the cases of large kidney "drug- ging" especially to be avoided. Hygienic treatment and milk diet, together with warm ♦Tyson, Medical Record, January 3d, 1891. 416j DISEASES OF THE KIDNEYS. baths (hot water), fifteen to twenty minutes, followed by wrapping patient in dry sheets and no exposure to draught. In the cases of small kidneys, of syphilitic origin, or due to arterio-sclerosis, patients to be sent to warmer climates, to lead regular life, and, if necessary, to be submitted for a long time to the action of potassium iodide. Diu- retin is, perhaps, the safest diuretic. When there is great arterial tension, patient to be kept in bed till tension is relieved. Mineral waters may increase arterial tension and can prove dangerous. Moderate massage and much rest in bed desirable. Milk Diet in Bright7s Disease:—Absolute milk diet: half-pint every two hours day and night will, at the end of three or four days, often cause marked polyuria and relieve dropsy, ursemia, and other bad symptoms. Mitigated milk diet: one or two quarts of milk daily, and gruel, porridge, rice, tapioca, custards given in addition. Mixed diet: patient drinks freely of milk with meals and between meals, or takes one meal in the morning of solid food and nothing but milk the rest of the day. Milk may be peptonized and an additional amount of cream added. The Cystitis of Diabetes:—Anti-diabetic diet, APPENDIX. 416k together with sodium salicylate, internally and in solution as an injection, is the treatment. Diabetes:—Mild cases are those in which a fortnight's restricted diet expels the sugar from the urine; moderate cases are those in which restricted diet reduces the sugar but does not wholly expel it. Severe cases are those in which diet exerts no influence. Fruit, milk, and alcohol are forbidden, but gymnastics, hydro-therapeutics, and alkaline mineral waters are useful. Gluten bread is not free from starch. Purdy recommends cakes from almond flour. Seegen allows a couple of ounces of bread. Fatigue of travel is very dangerous. Diabetes is cured only when the urine remains free from sugar in spite of ingestion of carbo- hydrates. Diabetic Coma:—First, in cases where there is weakness of the heart's action caused by the action of the sugar in the blood on muscular fibres of the heart: nutritious, easily digested food, moderate amount of alcohol, fresh and invigorating air, together with the ordinary diabetic treatment. In pressing- cases patient in recumbent position until first sound of the heart again becomes clear, and not to get up even for stools or for urinating; best stimulant, black coffee. Second, in cases of acute so-called "acetonsemia," with colic, high temperature 416l DISEASES OF THE KIDNEYS. and clear heart-sounds, the treatment is to get rid of the poison which is a product of decom- position in the bowel and lies in the bowel. According to Schmitz one or two tablespoon- fuls of castor oil remove it quickly. Treatment of Oxaluria:—The symptoms are essentially nervous and gastric Warm baths with frictions and cold affusions during the bath are of value for the nervous symptoms, especially for the trembling of the extremities and the insomnia; faradization is also recom- mended. Waters charged with gas are to be avoided, especially seltzer. The best diet is now said to be that similar to the diabetic Pepsin, hydrochloric acid, bicarbonate of sodium and lithium are recommended.* Diabetes with Albuminuria:—At Carlsbad two glasses daily of Sprudel water, together with Calcar. Arsen. sixth decimal trituration, a pen-knife bladeful daily, caused both sugar and albumin to disappear in three weeks. (Kafka.) Hematuria:—When other measures fail, try fluid-extract of Geranium in ten-drop doses. Tincture of Trillium is sometimes serviceable. Diuretin:—Name given to a substance com- posed of sodium salicylate and theobromine. Soluble in hot water. Diuretic. Useful in *Cantani. APPENDIX. 416m dropsies. Sixty grains a day given at first, and if this quantity makes no sensible increase in the urine, add fifteen grains daily till a sufficient result is obtained. As soon as the diuretic effect is established, the drug may be suspended. I have known it to decrease the dropsy and increase the urine in chronic Bright's disease when digitalis and other remedies failed. Piperazidin:—This substance, also called disethylenimin, has the property, it is claimed, of dissolving more uric acid by twelve times than is accomplished by lithium carbonate. It may prove, perhaps, to be of value in the treatment of uricaemia. Syzygium Jambolanum:—This remedy is holding its own in diabetes mellitus. Rhus Aromatica:—Is still very highly recom- mended in the incontinence of children. Sabul Serruleita:—Five-drop doses of the tincture for enlarged or atrophied prostate. Mullein Oil:—In five-drop doses for painful urination, is reported successful in some cases. Hypnotism in Diabetes:—Dr. F. R. Cruise, of Dublin, Ireland, has lately proved that by hyp- notism and suggestion it is possible to reduce the quantity of urine in diabetes by about one- half! Dr. Cruise has produced a great sensa- tion by his address and the demonstrations 416n DISEASES OF THE KIDNEYS. given before the Royal Academy of Medicine in Ireland. Rhus Aromatica in Diabetes:—Thirty-drop doses of the tincture given every 2 or 3 hours are recommended in diabetes insipidus and mellitus (McClanahan). Sambueus Nigra in Bright7s:—In the anasarca of acute nephritis and in the oedema of heart disease this remedy has acted well as a diuretic (Lemoine). Solidago Virga-aurea has lately come into notice for its action on the kidneys. Ferrum in Anamia from Bright7sDisease:—I have seen in one case great benefit from admin- istration of equal parts of ferric and ferrous oxides in solution, in the proportion found in \hi hsemoglobin of the blood. Oxygen gas may be given with benefit at the same time. The diet should be light, but there may be allowed one meal of solid food daily, if the bowels are methodically attended to. Vesicaria:—A diuretic; dose, 3 to 15 drops, as needed, 4 to 6 times daily, in chronic cystitis and in gravel for inflammation, and as an aid in expulsion. Aurum Murieiticum in Backache:—In one case of prolonged and severe sacro-lumbar pain with insomnia and frequent urination at night, with excess of night urine above day, I gave APPENDIX. 416o aurum muriatieum in one-twentieth of a grain doses, four times daily. In two weeks' time the backache and insomnia had disappeared, and the quantity of night urine was reduced to the proper ratio to the day. Treatment of "Colds77 of Lithcemic Origin:— In one case where the patient had had cold after cold for a period of months, examination of the urine revealed scanty secretion, high sp. gr., and abundant uric acid sediments, the latter even in urine two hours old. Anti-lithsemic diet (see page 274) and Londonderry water were sufficient to break up the tendency to colds, and the patient was not attacked by the influenza during the epidemics. Carlsbad Salts and Rubinat Water:—Stout patients derive benefit often from use of Carls- bad salts, as described page 288. Purgative waters are, as a rule, to be used cautiously in renal troubles, but in the constipation which so often aggravates diseases of the bladder and prostatic area, I have found Rubinat water of decided utility. Kronenquelle Water in TJricecmia:—Laucher, of Bavaria, has called attention to the value of Kronenquelle water in the treatment of gout and complaints of the uric acid diathesis. After taking one bottle daily there is noticed, accord- ing to Mortimer Granville, in from 8 to 10 416p DISEASES OF THE KIDNEYS. days, a great increase in urine, decrease in acidity and in the deposit of uric acid. Kronen- quelle water contains 2i grammes of solids per liter, or about 140 grains to the gallon. Lime is present as bicarbonate only, seven-tenths of a gramme per liter, or about forty-five grains per gallon. INDEX. Hon to Use the Index:—All therapeutic agents will be found in italics, thus, Arsenicum. The particular page on which the general indi- cations for a remedy is given will be in face type, thus: Arsenicum___115, 116, 159, 179, 183, 185, 188, 189, 190, 196, 204 This means that while casual reference to Arsenicum is found on pages 115, 116, 159, 179, 183, 185, 188, 189, 190, 196, the particular page on which the general indications for the use of this remedy are given is page 204. All other matter in ordinary type. PAG3. Aberdeenshire....................... u i Ab-coeses........-................229, 22:j Perinepkriiic.--.................... 252 Accentuation...............--......- 17-i Acetate, of Iron...................... 210 of Potassium....................... 180 Acetone......................-....... 381 Acid, acetic.......................... 40 Citric ..'...........-................ 40 Nitric.........................13, 17.40 Picric.............................. 4m Acid'im, Boracicum.................. 24 Carbolicum........................ 20<; PAGE. Ai-hVnn,, Citricum.................... 334 Il'jd'ocyanicum................... 1% Xitrlcum....................115, 153, 213 Nilroni'triaticum.............*..... 113 Oxalicum ......................... 2'<5 Phosiih'iricum____............. 163, 254 Picrirmn ..................___ .. 215 Sali.fi/licujn ........................ 282 Aconite.........119. 122, 179, 188, 202, 254, 31C, 32(5, 358 Adenoma............................. 308 Adirondacks......................... 273 Adonidin.........................___ 107 1417) 418 INDEX. PAGE. Adonis Vernalis...............167, 185,207 Agaricus..........................155, 196 Albumin............................. 11 Tests............................... 11 Estimation......................... 16 Testing............................ 198 Albuminimeter...............------ 17 Albuminoids.....-................... 192 Albuminuria......................74 to 255 Diabetic......................-..... 395 Functional......................... 76 Organic.........................77 to 255 In pregnancy.....................•- 177 Tuberculous........................ 299 Alcohol...................132, 189, 396, 397 Sweats............._______178, 195, 197 Stupor.......................... 193, 194 Ale................................... 133 Alkaline phosphates..................5, 38 Waters..................186,208, 290,330 Urine.........................270,287,318 Aloes................................. 185 Alum.......____..................187,344 Ammonia...........................40, 189 Aromatic........................... 118 Ammonium carbonate................ 318 Muriatieum..............%. 154, 160, 190 Amyl Nitrite ......................121, 183 Amyloid disease of Kidney, see Lar- daceous disease. Amyloid Liver........................ 401 Anacardium___..................... 196 Ansemia...................126, 129, 196,210 Aortic.....................-........ 175 Pernicious...............-......... 402 Analyses of Urine___148, 150, 171, 237, 264, 271, 302, 375, 395, 403, 405 Anses hetics.......................... 182 Anasarca......................197, 202, 213 Aneurism............................ 183 Angina Pectoris....................170,184 Angioma.............................. 308 Antimonium Crudum. ........203,32i Antimonium Tart.................179, 202 Antipyrin.................291, 367, 332, 392 Anuria .............................. 357 Aortic disease.....................173, 186 Apexbeat........................___ 168 Apium Virus......................... 121 PAGE. Apis.:...........121, 160, 179, 189, 196, 203 Apocynum.....157,179,186, 204, 358, 398 Apollinaris.......................... 287 Apoplexy.................106, 183, 193, 194 Apparatus, chemical................39.41 Microscopical..........................72 Argentum NitricumA15, 116, 153, 204, 278 Arkansas Springs.................128, 139 Arnica...........167, 183, 254, 291, 316, 358 Aromatic Compounds..................407 Arrow-root___.........................240 Arsenicum 115, 116, 159, 179, 183, 185, 188, 189, 190, 196, 204, 278, 285, 291, 307, 361, 362, 389 Arseniate of Strychnine.............183 Arsenic, Bromide.....................343 Arsenic, Iodide......................184 Arsenic and Lithia..............____393 Arterial degeneration...'____..........170 Tension............171, 175, 177, 182, 209 Arterio-Sclerosis...................---175 Ascending Nephritis ..................235 Ascites..................................183 Asparagus.............................285 Aspiration.............................248 Asthma.......................106, 183, 184 Astringents............................331 Atheroma___..........................175 Atropine Sulphate___........361, 365, 398 Atrophy, acute yellow............____401 Atlantic Ocean.........................141 Aurum Muriatieum...........161, 205, 391 Australia...............................142 Bacilli.............................60, 298 Backache......................123, 124, 301 Bacteria........27, 58, 59, 236, 237, 238, 243 Baltic..................................140 Barley water...........................240 Barium chloride____..........____38, 40 Barosma.............................____246 Baryta Mur...........................184 Baths, Cold........................364,365 Hot Air..115, 118, 120, 145, 155, 164 177, 182, 195, 196, 200 Hot..............................244, 329 Steam................................196 Turkish..............•............185,386 INDEX. 4I9 PAGE. Baihs, Russian...........- ............386 Warm____.........145, 233, 273, 290, 343 Beef Tea..............................167 B er...............................133, 138 Belladonna... .115, 127, 179, 180,183, 185, 196, 205, 254, 278, 285, 291, 328, 342, 361, 365 Benzoates........159, 162, 195, 199, 246, 361 Berbe/is......................240, 278, 291 Bermuda...............................141 Bethesda Water...........114, 132, 135, 292 Biborate of Ammonium................292 Bicarbonate of Soda..................135 Bile in urine_______..................401 Tests..................................19 Bile................................117, 189 Bismarck Brown........................72 Bismuth___.......................158, 288 Biuret Test............................400 Bladder, diseases of....................316 Diseases in Females................- 332 Diseases of Neck of..._.........339,345 Epithelium.............---.......... 62 Hemorrhage.....................324,338 Haemorrhage from Neck of...........347 Spasm of.............................236 Stone in..............................323 Suppuration in.......................219 Treatment of Diseases of............325 Tumors of.......................235, 322 Urine in diseases of..................320 Washing • ut....................331, 335 Blauds Pills...............-......126,210 Blood..............25,31, 75, 86, 91, 92,241 Casts........................63,71, 86, 97 Corpuscles.........................54, 56 Clots.................................242 From Bladder........................222 From Kidneys..........222, 225, 255, 256 From Urethra.......................222 In tuberculous Disease...............303 In malignant.....................303, 306 Boracic Acid.. .239, 240, 247, 250, 266 290, 330, 337 Borax..................................247 Bordeaux..............................274 Boroglyceride..........................346 Boettcher's Crystals...................351 BoudreaWs Pills..................126, 210 PAGE. Bournemouth..........................140 Brandy...................115, 132, 240, 287 Braemar.................................140 Bromide of Potassium.....33, 3d6, 391, 393 Bronchitis............................. 183 Brucke's Test......................___370 Bryonia... ..............113, 122,278, 390 Buffalo Lithia Water.............132, 276 Buttermilk.............................135 Cachexia...............................306 Cactus.................................161 Caffeine____.............156,126, 167, 186 Calcarea.... 163, 185, 205, 278, 285, 291, 305 Calcium Oxalate...................259, 283 Tests.......................28, 31, 49,217 Calcium Phosphate.................52, 333 Calculus...............................256 Analyses___.....................263, 271 Oxalate...............................259 Phosphatic.......................260,264 Renal.................................256 Situation.............................261 Treatment...........................272 Uric Acid....................___258,264 Treatment............................273 In both Kidneys___..................262 When to Operate for............. 293 California..........................139, 128 Calomel........................130. 188, 212 Camphor......................196, 254. 308 Cancer..........................218,227 251 Of Liver..........____...............401 Renal............................303, 305 Of Stomach...........................400 Urine in..............................410 Cannabis..................285,326,327, 342 Cannes........................-------139 Cantani's Powder.....................277 Cantharides Poisoning.................399 Cantharis .122, 155, 160, 179,205, 245, 278, 281, 285, 291, 293, 327, 342, 358 Cape Town_____..................139, 140 Capsicum..............................327 Carbolic Acid.....................122, 206 Carbolic Acid.......................72, 331 Carbonated Water.....................114 Cardiac asthma........................184 420 INDEX. PAGE. Cardiac complications___121, 124,155, 1N3 Condition............................101 Dilatation____.........106. 126, 170,171 Hypertrophy.......106, 125, 168, 177, 183 Failure..................106, 129, 170, 184 Lesions..........................__183 Carlsbad. ..154, 188, 275, 284, 288, 293 387, 389 Carolina, South....................139, 141 Castor oil..............................134 Casts....................................63 Blood...............................64, 71 Corkscrew.............................66 Fatty______..........................66 Epithelial...................... 65,70, t\ Granular...................51,65, 70, 109 Hyaline............................64,71 Mucus........................___66, 70 Nucleated............................65 Oil................................66, 109 Pus................____.............64 Yellow........................._____66 Waxy..........._.................51, 109 Cataract..............................396 Catarrh of Bladder.................325, &12 Of Kidney...........................164 Of Prostate...........................351 Of Urethra ,........................352 Catarrhal Ulcerations..................347 Catharsis.....................125, 156, 136 Catheter..........._...................223 Fever................................337 Catheterism.......................335, 364 Caustics................._.-..........344 Caustic Potash........___.............72 Cavernous Tumors____................308 Cells, epithelial.....................62,63 Cellulitis..........................108, 252 Cerebral Symptoms....94, 115, 119, 120, 125 Chamomilla...........................179 Champagne........................133, 283 Chelidonium..................189, 190, 207 Chimaphila.............................329 China........130, 155, 188, 196, 290, 311, 362 Arsen___...................159, 196, 240 Chloral Hydrate.........126, 130, 180, 196 Chlorate of Potassium.......254, 308, 388 Chloroform......................180, 196 Chlorides..........................6, 32, 36 PAGE. Chloride of Barium.....................40 Of Gold and Soda.....................162 Of Iron............................. 209 Of Sodium ..........................230 Chlorinated Soda.................___33, 40 Chromate of Potassium...............392 Cider.......................... .......132 Cirrhosis, renal............88, 104,107, 111 Of Liver___.....................166, 401 Citrate of Iron and Quinine...........130 Citrate of Iron, Quinine, and Strych- nine .................................398 Citric Acid..............................40 Clap-threads...........................353 Claret............................_____132 Clinical Notes 179, 180, 196, 2.>4, 205, 206, 2( 7, 208, 209, 210, 211, 212, 213, 214, 215, 216, 254, 291, 329, 330, 344, 367, 392, 398 Climatology___.................128, 138 Cloudy Swelling.......__................83 Clots..................................346 Clysmic Water_____'......___114, 135,326 Cocaine..........____255, 331, 333, 351, 392 Coccus Cacti...........................123 Codeine____.........................392 Cod Liver Oil.........160, 162, 163, 305, 398 Coefficient of Hseser..-..................7 Of Trapp........................147, 150 Coffea............___..................179 Colchicum............................_207 Cold............................76, 364 Compress____...................285, 311 Colic, renal____...................... 263 Treatment of....................290, 294 Collection of Sediment..................44 Coloring Matter, biliary.................19 Estimation of................._____39 Color of Urine ______6, 9, 84, 86, 88,89, 97 Coma.................95, 130,153, 193,194 Diabetic....................____379, 394 Complications........................106 Congestion, prostatic..................349 Renal----...........................166 Congress Water........................275 Conium................................196 Consistence of Urine.....................9 Constipation..............114, 134, 165, 185 Convulsions.......95, 102, 166, 182, 189, 196 42I l'AGK. Convallaria..............126, 166, 18«, 207 Copper Tests for Sugar____2, 369, 371, 377 Coronillin.........____...............107 Corr sloe Sublimate, see Mercurius Cor. Corrosive Sublimate Albumimate......392 Corpulence..............................76 Corpuscles, blood..................____55 Mil cus_____..........................57 Pus................................56, 58 Counter-Irritation.............______125 Cover-glass___........................46 Cramps..........................______313 Creasote......._____.........240,247, 394 Creolin................................331 Crescentic Pad........................310 Cresol Sulphuric Acid................407 Crotalus...............................123 CrotonOil..............................125 Cuprum..................115, 123,180, 2)7 Cups......................189, 195, 241, 254 Cyanotic Induration...............___105 Cylindrical Vessel...................42, 72 Cystitis, definition.....................316 Etiology.............................316 Diagnosis........................___317 Prognosis........................___325 Treatment...........................325 Urine in............................320 Cysto-pyelitis.....___.................300 Cystoscope_______................296. 321 Cystoepasmus___________.........362,308 Cysts..........................226, 227. 232 Hanger of opium habit.................393 Denmark.............................140 Diabetes, complications of ............394 Decipiens_____......................374 Insipidus..................39, 395, 330 Mellitus......%...................369,394 AndPregnancy..........-..... . ..395 Prognosis in.........................378 Treatment of....................... 38.2 Diagnosis of Acute Nephritis.......___96 Albuminuria, Functional.............74 Cirrhosis_____........................88 Chronic diffuse Nephritis.............8fi Chronic Hypersemia................. ..91 Chronic Interstitial Nephritis.........88 PAGE. Diagnosis: Chronic Parenchymatous.............84 Chronic Suppurative.--..............234 Cysts of Kidney___..................232 Cystitis..........................316, 339 Calculus, renal.......................256 Calculus, vesical................323, 324 Carcinoma, renal................... 305 Diabetes Insipidus...................395 Mellitus..............................373 Enuresis___.........................365 Floating Kidney.....................309 Gonorrhoea...........................332 Growths in Bladder..................322 Hsematuria .....___............220, 222 Hydronephrosis..................___229 Hypersemia...........................91 Lardaceous Disease..............____89 Liver Diseases............___._.....401 Motor Neuroses......................362 Nervous Disorders...................402 Oxaluria.............................283 Peptonuria...........................399 Phosphaturia____....................286 Perinephritic Abscess___............253 Pyelitis.......................______242 Pyelo-nephritis.......................235 Pyonephrosis.........................248 Pyuria...............................218 Sclerosis.............................88 Suppurative Nephritis...............234 Prostatic disorders____..............345 Tenesmus, renal............... .....312 Tuberculosis, renal...................298 Typhoid Fever___ ............... ..405 Upper-air Passages, diseases of......408 Uricaemia............................272 U rsemia..............................194 Diaphoresis...............117, 125, 130, 156 Diarrhoea..................135, 185,214,305 Diazo Reaction.......................405 Diet in anuria .........................358 Acute Nephritis.................114, 117 Subacute Nephritis...................123 Renal Carcinoma....................308 Chronic Nephritis_____..............131 Diabetes............._____________382 Diffuse Nephritis___.....________137 Cystitis..............................325 422 INDEX. PAGE. Diet in enuresis........................365 Lardaceous Disease................. 137 Lithsemia............................273 Cardiac Complications...............177 Oxaluria.............................283 Phosphaturia........................287 Pregnancy.......................118, 180 Prostatic Diseases...................351 Pyelo-Nephritis......................240 Pyelitis.............................246 Pyonephrosis.........................250 Sclerosis.........................137, 162 Tuberculosis.........................305 Diffuse Nephritis......85, 99,103, 111,117 Digitalis... 117, 121, 124, 125, 126, 129, 154, 155, 160, 165, 167, 208 Dimness of Vision.....................178 Diphtheria.............................127 Diseases of the Liver..................401 Distilled Water....................131, 250 Dizziness_____.......................178 Diuretics.. ..117, 123, 125, 156, 164, 180, 208 Doremus's Ureometer.........___.....32 Dropsy.74, 107, 121, 130, 183, 185, 186, 197, 200, 203, 204, 205, 207, 208, 211, 213, 215, 238 Drosera............................___291 Drowsiness.............................178 Dry soil................................397 Dyspepsia.....................213, i'iO, 281 Dyspnoea..........................178,209 Eclampsia.............___.......103, 192 Eczema............................107, 395 Egypt..................................140 Elaterium............125, 156,165, 195, 197 Empyema____.........................400 Endocarditis......................107, 184 Engad.ne..............................140 Enuresis______........................365 Eosin...........................,.......72 Epilepsy...........................___194 Epithelial cells.................61, 62,63 Epithelioma...........................322 Epistaxis -....................._.......187 Equisefum.............................367 Erigeron..........................____285 Ergot........307, 311, 338, 348, 351, 366,398 PAGE. Erysipeiac....................187,207, 395 Esbach's Tube..........................17 Estimation of Albumin..................16 Bile...................................20 Coloring Matter.......................39 Chlorides_____......................36 Phosphates..........____............38 Sulphates..........................___<38 Sugar.............................22, 376 Urates................................38 Urea..........______................32 Etiology of Renal Carcinoma..........305 Cystitis..........................317,339 Diabetes.............................370 Functional Albuminuria.........76, 127 Floating Kidney.............._____309 Incontinence of Urine..............-.360 Nephritis........____82, 84, 86,88,89, 91 Hydronephrosis___.............____229 Oxaluria.........___................283 Perinephritic Abscess.........._____252 Phosphaturia........................287 Prostatic Disorders..................348 Pyelitis___.........______..........242 Pyonephrosis....................___248 Renal Calculus.......................256 Tuberculosis..................____..302 Uricsemia................._________272 Eucalyptol___....................241, 247 Eucalyptus............_...............329 Euonymine.... 116, 154, 159, 179, 189, 208, 278, 348 Eupatorium.................209,358, 367 Eureka Springs...................____139 Examination of the Patient in Anuria_358 Calculus.............................256 Carcinoma...........____...........307 Cystitis.................-._..........340 Diabetes................372, 373, 379, 380 Floating Kidney.....................309 Hsematuria...........................222 Hy dronephrosis..........___........225 Incontinence of Urine..............._360 Paresis of Bladder...................363 Perinephritis........................253 Prostatic Disorders.............____348 Pyelo-Nephritis......................236 Pyelitis..............................242 Pyonephrosis........................248 INDEX. 423 PAGE. Examination in Pyuria.................355 Suppurative Nephritis...............234 Tenesmus, Renal.....................315 Tuberculosis.........................298 Tumors.........................____228 Urethritis.........._.................352 Uricsemia............................272 Examination of Urine in Albuminuria. 74 Diseases of Renal Pelvis..............217 Hsematuria......_...............220, 222 Hydronephrosis....._................230 Pyelonephritis...................___235 Pyuria..........___......_____219, 220 Pyelitis..............................243 Pyonephrosis........................248 Perinephritic Abscess................253 Renal Calculus.....237, 258, 259, 260, 261 Examination of Urine, chemical___5 to 42 Microscopical....................43 to 72 Examination of Urinary Sediment, Chemical..............................24 Microscopical.........................48 Exercise...............................145 Exudative Nephritis...................126 Fatty Casts....................66, 109, 195 Degeneration.....................___83 Favorable Signs.......................100 Fermentation, alkaline................243 Saccharine..........................23 Febrile Symptoms........_____94, 236, 242 Fehling's Solution...........20, 21,40,377 Ferric chloride reaction........-----381 Ferrum. .119. 121, 123, 124, 126, 129, 130, 155, 156. i59, 160, 161 186, 188, 209,247,290,311,328 Fer. et Chin. Citr....................130 Filtering........................___10, 40, 42 Fissure in vesical Neck................345 Floating Kidney....................._ 308 Fibrous Polypi.........................322 Flatulent Dyspepsia....................287 Florida.................................r 139 Folkestone____.........................140 Fowler's Apparatus....................133 Fractures...............................107 France___............................139 Fremitus, hydatid.....................233 PAGE. Friction of the Body..............____273 Fuchsin.............................48. 72 Functional albuminuria.........74, 98, 399 Disorder of Bladder..................332 Gangrene...............................187 Gastro-intestinal Symptoms........94, 187 Gelatinous Masses.................___234 Gelsemium.......179, 180, 196, 311, 328, 366 Georgia........................128, 139, 141 Geranium________.................338 Gizzards, things with..................274 Glonoin ...127, 130, 156, 179, 188, 190, 209 Glottis.................................189 Gluten Bread..........................385 Glycerine..............................125 Glycosuria...............372, 373, 395, 403 Gout----......................75, 157. 159 Gouty Pyelitis...................... 247 Graduate.........................___ 39 Granular Casts.........57, 65, 70, 109, 195 Graphites____....................... 392 Growths in Bladder................... 324 Of Kidney..................____305, 308 Guaiac................................ 29 Hsematuria..............220, 256, 293, 298 Treatment of...............3n7 311, 347 Hsemoglobin..................122, 221, 225 Hsemoglobinuria...................220, 311 Haemorrhage......................... 22^ Haeser's Formula....................7, 147 Haines's Sugar test................22, 370 Hamamelis........................311, 338 Hathorn water....................... 275 Headache.....................123, 129, 188 Heart, dilatation of.................. 170 Failure..........._________.....126, 170 In Renal diseases................. 168 Hypertrophy of.................... 168 Treatment...................177, 183, 184 Helleborus.....____155, 179, 185, 210, 358 Helonias..........................211, 398 Hemi-albumose....................399, 400 Hepar Sulphur..........127, 245, 246, 395 Hepatic disorders. ..153, 159, 166, 192, 208 High tension, arterial............... 175 Hippuric Acid.................. ..... 6 424 PAGE. Hissing in Ursemia.................. 193 Holland.............................. 140 Hunyadi Janos....................275, 293 Hyaline Casts........................64, 71 Hydatid Cysts....................232, 233 Hydrastinine____................... 338 Hydrate, Sodium............-...... 32 Potassium ___....................21, 40 Hydriodic Acid...............----- 398 Hydrochloric Acid............290, 405, 406 Hydrocyanic Acid................... 196 Hydronephrosis..........226, 229, 230, 396 Hydropericardium................108, 189 Hydrothorax.....................109, 183 Hydruria.....................396, 397, 402 Hygiene of Acute Parenchymatous Change............................115 Acute Diffuse Nephritis___.........117 Hemorrhage from Bladder..........325 Acute Post-Scarlatinal Nephritis.....120 Chronic Nephritis....................130 Sub-acute Nephritis..................128 Uricsemia............................273 Hypersemia.......................166,399 Hypobromite process...................32 Ice-bag................................187 Idiopathic Nephritis...................117 Ignatia............................179, 359 Increase of urea........................199 Increase of urine.....................199 Indican.............................39, 407 Indications for use of Remedies.......202 Injections..............................336 Iodide of Iron.........................210 Iodoform..........................331, 351 Poisoning............................331 Ipecac............................211, 309 Insanity and Epilepsy..................404 Interstitial Nephritis..........Ill, 132, 215 Intestinal Ulceration..................185 Iodides...................290, 3C5, 357, 392 Iodine.................................190 Iodine Solution____........:...........30 Iodoform...............................392 Irritability of Bladder.............3>.5, 360 Prostate.........................350, 354 Isle of Wight..........................140 Iron...................................210 PAGE. Jaborandi.............................180 Jaffe's Test............................407 Jaundice..............76, 108, 189, 236, 4 H Jumbul............................392, 398 Kali Bichromicum.......122, 153, 183, 391 Bromatum...........................391 lodatum........130, 158, 163, 211, 290, 305 Phosphoricum................_. .305 Kalrtda........................130, 179,211 Kolpo-uretero-cystotomy..............295 Kreasote..........................389, 394 Kreatin.................-..............191 Kreatinine........................-----5 Kidney, casts...........................63 Epithelium___................61, 62, 63 Gouty.................................88 Hypersemia of.........................91 Lardaceous................____......89 Large Red.............................89 Large White.......................83, 85 Pelvis, Diseases......................217 Blood from................-.........222 Pus from.............................219 Situation of___......................248 Small Red____........................87 Small Soft............................86 Small White............___..........86 Suppurative Diseases of_____.......234 Surgical......___................___235 Syphilis of...........................201 "Labor, Induction of...................181 LaBonrboule...........................160 Lactuca.........................._____196 Lachesis.......................123, 179, 212 Lactic Acid....................___390 Lardaceous Kidneys..85, 89, 105, 111, 137. 164, 135, 399 Treatment of.........................163 Larynx.................................215 Leeches................................125 Lemonade. ...........................115 Le'.tai.dria...............__......____390 Lesions, cardiac.....-.................183 Lesions of the Kidneys___87,106, 115. 170 Acute.................................96 Complication of an Acute Disease___99 INDEX. 425 PAGE. Complication Diffuse....................92 In Mineral Poisoning.................99 Parenchymatous......................99 Lesions, retinal.......................190 Leucorrhoea............... .............11 L-mewater and Milk............... .114 Lithsemia........274, 280, 372,402,403,404 Tendency to...............-..135, 372, 408 Lit/dated Hydrangea___ ..............292 Lithiasis____.....______........294, 408 Lithium Benzoate....159, 161, 162, 199, 361 Carb........................161, 212, 392 Litmus Paper............................11 Littre's Glands..........................62 Liver.............................166, 228 Cirrhosis of..........................166 Lipo:na........._......_.........-.....308 Loofah......_____.....................160 Londonderry Lithia Water .132, 159, 199, 250, 276, 361 Low Tension..........................177 Liquor Ammonise..................... 12 Liquor Ferri Muriatici................366 Liquor Potassm...........'___12,361,370 Liquor Potassse Test...................21 Lumbar Incision.......................304 Lycopodium.......................280, 328 Lymphoma____....................... 308 Lyons's instrument.................32, 35 Madeira............................. 133 Islands............................. 139 Malaga............................... 139 Malaria............................141, 157 Malpighian tuft...................... 82 Malta................................ 139 Manipulation......................... 299 Marienbad water.................... 275 Massage............................. 129 And electricity..................... 387 Meats..........._.................131, 137 Meat, raw____....................... 135 Medullary sarcoma.................. 322 Meningitis.....................-..... 127 Mercurius-.113, 116, 161, 245, 246, 254, 316 Corrosivus ..118, 120, 122, 127, 129, 130, 158, 159, 162, 165, 179, 212, 213, 327, 361 PAGE. Mercurius Cyanatus..............122, 212 Dulcis___.......................116, 213 lodatus.........................158, 162 Solubilis...................116, 361, 392 Metamorphosis...................... 83 Mexico.....................__........ 139 Micrococci.......................___ 59 Microscope............25, 26, 28, 29, 30,45 Microscopical work..................43, 47 Micturition___122, 223, 236, 257, 300, 306, 332, 362, 368 Milk.....................118, 133, 134, 135 " diet......................136, 137,404 " and bread...................131, 404 " pudding........................ 131 " skim.......___................. 131 " sugar........................... 167 Mineral waters......131, 154, 275, 326, 389 Miscellaneous Surgical measures___ 295 Mississippi Valley.................... 139 Mitral diseases...................... 172 " obstruction. ................. 172 " regurgitation...............172, 174 Moselle wine......................... 133 Motor neuroses...................... 362 Mountain air......................... 273 Movable kidney___.................. 308 Mucus......................27, 30, 31, 243 Casts.............................. 70 Corpuscles......................... 57 Prostatic........................... 351 Mucous cloud........................8, 28 Multiple renal abscesses............. 234 Nantucket.........................139, 140 Naples....,.......................... 139 Naso-pharyngeal catarrh............. 408 Neck of bladder..................223, 339 Catarrhal ulceration of.....342, 343, 347 Fissure of.............--.......--- 345 Hemorrhages of.................... 347 Inflammation of.................... 341 Suppuration in..................... 339 Varicose condition of.............. 347 Nephrectomy.. . _____.....231, 308, 310 Nephritic complications......-...... 163 Nephritis____92, 96, 98, 109, 137, 164, 361 Acute.92, 111, 122, 125, 129, 165, 248, 358 426 INDEX. PAGE. Acute diffuse.....................99, 117 Acute exudative........___98, 113, 126 Chronic... 92, 96, 101, 102, 111, 130 151, 399 Diffuse..........____1..........160, 299 Chronic diffuse......85, 96, 99, 103, 104, 111, 157, 168 Chronic interstitial..............Ill, 232 Interstitial..................85, 104, 111 Post-diphtheritic_______.......... 122 Post-scarlatinal.............120, 121, 122 Puerperal.......................... 101 Scarlatinal......................122, 399 Sub-acute.......................119, 127 Suppurative......177, 234,235, 237, 252, 349, 359 Tubal.............................. 85 Nephrotomy......................... 231 Nephro-lithotomy.................... 294 Neuralgia of the bladder............ 324 Neurasthenia........................ 402 Cerebral ........................... 403 Gastric............................. 403 New England........................ 141 New Mexico......................... 284 Newport............................. 139 New growth in bladder............... 324 Nitric Acid..........................19, 21 Nitric Acid...................123, 213, 392 Nitric Acid test...................... 14 Nitr a-muriatic Acid.................. 285 Normal constituents................. 32 Nux Vomica...113, 155, 161, 163, 213, 278, 280, 281, 288, 290, 291, 398, 407 Objects (microscopical) having color . 49 No color......................■..... 49 Ocimum............................... 280 Oilorof Urine........................ 8 CEdemaof glottis.................... 189 Oflungsor of glottis.............. 107 Oil of bitter almonds................. 407 Oliguria...........................357, 402 Oliver's test.......................... 401 Opaque cloudiness................... 38 Open fire-places...................... 387 Opium...................196, 308, 392, 394 PAGE. Ordinary constituents of urine...... 48 Organic albuminuria................74, 98 Osteo-malacia___.................... 400 Osteoma............................. 308 Oxygen gas...............126,145, 160, 196 Enemata........................... 388 Oxygenated water.................... 133 Oxalate crystals.....,.............323, 361 Oxalic Acid.................]........ 285 Oxaluria......................283, 291, 294 Oxynaphthoic Acid.............. ___ 67 Oysters.......................131, 137, 383 Papaine.............................. 280 Paraglobulin......................... 399 Paraldehyde......................... 167 Paralysis of detrusor_______......... 363 Of sphincter.......___............. 363 Parasites......................______ 324 Pareira Brava....................... 280 Parenchymatous (acute) degener- ation.............................99, 117 (Chronic) metamorphosis.......... 100 Change............................ 103 (Acute).....-----...............113, 115 (Chronic)........................... 151 Paresis of the bladder................ 363 Treatmentof___ ...........____ 364 Paroxysmal albuminuria............. 75 Pasadena............................. 139 Pau------........................,-. 139 Peptone, pulverized.................. 20 Peptone, tests for..................20, 401 Peptones............................. 400 Peptonuria...................396, 399, 400 Pericarditis.......................... 107 Perinephritic abscess.........._____ 252 Perinephritis........_____............ 252 Peripheral arteries. __................ 170 Pernicious anaamia.................. 402 Peritonitis...................___ ... 107 Suppurative........................ 400 Petroleum....................213, 246, 281 Phenol..............______+.___392, 407 Phimosis..............______........ 361 Phloridzin.......................... 391 Phosphate calcium..................26, 52 Triple.............................26, 53 INDEX. 427 PAGE. Phosphate of soda................... 393 Phosphates..32, 54, 217, 286, 323,361, 362, 403 Alkaline........................... 38 Earthy........................26, 37, 289 Phosphate of Strychnine............. 288 Phosphaturia......................287, 361 Phosphoric Acid....150, 163, 214, 289, 389, 396, 404, 405 Phosphorus....123, 155, 166, 213, 246, 281, 285, 290, 394, 398 Phthisis...........................107, 406 Phytolacca........................... 215 Pichi.........................280, 281, 330 Pickles........................._____ 383 Picric Acid........................ 130, 215 Pilocarpine..........---118, 179, 200, 392 Piper Methysticum...............___ 280 Place of residence____............... 138 Pleural Exudations.................. 4C0 Pleuritis............................. 107 Plumbum........................___ 215 Pneumonia___................107, 400, 406 Podophyllum......................113, 391 Poisons in the Urine____............ 399 Poland Water.....................114,135 Polyps, Fibrous...................... 322 Polyuria.......................396,397,398 Post-Scarlatinal Nephritis___....... 206 Potassium, see Kali. Potassium Iodide.................... 224 Poultry-.............................. 383 Precautions in Testing___........... 371 Pregnancy, Albuminurias of......... 177 Complicated by Bright's Disease... 181 AndDiabetes.....--............... 395 . Prognosis in Acute Hypersemia...... 105 Acute Nephritis____.......96, 98, 99, 109 Acute Parenchymatous Degenera- tion .................-............ 99 Acute Suppurative Nephritis....... 235 Albuminuria, Functional----...... 98 Albuminuria, Organic.............. 98 Carcinoma....................--- 307 Chronic Hyperaemia................ 105 Chronic Nephritis.......99, 104, 105, 108 Chronic Parenchymatous Metamor- phosis............................ 99 Chronic Renal Tuberculosis....... 3o4 Prognosis: Complications of Renal Lesions___ 106 Condition of the heart___......... 110 Cystitis............................ 325 Diabetes Insipidus_______......... 397 Diabetes Mellitus..............___ 378 ' Floating Kidney...........___:... 309 Gouty Kidney.................___ 104 Hydatids........................... 233 Hydro-Nephrosis___............... 230 Lardaceous Disease ............... 105 Parenchymatous Change Asso- ciated with Diabetes .....___..... 105 Perinephritic Abscess............. 253 Puerperal Nephritis.........101, 102, 105 Pyelitis..........................243, 244 Pyelo-Nephritis.................... 238 Pyonephrosis___..............___«. 249 Renal Colic in Children............ 295 Renal Tenesmus................... 316 Retention ._....................___ 358 Ureteritis....._____............... 316 Prostate...........................312, 352 Hemorrhages from________........ 347 Prostatic Congestion................. 349 Disorders.......................... 348 Hypertrophy................323, 348,349 Irritability......................... 350 Prostatic Urethra____................. 347 Prostatitis........................... 323 Chronic.............._____......^. 349 Protocatechuic Acid.......-------- 407 Protiodide of Mercury___........... 212 Psychical Influences................. 143 Puerperal Cases...................... 406 Convulsions ....................... 182 Fever_________................... 406 Kidney..........-.....------...... 235 Pulque.......................-....... 133 Pulsatilla.................245, 281, 328, 366 Pulse................................... 169 Pus......26, 29, 30, 57, 60, 74, 217, 236, 248, 257, 340, 341, 355, 400 Corpuscles.....................56, 57, 58 Laudable..................-........ 56 Plugs___.....................---- 64 Sediment........................... 299 Pyelitis.............241, 242, 243. 245, 248, 255, 341, 342 428 INDEX. Pyelitis calculous.............-....... 281 Chronic................243, 245. 246 247, 340, 342 Primary............................ 341 Secondary......................... 341 Secondary Acute................... 342 Secondary Chronic.......----..... 342 Pyelo-Nephritis......234, 235, 237, 238, 243 Pyelo-Nephrosis..................... 335 Pyonephrosis_______241, 242,247, 248, 255 Pyo-Salpinx.......................... 235 Pyridin............................. 167 Pyuria................--............. 243 Quality of the Urine............. Quantitative estimation of Sugar Quantity in 24 hours............. Quantity to collect............... Estimation of................-- Of Normal Constituents........ 147 22 1 9 16 32 "Ralfe' s Test for Peptones........... Reaction.............................7: Reagents and Apparatus............. Reagents and Apparatus for Micro- scopical Examination_____.■--- Raw Meat......---...............--- Remedial Measures in Acute Diffuse Nephritis.....................--- Remedies............................. Acute Diffuse Nephritis______... Acute Hypersemia................. Chronic Nephritis____...........151, Gouty Cases........................ Incontinence of Urine............. Lardaceous Disease................ Malarial Cases..................... Nephritis........................... Parenchymatous change........... Perinephritic Abscess.............. Phosphaturia....................... Pyelo Nephritis.................... Renal Colic......................... Renal Complications............... Tenesmus........................... Sclerosis............................ Suppurative Nephritis............. Uricsemia.......................... 135 118 184 118 164 157 159 361 163 159 202 151 254 288 240 291 190 316 161 240 278 PAGE. Renal Calculus................256, 258, 263 Renal Colic.......................... 290 Renal Colic in Children.......... 294 Renal Diseases, Complications of--- 183 Renal Hsematuria.................... 311 Renal Lesions.................-...... 106 Renal Pelvis........................- 234 Renal tenesmus...................314. 315 Renal tuberculosis, chronic......--- 297 Retinal lesions---..........------- 190 Rheum____........-...........--- - 122 Rhus Tox............-............H9, 215 Rough method of estimation of al bumin.............................. 16 Saccharin............................ 329 Salol.......................-184, 185, 330 Salicylates....._______.............. 282 SalicylicAcid.................----282, 392 * SantaBarbara.......................- 139 San Francisco........................ 142 Saratoga____..................... 139, 142 Sarsaparilla......................... 285 Scilla..............._______......----186 Sclerosis, complications.............. 161 Of coronary arteries---............ 184 Sclerosis, treatment.................. 107 Sclerotic conditions.................. 186 Scoparius.......................... 168 Sediment........24, 25, 26, 51, 53, 60, 286, 289 Collection of....................... 44 Of earthy phosphates.............. 289 Selection of........................ 43 Sediments of triple phosphate....... 290 Sediments, formation of............. 285 Sepia........................179, 245, 281 Septicemia........................... 191 Silica.....................254, 278, 285, 389 Simple pyelitis....................... 244 Situation of calculus................. 612 Skimmed milk........................ 133 Skin.........,....................... 253 Sleeping rooms...................... 387 Solania............................_. 119 Sodium chloride...................... 36 Sodium salicylate..................... 392 Solids................................ 7 Solvent treatment of calculus........ 277 INDEX. 429 PAGE. 1 Soups__ iter. 131 141 408 .... 229 Test for Chlorides........... ........ 36 Southern States. Coloring matter........... ...... 39 Spa-m of glottis____...... Micro-chemical........ ........ 53 Spasmodic contraction of ur< Mucus................. ........27, 29 Specific gravity............... ....7. 10 Peptones............___ 20 Spectroscope............... .... 221 Phosphates............___ ........26. 37 Squibb's urea instrument___ .... 33 Pus.......____........ ______26, 29 Stigmata Maidis............. .... 281 Sodium chloride......___ .....-... 36 .... 285 Sugar..................... .......20, 369 Stone in the bladder........ .322, 324 Sulphates................. ........ 38 Stramonium................. .196, 216 Ulcers in neck of bladder. ......345, 347 Strangulation of the kidney. .... 310 Urates___................ ......... 25 Strophanthus................ .... 184 Urea ..................... ......... 32 Struma....................... .... 107 Uric Acid................. ------- 25 Strychnine...............185, Sub-acute nephritis.......... Sugar........................ 916 367, 394 Tests, apparatus for........ ......... 40 127 Test solutions............... ___.'___ 40 20, 21, 22 Thlaspi..................... ......... 281 Sulphates.................... ...32, 38 Thomasville............___ ......... 139 Sulpho-carbolate of Sodium .... 392 ......154, 361 Sulphur..................... 245 254, 281 Tides, acid.................. ......... 270 Summary of prognosis___.. ___ 111 Alkaline................. ......... 270 Suppurative (diseases of bladder. .... 312 Tobacco........_......____ .....-... 385 Kidneys___................ .... 234 _______ 140 .... 312 Torulse......._____......... -........ 59 Urethra.................... .... 312 Total Phosphoric Acid....... . —..... 148 ______ 7 Symptoms of renal tuberculosis.. .... 298 Urea...................... ........ 148 Syphilis...................... .107, 157 Urine in 24 hours......... ......... 148 Ofthe kidney.............. 201 . 148 Transparency of urine...... —...... 8 Tricuspid disease........... _______ 174 ......... 63 .285, 291 Blood..................... ........ 63 Tallahassee.................. .... 139 Epithelial................. ........ 65 ... 328 Fatty...................... .......66, 214 Tartar Emetic............... .... 202 Granular...............__ .......65, 195 Tenesmus of bladder........ .... 328 Hyaline................... ........ 64 Renal..................*■___ ... 312 Illustrations of............ ....51, 70, 71 .103, 175 Mucous................... ........- 66 Low........................ ..... 177 Pus....................... ........ 64 Texas........................ .... 139 Yellow____................ ........ 66 Terebinthina_____118, 120, 122, 124, Tuberculosis of bladder___ ........ 297 159, 160, 179, 216, 246, 288. 293, 358 Renal..................... ........ 296 Test for Albumin............ .... 12 Tubercle bacilli............. _____60, 298 .... 28 Tumors, of bladder.......... ........ 322 Bile........................ .... 19 Non-renal.................. ........ 228 ___ 20 Renal...................... Turkish bath................. .227, 305, 308 Blood ...................... .... 25 ........ 386 ......... 405 43° INDEX. PAGE. Uranium Nitrate.........,.......389. 395 Urates............................... 5 Estimation___..................... 38 In neurasthenia__.....____....... 403 Uraemia______......................75, 97 Chronic..............'.............. 199 Symptoms of...............114, 178, 194 Treatment of..........117, 191, 195, 199 Urea................................5, 148 In cancer........................401, 410 In diseases of liver................ 401 Estimation of...................... 32 In neurasthenia.................... 403 In albuminuria..................... 75 In pregnancy....................... 182 In subacute nephritis......__...... 129 In urine of poor quality............ 150 In iusanity......................... 404 In epilepsy........................ 404 Urethritis___.....................320, 352 Chronic............................ 354 Gonorrhoeal........................ 352 Ureters, calculus in.................. 261 Constriction.................._____ 230 Diseases of......................... 312 Treatment......................... 316 Suction of.......................... 295 Uricsemia..........................272, 378 Headache in....................... 282 In children........................ 294 Uric Acid calculus................... 264 Uric Acid in diseases of upper air passages........................... 408 In neurasthenia................___ 403 Uric Acid diathesis, see Uricaemia... Urinary analysis................pp. 5 to 72 Urine, alkaline from fixed Alkali___ 287 Volatile Alkali___...............8, 286 Characters, physical............... 6 Color.....5, 6. 84, 86, 88, 89, 91, 97, 402 Consistence........................ 6, 9 Constituents....................... 5 Normal........................... 5 Odor............................... 6, 8 Quantity in 24 hours............5, 9, 148 Reaction..........e.............6,7, 11 Sediment......................24, 31, 48 Specific gravity..............1...6, 7, 10 Transparency..................... 6, 8 PAGE. Urine in abdominal disorders....... 407 Albuminuria (functional).......... 74 Ansemia (pernicious)............... 402 Calculus, renal.............____256, 257 Calculus, vesical...........____323, 324 Cancer..................___303, 306, 409 Chronic renal lesions.............. 97 Cirrhosis........................... 88 Cystic degeneration................ 232 Cystitis.....................317, 320, 341 Diabetes.....................373, 374, 396 Diabetic coma..................... 379 Diffuse lesions..................... 86 Epilepsy........................... 404 Functional disorder of bladder___ 332 Growth in bladder.............____ 322 Hydruria.......................... 397 Hsematuria......................220, 222 Hyperaamia........................ 91 Hydronephrosis.............___226, 229 Incontinence______________...... 360 Interstitial disease................. 88 Insanity........................... 404 Lardaceous disease................ 89 Lithsemia.......................„.. 258 Liver diseases...................... 401 Motor neuroses...............____ 362 Neurasthenia.................____ 403 Oxaluria.........................259, 283 Parenchymatous changes_____82, 83, 84 Paresis of bladder___............. 363 Perinephritis...................... 253 Peptonuria......................... 400 Phosphaturia........._________286, 289 Polyuria........................... 396 Pregnancy......................... 178 Prostatitis.............320, 323, 349, 351 Pyelitis..........................243, 303 Pyelo-nephritis..................... 236 Pyonephrosis...............______ 248 Pyuria...........................219, 355 Sclerosis........................... 88 Subacute nephritis................ 128 Suppurative nephritis................236 Tuberculosis........_____......298, 301 Typhoid fever...................... 406 Upper air passages (diseases of)... 408 Ursemia.............................. 198 Ureteritis......................_____ 312 INDEX. 431 PAGE. Urethritis............................ 352 Uricaemia.............................258, 273 Uva Ursse-----....................293, 329 Vaginal epithelium ................. 62 Vals...............................275, 277 Valvular lesions.—................... 96 .Varicose conditions...............324, 347 Vascular tension.................... 76 Tumors............................ 322 Vascular thickening of kidney...... 104 Vaseline.............................335, 388 Veratrum Vir................179, 180, 196 Vertigo________.................... 175 Vesical, see bladder and cystitis___ Vichy...............114, 154, 247, 275, 277 Villous tumors....................... 322 Volume of urine...................... 148 Vulvitis............................... 361 PAGE. Waters, drinking in cystitis......... 325 In lithsemia........................ 276 In oxaluria........................ 284 "Wateryurine....................._._ 226 Washing out, bladder...........___331, 335 Stomach........................... 285 Waxy kidney_____................. 89 Whisky............................... 284 Wholewheat bread.................. 274 Womb, diseases of...............--- 332 Woollens.......................118, 273, 397 Wormwood.......................... 244 Zoogloea.....,......................... 59 Zymotic diseases..................... 248 432 SUPPLEMENTARY INDEX. SUPPLEMENTABY IJSTDEX. (Second Edition.) page Acetonasmia, treatment of. . 416k Arterial tension, treatment of. 416 j Aurum Muriatieum, for back- ache ..................... 416 o Baths in Bright's.......... 416 j Bright's Disease —■ Diet in................... 416 i Of Pregnancy............ 416 i Treatment of............. 416 i Calcarea Arsen............ 416 l Carlsbad Sprudel Salt....... 416 l " Colds " due to lithaemia.... 416 o Diabetes— Calculation of Sugar in Urine.................. 416 s Cystitis in................ 416 j Diet in................... 416 k Hypnotism as treatment of 416 n When cured.............. 416 k With Albuminuria........ 416 l Diabetic Coma............. 416 k Diasthylenimin............. 416m Diuretin..........416g, 416j, 416 l Examination of Patients... . Examples for practice..... Faradization in Oxaluria ... Ferrum in Bright's.......... Geranium. . .. Gluten Bread. Hematuria— Treatment of. Hypnotism .... 416 h 416 f 416 l 416 n 416 l 416 k 416 l 416 n Induction of labor in Bright's 416 i Kephir in Bright's......... 416 i Koumiss in Bright's........ ±\6 i Kronenquelle Water........ 416 o Massage................... 416 j Matzoon................... 416-1 Milk Diet in Bright's....... 416 j Mineral Waters— Dangers in use of........ 416 j Mullein Oil................. 416m Oxaluria.................. 416 l Oxygen Gas................ 416 n Pepsinum................. 416 l Piperazidin................ 416m Prostate, Disorders of...... 416m Rhus Aromatica.......416m, 416 n Rubinat Water............. 416 O Sabul Serrulata............. 416m Sambucus in Bright's........ 416 n Salicylate of Soda......416k, 416l Solidago................... 416 n Strophanthus............... 416 g Syzygium................... 416m Total Solids- Table of................. 416 o Trillium................... 416 l Urea— Ratio of to Salts.......... 416 o Phosphoric acid 416d Uric acid...... 416d Uric acid (tables)......416a, 416 b Uricaemia— Kronenquelle water in .... 416 o Urine— Day compared with night.. 416 e Vesicaria.................. 4jg 0 • NOW READY! « IUSO 2^ 2rT I _£>_ « ---AND--- OTHER DISORDERS OF SLEEP. --BY-- HF.XRY M. LYMAN, A.M., M.D. Professor of Physiology and Diseases of the Nerves in Bush Medical College. Prof, of Theory and Practice of Medicine in The Woman's Medical College Physician to Presbyterian Hospital of Chicago. CONTENTS: I.—Nature and Cause of Sleep. II.—Insomnia or Wake- fulness. III.—Remedies for Inson\ni«, IV.— Treatment of Insomnia. V.—Dreams. VI.—Somnambulism. VII.—Arti- ficial Somnambulism or Hypnotism. 'Insomnia and Other Disorders of Sleep,' by Dr. Henry M. Lyman, (Chicago: W. T. Keener), is a medical book whose matter and style carry it into the higher grades of literature! It represents thought and knowledge, and to students interested in psychical research the last half of the book should be useful and attractive. The first half is limited in its adapta- bility to practising physicians.—The Nation. It is pleasant to find a book which is clearly the result of a natural literary effort and the author's fondness for his theme—a book not written to "supply a long-felt want" or "to fill an existing gap." Dr. Lyman's is such a one, and 6hows that the subject of which he writes has been a pleasant study. It is readable and full of interest, and is quite up to the times, which is important, as the last work upon Sleep, a very good one by the way, was written by Dr. Hammond nearly fifteen years ago. Dr. Lyman agrees with Mosso that sleep depends rather upon molecular disturbance than upon fluctuations in the blood-supply, which is the modern and generally accepted theory. His considerations of the pathological states which induce wakefulness are especially full and practical, and his therapeutical suggestions, despite a tendency to polypharmacy and rather heavy dosage, are in the main excellent.—The New York Medical Journal. Those who would like to acquaint themselves with what science has to 6ay on these topics and learn how they are regarded by the wisest students of this age, may turn with profit to the pages of this book. The author is well known, not only as a skilled physician and accomplished teacher, but as one of the most polished writers of the American Medical Press.—Philadelphia Medical and Surgical Reporter. The author has evidently brought to bear upon the subject, extended research, and close observation. Insomuch that there are few medical practitioners who may not find in it much that is both interesting and profitable, that is practical ***** It is the best book on the subject.—The Sanitarian. ONE VOIiUME. 12MO. CliOTH, - - $1.50. W. T. KEENER, Medical Publisher, Importer and Bookseller, 96 Washington St., CHICAGO. NOW READY! Indigestion and_ Biliousness. J. MILNER FOTHERGILL, M.D., Member of the Koyal College of Physicians of London; Senior Assistant Physician to the City of London Hospital for Diseases of the Chest ("Victoria Park); late Assistant Physician to the West London Hospital; Associate Fellow of the College of Physicians of Philadelphia. " Dr. Fothergill's writings always command attention; they are sprightly and full of instructive facts, drawn mostly from his own large experience. This volume is written from a physiological standpoint, and begins with an account of natural digestion, by way of introduction or antithesis to the main topic of the book. As the liver is the great storehouse of supplies for the use of the system, four chapters are devoted to its functions and their disturbances. In referring to the influence of mental strain and worry, Dr. Fothergill says: 'Talking one day with Mr. Van Abbott, whose biscuits for diabetics have such a well-deserved renown, I asked him, "Who are your diabetics mostly?" The reply* was very significant. " Business men, com- paratively old and gray for their years; men who look as if they had a deal on their minds." This was the response. It stands in suggestive relationship to the fact of acute diabetes being set up by shock or other mental perturbation, or of its artificial production by the puncture of the floor of the fourth ventricle.' The whole book is practical and interesting reading." « " The relation of digestion to habits of life, to methods of living, and to the perfect nutrition of the body, are treated in a masterly manner, and abound in practical hints of the greatest possible utility to the practicing physician. Altogether, the work is a remarkably comprehensive study of a subject which is too little understood by the majority of medical men." —New York Medical Record. One Volume, 12mo., Cloth, 82.25. Mailed postpaid on receipt of price., V. T. KEENER, PUBLISHER, 96 Washington Street, CHICAGO. THE WORKS OF NICHOLAS SElSHSr, Ph.D., M.D., Professor of Practice of Surgery and Clinical Surgery in Rush Medical College; Attending Surgeon Presbyterian Hospital. I. EXPERIMENTAL SURGERY. Contents—Fractures of the Neck of the Femur, with special reference to Bony Union after Intra-Capsular Fracture. II. Experimental Researches on cicatrization in Blood Vessels after Ligature. III. An experimental and clinical study of Air-Embolism. IV. The surgery of The Pancreas as based upon experiments and clinical researches. V. An experimental contribution to Intestinal Surgery, with special reference to the Treatment of Intestinal Obstruction. VI. Rectal Insufflation of Hydrogen Gas as an Infallible Test in the Diagnosis of Visceral Injury of the Gastro-intestinal Canal in Penetrating Wounds of the Abdomen. Complete in One Handsome Volume, 8vo. Cloth $5.00; Half Mor. $6.00. The different parts of this volume have been published from time to time in Transactions of The American Surgical Association, and in periodicals not readily accessible to the majority of the Medical Profession. In response to a very general demand they have been revised by the Author and published in a convenient sized volume, carefully indexed. II. INTESTINAL SURGERY. Contents—The Surgical Treatment of Intestinal Obstruction. II. An experimental contribution to Intestinal Surgery with special reference to the Treatment of Intestinal Obstruction. III. Eectal Insufflation of Hydrogen Gas as an Infallible Test in the Diag- nosis of Visceral Injury of the Gastro-intestinal Canal in Penetrating Wounds of the Abdomen. IV. Report of cases. One Handsome Volume, Svo. Cloth *2.50. III. THE PRINCIPLES OF SURGERY. In One Handsome Octavo Volume. Cloth $4.50 net. Leather $5.50 net. From The American Journal of Medical Science. In at work characterized not only by careful arrangement and clear exposition, but also by a paience of research and an originality of conception which promise the author a lasting fame in the annals of surgery, there must necessarily be much to praise; and again, it is a poor book in which there is nothing to criticise. The moat striking, the most valuable of Senn's original conceptions or applications are: 1. The uses of gaseous enemeta both for diagnostic and therapeutic purposes. 2. Lateral approximation by decalcified bone plates. 3. The application of omental grafts in abdominal 6urgery; and, 4. The mechanical irritation of peritoneal surfaces between which it is desired that adhesion should take place. The value of all these methods has been experimentally proven, and they have been suc- cessfully applied by Senn and by other surgeons who have carefully reviewed his work. It is difficult to determine whether the enthusiasm and the confidence with which he writes should be praised or condemned. After completing his book, the surgeon lays it down with the con- viction that at last the difficulties and dangers of abdominal work have been overcome, that the definite rules of operative procedure are established, that this branch of surgical knowl- edge is completed from Alpha to Omega. In the toil and travail of an obscure case there may be a tendency in the mind of the operator to resent this "cock-sure " style which filled his mind with such joyous anticipation, but when one or another of Senn's brilliant expedi- ents has finally brought him to a successful termination, he may be disposed to look more forgivingly on this fault. . The greatest value of Senn's work is its suggestiveness. He has set surgeons in all countries to thinking and planning. His methods as such may none of them be permanent, but he has given an impetus to abdominal surgery the outcome of which none can foresee, but which is full of promise. He is in the very van of progress, a leader who is not infallible, but who has earned by hard work and ability the enviable place he holds in the scientific W°rlThe gaseous enemeta which he advocates as an infallible test in the diagnosis of wounds of the gastro-intestinal canal will probably not be found to sustain this claim, yet no one can deny the immense value of this method, nor withhold admiration for the genius which prompted its application. Finally, his book should be read to be duly appreciated and no higher tribute can be paid to its value than that it stimulates the surgeon to better thought and better work.____________________ W. T. KEENER, Medical Publisher, Importer and Bookseller;, 96 Washington Street, CHICAGO. 3srcrs*7" :k:e3^»id"z-z RECTAL AND ANAL SURGERY, WITH A DESCEIPTION OF THE SECRET METHODS OF THE ITINERANTS. BY EDMUND ANDREWS, A.M., M.D., LL.D. Senior Surgeon of Mercy Hospital, Professor of Clinical Surgery in Chicago Medical College. —AND— E. WYLLYS ANDREWS, A.M., M.D. Surgeon of Mercy Hospital and Adjunct Professor of Clinical Surgery in Chicago Medical College. SECOND EDITION. REVISED AND ENLARGED. The rapid sale of the First Edition now compels the publication of a Second Edition, which has been entirely rewritten and considerably enlarged. While still keeping to the idea of a practical working treatise, rather than one devoted to the historical and theoretical sides of the subject, it has been felt necessary in the new edition to introduce a chapter upon the special Anatomy of the Eectum and Anal Region, for ready reference in daily prac- tice, and to make clear and unmistakable the exposure of that shallow pseudo- pathology which ignorant or venal specialists have tried to foist upon the public and even upon the profession. A new chapter has also been added upon " Proctitis " and its most ap- proved treatment. In the matter of new operations, such as Whitehead's, an endeavor has been made to introduce the latest results of clinical trial as found in periodi- cal literature down to the time of publication, as well as in the newer treatises. The subject of Anal Fissure has been more fully examined and illustrated than in the last edition, and.all the known methods of treatment, including the itinarant and the so-called " systems," carefully considered. It has been the endeavor in this edition, as in the former, to give relatively a large place to the more common Rectal Diseases which are so constantly coming before the practitioner, and less to the rare and unusual cases which practically are of less moment. Accompanying the general descriptions of the various forms of treatment, the formulae which experience has proven most useful have invariably been introduced. The aim has been to select these formulae so far as possible from the best sources, eliminating those which are untried or have not stood the test of trial. Another new feature is the Fokmulabx at the close of the book, containing over fifty practical working prescriptions, and including all of any note of the best Foreign and American surgeons, as well as some new ones, and those employed by traveling or local "Rectal Specialists" for injection of haemor- rhoids and other purposes. This Formulary may be relied upon as nearly a complete compilation of the remedies advised by Curling, Van Buren, Ball, Kelsey, AUingham, Esmarch and others, and, ior hurried reference, it is believed it will be found a prac- tical benefit to the average practitioner and oftentimes save him the turning over of many volumes when time is precious. One Volume, 8vo, Cloth. Profusely Illustrated. $1.50 net. Mailed, Postpaid, on Receipt of Price. W. T. KEENER, Medical Publisher, Importer and Bookseller, 96 Washington St. <3HICZ:A&CD_ s\ j*U& h, "v NLM051107595