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M.E.C.P. (LOND.) 













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IN no branch of medicine more than in diseases of the 
urinary tract and disturbances of the act of micturition 
is greater difficulty experienced in the separation of 
medical from surgical conditions. For this reason the 
co-operation of physician and surgeon in the prepara- 
tion of this small work requires no justification. The 
aim of the authors has been primarily to assist the 
general practitioner in identifying a lesion from the 
symptoms which are present. Only such pathological 
details are included as can be strictly regarded as 
essential to this end ; and whilst elementary clinical 
pathology has not been neglected, only the barest 
reference has been made to those methods of investi- 
gation which demand the resources of a well-equipped 
laboratory and the technical skill of an experienced 

It has been thought unnecessary to elaborate certain 
methods of treatment, which only a surgical specialist 
could adequately undertake, but a more detailed 
description has been given of measures which are 
regarded as urgent, and which a practitioner would 
consider to come legitimately within his province. 

A. A. 

LONDON, September, 1921. A. C. M. 



PBBFACE . . . . 9 T 


VARIATIONS . . , . 1 

II. ALBUMINURIA . . . . .7 

III. H.EMATURIA . . . . .15 

IV. PYTJRIA . . . . . .27 

V. GLYCOSURIA .\. . . . .30 




IX. NEPHRITIS ' . ." . . .70 


XI. BACTEBIUBIA . . . . .84 


XIII. CYSTITIS . . . . .91 




INDEX ...... 11Q 





A BRIEF chapter upon the appearance and other 
characteristics of normal urine affords a convenient 
introduction to the study of pathological conditions 
of the urinary tract and of other systems which may 
lead to disturbances of micturition. In this way 
may first be emphasised the circumstance that con- 
siderable variations are compatible with health, and that 
even the existence of admittedly abnormal substances 
may be occasionally encountered in conditions which 
cannot strictly be termed disease. 

Characteristically, healthy urine freshly voided has 
a clear limpid appearance, and remains so for hours. 
At a variable period after its excretion, a faint cloud 
of mucus gradually settles to the bottom of the specimen 
glass, the chief importance of which is that it should 
not be mistaken for tube casts and prostatic threads 
occurring in chronic gonorrhoea and gleet. In women, 
the mucus cloud is normally denser from admixture 
with vulval and vaginal secretion and epithelial scales. 
A general cloudiness present in freshly voided urine 
denotes as a rule the presence of pus or of bacteria, 
but such a turbidity may be due merely to the precipi- 
tation of phosphates in large quantity in an alkaline 
urine, as is easily shown by its complete disappearance 



when dilute acetic acid is added. Turbidity which 
appears on standing is only an indication of the presence 
of urates : such turbidity rapidly clears up on heat- 
ing. On very rare occasions a cloudy appearance is due 
to the suspension of finely divided particles of fat, 
a condition known as chyluria. (See page 40.) 

In considering appearance one naturally passes to 
the colour of urine. This is normally a faint amber 
yellow due to urochrome, and its intensity varies with 
concentration. Thus in summer, urine is generally 
darker, and the urine passed on rising is of a more 
intense yellow than that voided during the rest of 
the day. In fevers, also, .the colour is dark, partly 
as the result of concentration and partly from excess 
of pigments. Very light-coloured urine results from 
the natural dilution consequent upon the imbibition of 
large quantities of fluid, and a light colour is similarly 
encountered in the urine of low specific gravity in 
diabetes insipidus and granular kidney. A very light 
dilute urine is sometimes passed after an hysterical 
seizure. But coloration alone is no certain indica- 
tion of low specific gravity, for a very light-coloured 
urine is frequently seen in diabetes mellitus, containing 
a large quantity of sugar and of high specific gravity. 

The colour of urine may be modified by the presence 
of pigments, some normally present in urine but in 
certain circumstances excreted in excessive quantity, 
others adventitiously introduced if certain drugs or 
foodstuffs have been taken. Thus beetroot, bilberries, 
and other fruits and vegetables may lead to a distinctly 
dark coloration, whilst the administration of rhubarb, 
senna and santonin is usually followed by the passage 
of urine of a deep yellow colour from the excretion of 
certain colouring materials which these drugs contain. 
The salicylates and resorcin are two other examples 
pf drugs which may colour the urine dark brown, 


The aniline dyes which are sometimes employed to 
colour cheap sweets and ices frequently give a dis- 
tinctly greenish-fluorescent appearance to the urine. 
Methylene blue, whether ingested in the same manner 
or directly as a drug, gives a colour to the urine varying 
from a deep green-blue to a light green according to 
the quantity of the drug taken. 

None of the above-mentioned colorations have 
any pathological significance, but they cannot in all 
cases be distinguished by inspection alone from some- 
what similar colours which are the result of pathological 
conditions. Thus a pink colour may denote the 
presence of a small quantity of blood pigment and 
a state of hsematuria, of haemoglobinuria, or of 
hsematoporphyrinuria. By appropriate means the 
presence of blood pigment can of course be rapidly 
detected (see page 15). Should the blood pigment be 
present in larger quantity the urine will be coloured 
brown of greater or less intensity even to the degree 
of blackness. Black urine may also be encountered 
in those rare metabolic disturbances, melanuria and 
alkaptonuria, as well as in the condition of indicanuria, 
when a profound degree of intestinal putrefaction 
is responsible. But the two former are distinguished 
by the circumstance that the urine when voided is 
clear, and becomes black only on exposure to air. 

Bile in the urine leads to an appearance which, 
although not easy to describe, is very characteristic. 
It is of a rich orange yellow, possessing a greenish tint, 
and the composite colour is particularly evident in the 
foam on the surface which is readily produced on shaking. 

To sum up, then, an abnormal coloration of the 
urine may be due to the presence of an exceptionally 
large quantity of certain pigments which are normally 
present in urine, or to pigments present in certain 
drugs and foodstuffs, or to pigments derived from the 


blood (and bile). Since it is the last named which 
constitute the only pathological constituents, it is for 
these alone that special tests must be performed, and 
these will be found under the corresponding headings. 

The odour of normal freshly voided urine is peculiar 
and unmistakable. It is described as aromatic, but 
it is too familiar to demand description. It is more 
marked when the urine is concentrated. The charac- 
teristic odour may be altered in pathological conditions 
when decomposition, either intra- or extra-corporeal, 
has occurred and the urine has become ammoniacal 
or putrid, according to the degree and nature of the 
decomposition. In lesser degree even perfectly healthy 
urine becomes ammoniacal if left exposed for any 
considerable length of time. 

In diabetes mellitus the urine may possess a distinctly 
sweet or acetone (ripe-apple) smell. Other odours are 
imparted by the presence of aromatic substances present 
in certain drugs or foods. Thus turpentine gives the 
odour of violets ; copaiba and peppermint may contri- 
bute their characteristic smell ; and asparagus and garlic 
are other familiar odours which can usually be identified. 

The reaction of normal urine is acid to litmus. The 
acidity is due not to free acid, but to the acid salt, 
dihydric sodium phosphate (NaH 2 P0 4 ), which is normally 
present with the monohydric salt (Na 2 HP0 4 ) in the 
proportion of 3:2. The monohydric salt may, how- 
ever, be present in increased amount ; and as both 
phosphates are able to exert their own specific reaction, 
urine not infrequently exhibits the curious property 
of turning red litmus blue and blue litmus red its 
amphoteric reaction. 

The acidity of urine is increased if animal food in 
excess is taken. On the other hand, vegetable foods, 
being rich in bases, reduce the acidity. A tendency 
also exists for the acidity to diminish after any meal, 


as the secretion of hydrochloric acid in the stomach 
sets free bases and leads to an increase of monohydric 
sodium phosphate. An alkaline urine may thus be 
secreted as such if hydrochloric acid is being rapidly 
satisfied or is not being normally produced, as for 
example in carcinoma of the stomach or in achylia 
gastrica. But more commonly when the urine is 
alkaline it has actually been secreted as a normal 
acid fluid and become decomposed in the bladder by 
the Micrococcus urece, alkalinity thus taking the place 
of acidity. Such a condition of alkalinity occurs in 
vesical stagnation from any cause, whether from stric- 
ture of the urethra, enlarged prostate, or spinal disease. 

Finally, the urine can be rendered alkaline by the 
oral administration of the carbonates, citrates, or 
acetates of potassium, although the reverse process, 
the conversion of an alkaline into an acid urine, is not 
so easily performed. 

The specific gravity of urine is on the average between 
1012 and 1022. Variations depend so much upon 
many quite natural conditions that marked divergences 
from these figures are possible in the absence of any 
disease. Thus, if a large quantity of fluid has been 
ingested the specific gravity may fall to as low as 1005 ; 
whilst, on the other hand, during very hot weather, 
concentration may easily occur to raise the specific 
gravity to 1030. In diabetes mellitus, the normal ex> 
pectation is a urine of high specific gravity, and in general 
one may say that light-coloured urine is associated with 
low specific gravity but that this is not always the case 
in diabetes mellitus, in which a very light-coloured urine 
of high specific gravity is frequently present. 

Urine of low specific gravity is generally found in 
the condition of granular kidney and in diabetes 
insipidus. In the last named a urine with a specific 
gravity no higher than 1001 may be encountered. 


The quantity of urine passed in twenty -four hours 
is on the average from 40 to 50 ounces, but may 
be subject to wide variations 'in perfect health. The 
quantity depends partly upon the amount of fluid 
taken and partly upon the relative activity of the 
sweat glands and the bowels, with consequent loss 
through these channels. Excretion through the lungs 
may also be an important factor if violent exercise 
is indulged in. Normally, the secretion of urine is 
reduced during the night : it is increased in arterio- 
sclerosis, diabetes insipidus and mellitus, and in certain 
cardio-renal diseases when the diurnal secretion is 
reduced owing to circulatory demands but the tone 
of the vascular system under the recuperating influence 
of sleep improves so that secretion and excretion 
occurs at night of the fluid retained during the day. 
The whole subject of polyuria is considered in detail 
later (see page 46). For the present it suffices to 
mention that the total quantity of urine passed is 
pathologically increased in diabetes, granular kidney, 
and cerebral injuries. It is frequently much increased 
after an epileptic attack and in some hysterical con- 
ditions. It may also be noted that the quantity of 
urine may substantially exceed the total quantity of 
fluid ingested, desiccation of the tissues occurring to 
supply the excess, 'although, in normal circumstances, 
the 40 or 50 ounces passed in twenty-four hours 
represent two-thirds of the fluid taken. Diminution 
of urine is seen in acute Bright's disease, in cardiac 
failure, in fevers and conditions accompanied by 
low blood-pressure. It is diminished after any con- 
siderable loss of fluid from the body, particularly 
haemorrhage, protracted vomiting and diarrhoea. 
And it is naturally diminished in conditions of sup- 
pression and obstruction to its passage. 


THE presence of albumin in the urine is frequently 
regarded as evidence of disease of the urinary tract 
and especially of the kidneys. This, however, is far 
from being the case : albuminuria may be present 
to a comparatively large extent as a transient pheno- 
menon of negligible character, and it may even occur 
as a persistent condition in the absence of any disease 
of the urinary tract. Its presence, then, does not 
indicate that some pathological condition is present ; 
still less does it prove that the kidneys are diseased. 
Albuminuria must always be considered as a symptom 
to be correlated with all associated circumstances. 

In any case in which albumin has been detected 
it is desirable to examine a centrifugalised specimen 
of the urine for cells or casts, which must in themselves 
constitute at least a part of the protein substance 
responsible for the positive test. One's view of a 
case completely alters with the discovery that such 
constituents are present. 

It will be convenient first to consider those cases in 
which no deposit is discovered on microscopic examina- 
tion, i.e. conditions of simple albuminuria. At this 
stage a few words may not be out of place respecting 
the usual tests for albumin which for ordinary clinical 
purposes are the following : 

(1) Nitric Acid Test (Heller's). Pure concentrated 
(not fuming) nitric acid is poured into a test-tube to 
the height of 1 inch. The tube is then slanted and 
urine is gently poured (preferably through a pipette) 


down the side of the tube so that it floats on the acid. 
The tube is then restored to the vertical position. 
A white cloud at the junction of the two fluids is a 
positive test for albumin : a dense coagulum forms 
if the percentage is large, a faint opalescence only if 
in lower concentration. In the latter event several 
minutes may elapse before the cloud is clearly visible. 

Certain precautions are necessary in connection 
with this test. Mucin occasionally precipitates out, 
but higher up in the urine than at the junction level. 
Concentrated urine containing a large amount of 
urates often yields a precipitate of urea nitrate, but 
the colour is yellow rather than white. If any doubt 
exists as to the nature of the precipitate j the urine 
should be diluted and warmed before being added 
to the nitric acid. Sometimes the urine of patients 
who are taking copaiba may become turbid on the 
addition of nitric acid. 

(2) The Boiling Test. The reaction of the urine 
is first taken. If alkaline or not distinctly acid, a few 
drops of dilute acetic acid are added. A test-tube is 
then filled to three -fourths its capacity and the upper 
part of the column is boiled, the tube being held 
obliquely in the flame for this purpose. The presence 
of albumin is indicated by turbidity of the portion 
boiled, such turbidity varying from a faint haze to a 
dense coagulum which may be practically solid. Acetic 
acid is then added to the urine ; persistence or even in- 
crease of the turbidity occurs if albumin is present ; 
should the cloud disappear, its presence was due to phos- 
phates or carbonates only. In any case, even if the urine 
is definitely acid, a few drops of dilute acetic acid 
should be added after boiling, whether turbidity is 
present or no. 

Many other more delicate tests for albumin have 
been elaborated, but for clinical purposes the above- 


mentioned are not only sufficiently reliable but suffi- 
ciently delicate. Before leaving the subject, however, 
a point of special consideration relating to the boiling 
test must be mentioned. 

Should a precipitate appear when the urine is heated 
and gradually dissolve as the heating is continued until 
it has completely disappeared when the urine boils, 
the rare condition of Bence Jones albumosuria is present. 
This protein body is specifically associated with multiple 
myelomata, and it is conceivable that the urinary 
phenomenon to which it gives rise might be overlooked 
if the boiling test were not carefully conducted. 

Albuminuria without Evidence of Disease. 

Many terms are in current use to express this condition, 
such as " physiological," " postural," " intermittent," 
"functional," "transient," "adolescent," "cyclical," 
" orthostatic," " familial " albuminuria and " leaky 
kidneys." Whilst these various terms have certain 
special features, they have in common the circum- 
stance that the individual in question displays the 
peculiarities familiar in vasomotor asthenia and most 
frequently exhibited at the period of adolescence, when 
neuro-circulatory disturbances are likely to be pro- 
duced owing to instability of the vaso-motor system 
at this time of metabolic stress. An important investi- 
gation in all cases of albuminuria is the estimation 
of the blood-pressure which, in subjects under present 
consideration, is invariably low. It has been observed 
that the type of young adult who is prone to such 
attacks of albuminuria is also liable to attacks of 
fainting upon exposure to cold and deprivation of 
food. The postural element is indicated by the cir- 
cumstance that whilst the early morning urine is free 
from albumin, that passed about 10 or 11 a.m., after 
the subject has been up and about, exhibits the 


phenomenon which again disappears by evening. If he 
remains in bed, or at least in the horizontal position, 
all day, the urine will be free from albumin. In the 
majority of such subjects the lumbar spine is markedly 
lordotic, and in certain cases it is possible to induce 
a temporary albuminuria by placing the subject in 
an appropriate posture for a quarter of an hour. It 
is suggested that distension of the renal veins with 
congestion of the kidneys may be the determining 
factor, and it has been claimed by some Continental 
workers that in this type of albuminuria the urine 
from the left kidney (as shown by catheterisation of 
the ureters) alone exhibits the peculiarity, due, it is 
suggested, to pressure of the ureter on the left renal 
vein. But in any case the mechanical element does 
not appear to be the only one ; there must be some 
physiological peculiarity, such as decreased coagulability 
of the blood, since the administration of calcium 
chloride or lactate will often prevent the albuminuria. 
It may be noted that part of the protein in these cases 
is frequently a mucin or nuclein compound, and not 
all serum albumin or globulin. 

The albuminuria which occasionally follows very 
strenuous exercise is again hardly to be considered 
a pathological condition. It has been observed on 
several occasions after a very hard boat race. One 
of the present authors has had considerable experience 
of the physiological effects of track athletics, and he 
has failed to detect albumin in the urine of both short 
and long distance runners even after very severe 
exertion, for which reason it may be assumed that the 
exertion alone is not responsible, but that the posture 
of the oarsman during his exercise may also be a factor. 

In some susceptible persons albuminuria follows a 
cold bath, again in all probability as a vaso -motor 


A condition which has been described as " alimentary 
albuminuria " may occur analogous to alimentary 
glycosuria, when the ingestion of an excessive amount 
of protein food may be responsible for its appearance 
in the urine. This condition is not so common as 
one in which, owing to an idiosyncrasy, white of egg 
reaches the blood unchanged, to be excreted from the 
body through the kidneys. 

It is perhaps necessary to interpose as a warning 
that the passage of urine shortly after a seminal emission 
may lead to the identification of albumin, owing to 
the presence of spermatozoa and prostatic secretion, 
and that the same condition is almost invariable in 
women from admixture with vaginal and vulval secre- 
tions, unless a catheter specimen has been taken. 

Albuminuria is not uncommon during pregnancy, 
as a physiological sequel of the extra work thrown 
upon the kidneys by the placental circulation, but 
such a condition cannot in itself be distinguished from 
a more serious pathological albuminuria due to irritation 
of the renal epithelium by foetal products, and consti- 
tuting one of the toxaemias of pregnancy. In such an 
event associated symptoms must be taken into con- 

When considering albuminuria in pathological cir- 
cumstances, it is found that variable degrees of 
albuminuria are not uncommon in many febrile con- 
ditions, particularly in scarlet fever, diphtheria, 
follicular tonsillitis and pneumonia ; and although 
such a condition is often transient only, it is hardly 
possible to deny that the toxin in question may have 
induced an actual nephritis, more especially as the 
quantity of albumin is larger than one is accustomed to 
see as an accompaniment of a purely febrile condition, 
and is more persistent, although subsidence during 
convalescence is the rule. 


Albuminuria of slight or moderate degree occurs in 
cardiac failure, in cirrhosis of the liver, in obstruction 
of the inferior vena cava from thrombosis or external 
pressure, and in primary anaemias and severe secondary 
anaemia, again from the circulatory disturbances or 
changes in the blood which occur in these conditions. 

A small amount of albumin is also frequently present 
in chronic alcoholism, in gouty subjects, in sufferers 
from Graves's disease and myxcedema, and not un- 
commonly after apoplectic and epileptic attacks, when 
traces of sugar may also be present. 

Albuminuria and Renal Disease. 

Up to this point albuminuria has been regarded 
as due to a variety of conditions among which disease 
of the urinary tract is not included. It is now necessary 
to distinguish those cases in which albuminuria is an 
index of a renal disease and in which, as has already 
been said, the identification of certain cellular elements 
in the deposit microscopically examined is of impor- 

The deposit may consist of pus cells, blood cells, or 
urinary casts. These may or may not be responsible 
for the whole of the albumin present, but until their 
origin and significance has been established the cir- 
cumstance that albuminuria in greater or less amount 
is present recedes into the background. 

The presence of blood constitutes the condition 
haematuria (or haemoglobinuria), to which the reader 
is referred as aseparate consideration in Chapter III. 

Similarly as regards pus : the subject of pyuria is 
considered in Chapter IV. 

The remainder of this chapter will be devoted 
to the subject of casts, i.e. nephritis, acute and 



Whilst the occasional presence of isolated casts 
cannot be considered as pathological, speaking generally 
they denote nephritis. The nature of the cast is of 
considerable importance in order to assess the character 
and severity of the renal lesion which is responsible 
for their production. 

The simplest form of cast is one which is composed 
of a structureless, almost transparent matrix, this 
type is called hyaline, and its exact formation (and 
relative significance) is still a matter of dispute among 
pathologists, some of whom regard it as a result of 
coagulation of mucus, and therefore unimportant. (The 
term cylindroid is sometimes employed for an aggrega- 
tion of salts, e.g. phosphates or urates held together 
by mucus and drawn out so as to resemble a renal 
cast.) Embedded in such a matrix may be recognised 
epithelial cells, red blood corpuscles, white blood 
corpuscles, granular debris or fat globules, according 
to which the casts are designated epithelial, blood, 
leucocytic, granular, and fatty casts respectively. 
Blood casts alone may be present in any condition 
of haematuria, whether nephritis is present or not, and 
their existence is no evidence of nephritis unless other 
casts are also present. 

Casts may occur in the following conditions : 

(1) Malignant disease of the kidney. A micro- 
scopical examination of the urine will almost certainly 
show the presence of fragments of new growth. 

(2) Infarction of the kidney. In the great majority 
of cases, malignant (infective) endocarditis is present 
and definable by other clinical evidence, notably cardiac 
murmurs, intermittent pyrexia, the presence of haemor- 
rhages, e.g. in the form of petechiae, or in the retina or 
of other infarcts, e.g. the spleen or lung. Increasing 
anaemia will also occur. 

(3) Lardaceous disease of the kidney, nowadays 
a rare condition, which (together with lardaceous 
disease of other viscera) - accompanies long-standing 
suppuration and chronic wasting diseases, e.g. bron- 
chiectasis, tuberculosis, tertiary syphilis. No special 
urinary features characterise this disease, although 
lardaceous casts which give the typical reaction with 
iodine may occur. The diagnosis is inferred from 
the evidence of renal disturbance in the presence of 
one of the diseases referred to. 

(4) Acute nephritis. In most cases, but not in- 
variably, the condition is characteristic, pyrexia, 
anasarca, especially oedema of the face, ankles and 
genital organs, witH scanty concentrated urine con- 
taining blood cells and casts of any or all descriptions. 
Such a disease may be primary and occur in the course 
of an acute illness, e.g. scarlet fever, diphtheria, influenza, 
pneumonia, or as an acute exacerbation of a previously 
existing (chronic) nephritis. (See page 70.) 

{5) Nephritis in pregnancy. This would appear 
to be a special form of acute nephritis due to some 
toxin elaborated by the foetus or by the mother. 

(6) Chronic nephritis. The quantity and nature 
of casts varies considerably. Blood casts which denote 
an acute* inflammatory condition are absent, and 
epithelial casts are comparatively scanty. In many 
cases of chronic nephritis casts are to be found only 
in the smallest numbers. (See page 74.) 


IN the consideration of blood in the urine there must 
first be distinguished admixture with the colouring 
matter (haemoglobin) only : haematuria proper means 
admixture with all the constituents of blood. Whilst 
all the various chemical tests for blood are given by 
both conditions since they depend on the presence 
of haemoglobin the essential feature, the identifica- 
tion by the microscope of red blood corpuscles, 
alone enables one to decide that true haematuria is 

The advantage of microscopical examination is not 
only to obtain unequivocal evidence that blood and 
not haemoglobin alone is present, but it ensures the 
identification of minute quantities which would not 
be detected by other means, however delicate. 

The chemical tests most frequently employed are 
the following : 

(1) The Preparation of Hcemin Crystals. The urine 
is centrifugalised, and the deposit obtained is placed 
on a microscopic slide. To it are added a grain of 
sodium chloride and two drops of glacial acetic acid. 
A cover-glass is then placed over the whole and 
the mixture heated to boiling. On cooling, small 
brown crystals of haemin, which are rhombic plates 
with bevelled edges, will be visible microscopically. 
Although in certain circumstances this test may have 
special advantages, it is superseded in ordinary clinical 
practice by one of the following. 

(2) The Gfwawm Test. A few drops of .freshly 



prepared tincture of guiacum are added to 10 c.c. of 
urine in a test-tube. Ozonic ether is then poured 
slowly down the side of -the tube. The test may 
alternatively be performed by making a dilute solution 
of the tincture in ozonic ether and adding that to 
the urine. A blue coloration indicates the presence 
of blood, but if the latter is in small quantity only, 
the reaction may not appear until the test-tube has 
been slightly warmed. The guiacum reaction is not 
specific for blood but is on the whole satisfactory 
for ordinary clinical practice. Whenever possible, the 
benzidin test should be performed. 

(3). The Benzidin Test. A supersaturated solution 
of pure benzidin in glacial acetic acid is first prepared. 
The urine to be tested is thoroughly boiled and then 
allowed to cool. To ten drops of the benzidin solu- 
tion the same quantity of urine is added, followed by 
twenty drops of hydrogen peroxide (20 vols.). A 
positive reaction is a blue or bluish-green coloration 
within half a minute. The test is very delicate, and 
its delicacy is sometimes advanced as an objection to 
its clinical employment ; but if care and cleanliness 
are observed, there can be no real disadvantage in 
its use in ordinary practice. 

Spectroscopy. If the urine is very dark, it should 
be diluted before examination. The presence of oxy- 
haemoglobin will be evident by the two characteristic 
bands in the spectrum or by the additional band 
if methaemoglobin is present. The addition of 
ammonium sulphide solution reduces haemoglobin to 
the state of " reduced haemoglobin " characterised 
by a single broad band. 

In rare cases the special absorption spectrum of 
haematoporphyrinuria may be detected. 

Before dealing with the differential diagnosis of the 
site in the urinary tract from which the blood may 


be derived it will be convenient to systematise the 
possible causes of hsematuria as follows : 

A. Diseases of the Urinary Tract. 

(1) Renal. 

Trauma, Neoplasm, Calculus, Tuberculosis, 
Acute Nephritis, Granular Kidney, Coli 
Bacilluria, " Idiopathic or Essential Hsema- 
turia." (Under trauma may be included 
such causes as irritation of the kidney by 
turpentine or cantharides.) 

(2) Ureteric. 

Impacted Calculus, Neoplasus. 

(3) Vesical. 

Trauma, Neoplasm, Papilloma, Calculus, 
Tuberculosis, Acute Cystitis, Deposition 
of Bilharzia Hsematobia. 

An enlarged (vascular) prostate may be in- 
cluded in this category. 

(4) Urethral 

Trauma, Calculus, Caruncle, Naevus, Acute 
Urethritis, Malignant Disease. 

B. Extra-Urinary Causes. 

(1) HcemorrJiagic Fevers. The haematuria may, how- 

ever, be due to an actual acute nephritis. 
This was certainly the case in the last 
influenzal pandemic, when haematuria, apart 
from acute nephritis, was not seen in cases 
investigated ad hoc. 

(2) Infarction of the Kidney. In this condition 

infective endocarditis is invariably present. 

(3) Arterio-sclerosis. Haemorrhages from any mucous 

surface are not uncommon in conditions of 
high blood-pressure, and haematuria may 
occur from this cause alone. 


(4) Primary Blood Diseases : the leukaemias, per- 
nicious anaemia, splenic anaemia, purpura 
haemorrhagica, haemophilia. 

Notwithstanding this formidable list of causes, 
it is almost always possible fairly rapidly to narrow 
down the most likely situation of the lesion from the 
history of the onset or from associated circumstances. 
It will be best, perhaps, to eliminate the commonest 
conditions first and to assume that the patient is not 
obviously acutely ill, as would naturally be the case 
in acute nephritis and in any of the haemorrhagic 
fevers. Further, any injury capable of producing 
haematuria would certainly be of a sufficiently severe 
character to call attention to the viscus affected. It 
is possible, though hardly probable, that poisoning by 
oantharides or turpentine could be overlooked. 

A distinction of great importance is to ascertain 
whether or not the onset of the haemorrhage was 
sudden and accompanied by pain. In this connec- 
tion it is manifest that we are dealing with a condition 
of frank haematuria so conspicuous that the patient's 
attention is drawn to the abnormality, and not to 
the presence of small quantities of blood which are not 
macroscopically conspicuous, but which are discovered 
during microscopical investigation. 

Sudden onset with unilateral lumbar pain suggests 
a renal origin. The kidney may be unduly tender 
on palpation. These features do not always enable 
one to define the nature of the renal lesion, but an 
examination of the heart would confirm any suspicion 
that renal infarction had occurred. It must be men- 
tioned, however, that slight degrees of haematuria 
may occur in infective endocarditis without the 
symptoms of infarction, and in fact the identification 
of blood in the urine by the microscope has pointed 


the way on many occasions to a diagnosis of infective 
endocarditis with obscure symptomatology. 

Malignant tumours are always the cause of profuse 
haematuria, a symptom always very suspicious if a 
tumour in the loin is palpable. Renal tuberculosis 
or calculus is rarely accompanied by very profuse 
haemorrhage. The rapid development of a varicocele 
is a significant point if a renal growth is suspected. 

Sudden onset without pain suggests a vesical origin, 
e.g. papilloma, or an early case of prostatic enlarge- 
ment with vascular engorgement. In either of these 
conditions blood may be passed in considerable quantity 
independently of micturition, as would also occur in 
that rare condition urethral naevus, as well as in 
commoner pathological conditions of the urethra (q.v.). 

As a simple and convenient distinguishing investi- 
gation may be mentioned the three-glass test, in which 
the patient is requested to micturate in three portions. 
Should most blood appear in the first urine passed 
or blood be passed, at once independently of urine, 
a urethral cause for the haemorrhage is suspected ; 
should the urine be equally coloured in all three cases, 
a renal origin is probable ; whilst if the last urine 
passed is more bloody than the others, the source is 
most likely vesical. But such a means of differentia- 
tion is crude, and, whenever possible, urethroscopy 
or cystoscopy should be employed. 

Blood arising from the urethral mucous mem- 
brane independently of micturition may be due to 
(1) trauma, (2) urethral calculus, (3) malignant 

The antecedent history of trauma is always sufficient 
to enable a diagnosis to be established without the 
aid of special investigation. In connection with 
trauma one must not forget the passage of an instru- 
ment which may have resulted in injury. Instances, 


too, occasionally occur when a pin or other foreign 
body has been pushed into the urethra. Should rupture 
of the urethra be complete, surgical treatment is urgently 
necessary. Should the rupture be incomplete, in 
which case there will be neither extravasation of urine 
nor a swelling in the perineum, the patient is at once 
confined to bed, an injection of morphia, J grain, is 
administered, and a catheter (No. 22 French size) is 
passed and tied in position. The latter should not 
be retained longer than seven days. Eventually 
stricture develops, for the treatment of which the 
reader is referred to page 109. 

When haemorrhage follows instrumentation, it will 
almost invariably cease if the patient is put to bed and 
given morphia. But should bleeding persist, a large 
catheter (No. 22 or 24 French size) should be inserted 
into the urethra and retained, as in the case of 
incomplete rupture just mentioned. In such cases 
it is well to irrigate the bladder with warm nitrate of 
silver solution, 1 in 8,000, to wash out any clots which 
collect in the urethra or bladder. 

A urethral calculus is best diagnosed by the urethro- 
scope, but should the practitioner not find its passage 
convenient, the use of a sound will suffice ; a click 
is heard when the instrument touches the stone. 
Sometimes the stone becomes impacted in the urethra, 
causing urgent distress in addition to haemorrhage. 
For its removal a general anaesthetic is preferable, but 
the operation may be performed under local anaesthesia, 
two drachms of 2 % novocaine solution being injected 
into the urethra with a suitable syringe and held there 
for five minutes by digital compression of the penis. 
If the stone is situated in the anterior urethra, it may 
then be extracted with crocodile forceps. If in the 
posterior urethra, it should be forced back into the 
bladder by Bigelow's evacuator and cannula (an 


operation demanding a certain amount of special 
experience) and subsequently crushed with a litho- 
trite. Finally, should the stone lie behind a stricture, 
external urethrotomy must be performed. 

A malignant growth of the urethra does not cause 
spontaneous haemorrhage until ulceration occurs. At 
this stage of the disease the urethroscope must be em- 
ployed as an aid to diagnosis. (See also page 108.) 

If the site of the haemorrhage is vesical, this will 
be evident on cystoscopic examination. Furthermore, 
such an investigation will, even in those cases when 
the bladder can be exonerated, enable the observer 
to see the condition of the ureteric orifices, to collect 
urine separately from the two kidneys, and so obtain 
evidence to show which side is at fault and material 
whereby supplementary evidence of the nature of 
the renal lesion may be secured. For example, if 
the urine from both ureters contains blood, the surgeon 
can exclude a renal growth. 

Microscopical Examination. In addition to blood 
cells, the urine may contain pus cells, fragments of 
new growth, ova of Bilharzia hsematobia, renal casts, 
crystals of oxalates. Naturally, should any of these 
constituents be identified in the urine obtained from 
one ureter by separation whilst the urine from the 
other kidney is normal, unequivocal evidence as to 
which side is affected is obtained. But if separation 
has not been practicable, one may be compelled to 
correlate the pathological condition of the urine with 
the symptoms referred to one or other side with in 
some cases misleading results. 

Unilateral pain in the lumbar region radiating to 
the groin or testicle of that side, produced or aggra- 
vated by exertion or jolting, as in riding or driving over 
rough surfaces, is the typical history of renal calculus. 
Such attacks of pain are intermittent, colicky in 


nature, and accompanied by a fair degree of haematuria. 
In the urine, pus cells and crystals, particularly of 
calcium oxalate, are often to be found. The diagnosis 
would be strongly supported by radiographic examina- 
tion in which a shadow, the outline of a calculus in 
appearance, was visible. 

Such a stereotyped description is not generally 
ratified. A large calculus of pure uric acid may 
throw no shadow for example, and the surgeon must 
then rely upon such evidence as is available the 
condition of the urine and the history of the attacks, 
with the absence of any other disease capable of 
producing such symptoms. The "treatment of renal 
calculus is considered in detail in the chapter on 
stone in the urinary tract. (See page 115.) 

Oxaluria, in which crystals and blood are passed 
with the urine, occurs in some persons particularly 
predisposed, and especially after the ingestion of 
rhubarb and tomatoes. In these no X-ray shadow 
will be found. (See Oxaluria, Chapter VI.) 

In acute nephritis no localising symptoms occur. 
The urine is scanty, and contains casts as well as blood 
cells. The associated features a severe illness with 
pyrexia of sudden onset or following a recent attack 
of scarlet fever point to the diagnosis. (See page 70.) 

In chronic nephritis, haemorrhage from the kidneys 
may be the only sign. (See page 74.) 

Tuberculous disease of the kidney may not be suspected 
from the general condition of the patient, but investi- 
gation may be suggested from the circumstance of 
persistent slight haematuria with pyrexia and urinary 
frequency being discovered in a young adult. Specific 
examination for the tubercle bacillus is essential, and 
this may involve injection of urine into a guinea 
pig. The routine palpation of the epididymes and, by 
rectal examination, the vesiculae seminales and prostate 


must of course not be omitted. (See the special 
consideration of tuberculous disease of the urinary 
tract, page 87.) 

In vesical disease, other than tumours or early 
prostatic enlargement, there will be a history of 
tenesmus, of suprapubic pain and of frequency of 
micturition both by day and night. Such a history 
denotes cystitis, either of acute onset or accompanying 
some other vesical condition such as calculus. In 
vesical calculus which has not yet caused cystitis, 
diurnal but not nocturnal frequency is to be expected. 

In the vesical causes now to be considered bleeding 
is most usual at the end of micturition. The same 
symptom is commonly encountered in the acute 
urethritis of gonorrhoea, with which confusion is 
not likely. 

If acute cystitis is present, it will be suggested by 
the history of sudden urgent micturition followed im- 
mediately by the passage of a few drops of blood. 
In such a case the temperature soon rises and blood 
is passed mixed with urine in small quantities at 
frequent intervals. There is a good deal of pain both 
on the passage of urine and independently of micturi- 
tion. Cystoscopy in such a case shows an acute inflam- 
matory condition of the whole mucous membrane of 
the bladder. (Cystoscopy at the same time eliminates 
other causes of vesical haemorrhage, such as papilloma, 
stone, or bilharziasis.) 

The patient should remain in bed so long as fever 
and painful micturition persist. Morphia will gener- 
ally be needed for the pain, and if, as is frequently 
the case, the Bacillus coli is the organism responsible, 
large doses of sodium bicarbonate are administered 
to render and maintain the urine alkaline. If the 
organism isolated is of the cocci group, the urine should 
be rendered acid (by acid sodium phosphate), ancl 


urotropin is given. In either case alcohol is contra- 
indicated, and the diet should be bland, consisting 
chiefly of milk and barley water. 

Lavage should never be employed in the case of 
acute cystitis, the mucous membrane is too irritable 
to tolerate such treatment. 

Stone in the bladder is most easily identified by 
cystoscopy, but skiagraphy may sometimes be of 
assistance, or the diagnosis may be made by the passage 
of a bladder sound. Unless the stone is very large 
and associated with an enlarged prostate or lying in 
a diverticulum, litholapaxy will suffice for its removal. 
Suprapubic cystotomy is an alternative treatment. 
(See further, Chapter XVII.) 

Whilst adenomatous enlargement of the prostate 
may cause hsematuria, carcinomatous disease of the 
prostate is not usually accompanied by haemorrhage. 
Cystoscopy will reveal the presence of a tumour 
which may be entirely intravesical, and therefore not 
palpable by rectal examination. 

For treatment, see Chapter XV. 

Bilharziasis. This condition should be suspected 
as a possibility when hsematuria is under consideration 
in patients who have lived in South Africa and Egypt. 
The authors saw many cases during the War in soldiers 
who had returned from the East, and frequently the 
disease in question had been overlooked as unfamiliar 
in this country. 

The characteristic ova will be evident in the urine 
microscopically, and a deposit upon the bladder wall 
may be seen cystoscopically. In some cases a curious 
and very characteristic symptom is present, viz. a drop 
or two of blood appearing at the urethral orifice abso- 
lutely at the end of micturition. 

Until comparatively recently no treatment appeared 
to benefit this condition. Many observers have now 


reported excellent results by the use of tartar emetic 
given intravenously. For detailed description of this 
form of treatment the reader is referred to Dr. 
Christopherson's articles in the Lancet of September 7, 
1918, and June 14, 1919. The drug is injected in a 
dosage at first of \ grain three times a week. The dose 
is then increased at each subsequent injection up to a 
maximum of 2 grains. In all, 25 grains are given. 

The occurrence of haematuria in blood diseases may 
occasionally present itself as an isolated feature for 
explanation. More usually the diagnosis has been 
made, and a particularly close watch is then kept 
upon the urine for evidence of haemorrhage. We 
have already mentioned that in infective endocarditis 
microscopical examination of centrifugalised urine 
may reveal the presence of blood corpuscles, often in 
itself a link in the chain of evidence of a doubtful case 
of this disease. 

As will be seen in the list of possible causes of hsema- 
turia at the head of this section, a small residue of 
question-begging causes must always remain, and 
occasionally a case presents itself for which the most 
elaborate investigation fails to supply a reason. If a 
sufficiently high blood-pressure is present to justify 
a diagnosis of arterio -sclerosis, especially if the urinary 
symptoms familiar in granular kidney are present, 
a fairly satisfactory explanation is at hand. Other- 
wise one is compelled to assume the possibility of a 
renostaxis, analogous to " epistaxis of idiopathic 
origin " and gastrostaxis. Most of such cases do not 
call for treatment, although the symptom is naturally 
alarming to the subject. One such case came under 
the authors' care and was submitted to prolonged 
observation, during which the amount of blood thus 
lost at each period of haemorrhage was estimated. 


It was found to be really trivial in extent, although 
imparting a very decided colour to the urine. 
Exploratory nephrotomy in such cases leads to the 
discovery of no lesion, but after incision of the kidney 
cure has sometimes followed. 


This condition will hardly be suspected until, on 
making a systematic examination of a urine obviously 
containing much blood, few or no corpuscles are found. 
The condition is due to the destruction of red corpuscles 
within the bloodvessels, resulting in hsemoglobinaemia, 
the free haemoglobin .being removed from the blood 
plasma by the kidneys. Such destruction may be 
caused by certain poisons, e.g. potassium chlorate, 
or occur in certain pathological states, e.g. black water 
fever, but the most important clinical condition with 
which it is associated is paroxysmal hcemoglobinuria, 
the pathology of which is obscure. It is induced in 
susceptible subjects through exposure to cold. In 
certain cases Raynaud's disease also occurs at the 
same time of exposure, for which reason a vasomotor 
influence is supposed. But it has been noted that 
in most subjects of paroxysmal hsemoglobinuria the 
Wassermann reaction of the blood is positive, so that 
syphilis plays a part in its causation. 

In a typical case of hsemoglobinuria the urine does 
not look like blood mixed with water, but resembles 
rather a black liquid, e.g. porter, the hsemorrhagic 
character of which becomes more evident on dilution. 
Filtration perceptibly diminishes the colour in the 
case of haematuria, but not of a urine in which haemo- 
globin alone is present. As we have already mentioned, 
the microscope is the distinguishing test, the chemical 
reactions and the spectroscopic peculiarities being due 
to the blood pigment, 


WHEN investigating a case of suspected pus in the 
urine it is well to remember that the specimen to be 
examined should be taken from the total urine passed 
in twenty-four hours. 

The familiar method of testing for pus in the urine 
is to add an equal quantity of caustic potash solution 
and to mix the two liquids by rapidly passing them 
backwards and forwards between two test-tubes. A 
positive result is the production of a gelatinous ropy 
mass. The best and most accurate test is identifica- 
tion of the typical pus cells under the microscope. 
Pus cells are leucocytes undergoing degeneration ; they 
are well stained by a solution of iodine in potassium 

If the presence of pus is detected, the practitioner 
may then proceed to further tests to enable him to 
locate the seat of the disease. Thus the two-glass 
test will assist in excluding the urethra and prostate 
as the organs involved. If the urine passed into the 
first glass contains pus and into the second is clear, the 
pus can only come from the prostate or urethra. On 
the other hand, when there is pus in both specimens, 
these regions cannot be definitely excluded, for such 
a condition exists in prostatic abscess but it demon- 
strates that the seat of inflammation may be in the 
upper urinary tract. 

In every case of pyuria the urine must be submitted 
to bacteriological examination. As an example of 
the necessity of such a routine examination one of 


us recalls a case of pyuria with slight muco-purulent 
discharge from the urethra.. There was a history of 
an attack of gonorrhsea twelve months previously, and 
a diagnosis of chronic prostatitis of venereal origin 
had been made. However, bacteriological examination 
demonstrated the presence of the tubercle bacillus, and 
further investigation revealed extensive tuberculosis of 
the prostate and base of bladder. 

If a urethral origin for pyuria has been established 
urethroscopy should be performed. Thus may be 
diagnosed a commencing stricture, early malignant 
disease of the urethra, stone, and chronic inflam- 
matory affections of the prostate. Should the two- 
glass test favour the view that the origin of the 
pus is in the bladder or kidneys, the cystoscope 
must be requisitioned to assist in the diagnosis. 
If cystitis is discovered, then it will be necessary 
to determine whether this condition is primarily 
vesical or secondary to a lesion in another part of 
the urinary tract. By the aid of the cystoscope it 
is possible to note whether a purulent urine is escap- 
ing from one ureter or both. Having excluded the 
genitalia as the source of infection of the bladder, and 
if there is no evidence of spread of infection from the 
urethra, it is a wise procedure to catheterise both 
ureters and make a bacteriological examination of 
the urine excreted from each kidney. 

The diagnosis of medical diseases of the kidneys 
is greatly aided by an examination of the urine from 
each side. In this way the physician may obtain 
valuable data with regard to the involvement of one or 
both organs. Finally, much information may be gained 
by radiography of the whole urinary tract. By its means 
we are able to judge the size of the kidney, and the 
presence or absence of shadows in any of the urinary 
organs. The more common causes of pyuria are set 


out in the following table, and their diagnosis and 
treatment discussed in the chapters that deal specific- 
ally with affections of the different urinary organs. 

I. Diseases of the Urethra. 

(a) Urethritis. 

(1) Gonococcal. 

(2) Traumatic, from catheter or presence of 


(3) Tuberculous. 

(6) Malignant disease of urethra. 
(c) Stricture of urethra. 

II. Diseases of Prostate. 

(a) Prostatitis. 

(1) Gonococcal. 

(2) Non-gonococcal 

(6) Stone : in the prostate gland. 

III. Diseases of Bladder. 

(a) Cystitis. 

(1) Primary. 

(2) Secondary tuberculous and non-tubercu- 


(6) Malignant disease, 
(c) Bursting of abscess into bladder from without. 

IV. Diseases of the Kidney. 

(a) Pyelonephritis. 

(1) Tuberculous. 

(2) Non-tuberculous. 
(6) Pyonephrosis. 

(1) Primary. 

(2) Secondary to calculus or growth. 


THE capacity of metabolising sugar is a variable one. 
Thus the ingestion of so large a quantity as 6 ounces 
of glucose will, save in rare exceptions sufferers 
from pituitary insufficiency with an abnormal sugar 
tolerance result in the excretion of sugar by the 
kidneys within the. following hour ("alimentary 
glycosuria "). In the average healthy person glycosuria 
will not result from the administration of 4 ounces 
of glucose, although every individual has a natural 
limit beyond which his capacity to metabolise sugar 
does not extend, so that in some alimentary glycosuria 
is much more readily produced than in the majority ; 
and although this may be only after the ingestion of 
a comparatively liberal sugar allowance, such persons 
are regarded as possessing an inferior carbohydrate 
metabolism and to be likely candidates for diabetes. 
In another class are placed individuals who excrete 
sugar after taking carbohydrate food in ordinary quan- 
tities, whilst the most severe sufferers from diabetes 
exhibit glycosuria even when all carbohydrate food is 
withheld, and metabolise it from protein. 

Quite apart from the question of alimentary glyco- 
suria, many other conditions which are not diabetes 
are noted when sugar may appear in the urine. Thus 
a small degree of intermittent glycosuria is not in- 
frequent in gouty subjects, and especially in those 
addicted to alcoholic excess. It is often present in 
Graves 's disease. In tumours of the brain and in 
certain chronic diseases of the nervous system, especially 



when the meninges are the seat of long-standing syphi- 
litic disease, sugar may appear in the urine, and the 
same phenomenon is to be expected in acromegaly 
excess of the secretion of the posterior lobe of the 
pituitary gland. 

Glycosuria as a transient phenomenon is not 
uncommon in children, particularly during and shortly 
after an attack of pertussis. 

A condition sometimes occurs in which the kidneys 
possess a permeability for sugar analogous to the 
" leaky kidneys " which allow albumin to pass and so 
appear in the urine (see page 11). In this type of 
" renal glycosuria " carbohydrate metabolism itself 
is not at fault. 

As a physiological phenomenon, sugar is frequently 
present in the urine of pregnant women and nursing 
mothers, but in this condition the sugar is not glucose, 
but lactose, absorbed from the mammary glands and 
passed through the liver unchanged : its presence ceases 
with the termination of lactation. 

A rare condition of sugar in the urine is presented 
by pentosuria, the sugar in this instance being pentose. 
not glucose. It is the result of some metabolic disturb- 
ance, but is not diabetes, although frequently mistaken 
for this disease. It will be referred to later. 

Glycosuria may exist for a comparatively long time 
without giving rise to any symptoms whatever, and 
it may be detected for the first time during a routine 
investigation of the urine. The diabetic subject may 
present himself with any of a large variety of symptoms 
other than those referable to the urinary tract. For 
example, the complaint may be of pains in the legs, 
and peripheral neuritis may be present. Or there 
may be general symptoms of lassitude, weakness 
and loss of weight ; tuberculosis, Addison's disease, 
or malignant disease being simulated. Ocular symp- 


toms may be the first subjective manifestations, and 
diabetic retinitis or cataract be identified. The patient 
may complain of persistent and repeated crops of 
boils or attacks of eczema, or suffer from perforating 
ulcer of the foot or of gangrene of some distal portion 
of the body. A common symptom is an abnormal 
hunger or thirst, the latter more commonly than the 
former. And, finally, the complaint may be of in- 
creased frequency of micturition, although polyuria 
and not pollakiuria is the real condition. 

Whilst a routine test for sugar should never be 
neglected in the detailed examination of any patient, 
this precaution is particularly desirable should any of 
the above-mentioned signs and symptoms be presented. 

It will be convenient at this stage to describe the 
tests for sugar, by which one means glucose. For 
clinical purposes either Fehling's or Benedict's test 
are the most convenient to employ. 

Fehling's test will demonstrate 0*02 % glucose. The 
solution employed is an alkaline solution of potassio- 
tartrate of copper, and its composition is : 

(A) 34-64 grams of pure copper sulphate dissolved 
in 500 c.c. of distilled water. 

(B) 180 grams Rochelle salt and 70 grams of sodium 
hydrate dissolved in 250 c.c. of distilled water : when 
cold the solution is diluted by the addition of distilled 
water to 500 c.c. 

These two solutions should be kept separately, as 
the combined reagent tends to become self-reducing. 
At the time of performing the test, equal parts are 
mixed and boiled. An equal quantity of urine is 
separately boiled and added. Should reduction not 
occur a brick-red precipitate (cuprous oxide) or a 
yellow precipitate (cuprous hydroxide) the absence 
of sugar may be assumed. In practice the boiling 
urine is added a few drops at a time, whereby some 


impression of the quantity of sugar present may be 
obtained. An equivocal reaction a greenish -yellow 
coloration, but not a precipitate, is sometimes seen ; 
and since prolonged boiling tends to produce such 
a colour with a normal urine, it is advisable not to 
boil the mixture, but to mix the two separately boiled 
liquids, which procedure should be sufficient to detect 
or exclude the presence of sugar. 

Precautions. (1) If albumin is present, it should 
first be separated by boiling and filtering before the 
Fehling's test is performed. 

(2) Avoid prolonged boiling, which may enable sub- 
stances present in normal urine to reduce Fehling's 
solution. Such substances are uric acid, creatinin 
and glycuronic acid. The first named will rarely be 
present in sufficient quantity to give the reaction ; 
creatinin will do so only on prolonged boiling. The 
interest and importance attaching to glycuronic acid 
is that it may appear in the urine of a patient taking 

(3) Although the specific gravity of sugar-containing 
urine is usually high, this is not necessarily so. The 
mere circumstance that the specific gravity is compara- 
tively low should never be a reason for neglecting to 
perform the test. Diabetes mellitus has been dis- 
covered with a urine of specific gravity 1008. 

Benedict's test, although far less frequently employed, 
is really much simpler and its results are less equivocal. 
The composition of Benedict's solution is : 

Copper sulphate, 17-3. 
Sodium (or potassium) citrate, 173. 
Crystallised sodium carbonate, 200. 
Distilled water to 1,000. 

The test is performed as follows : Eight to ten 
drops of urine are added to 5 c.c. of the solution ; 



excess of urine should be avoided. The mixture is 
boiled for two minutes and then cooled. If a small 
amount of sugar is present, a green, yellow, or red 
precipitate slowly forms ; if a large quantity, the 
precipitate appears rapidly before cooling takes place. 
An important advantage is that the substances other 
than glucose above enumerated, which reduce Fehling's 
solution, do not reduce Benedict's solution. Perhaps 
a disadvantage which prejudices its more general use is 
its great delicacy.; O'Ol % sugar can thus be detected. 
Confirmatory Tests. The decomposition by yeast of 
sugar into alcohol and C0 2 affords a method both of 
identifying the presence and estimating the quantity 
of sugar, which for several reasons will always make a 
strong appeal to the practitioner. In the first place, the 
procedure is exceedingly simple, and yet sufficiently 
accurate for clinical purposes O05 % sugar can be 
demonstrated. In the second place, the presence of uric 
acid, xanthin, creatinin and glycuronic acid become of 
no consequence, as they do not enter into the reaction. 
Thirdly, only fermentable sugars will be detected, hence 
pentose (which is a non-fermentable sugar) cannot 
be mistaken for glucose. Fourthly, as has already 
been stated, estimation of the quantity of glucose can 
be made by a simple calculation. The test is per- 
formed as follows : The urine should first be tested 
with Fehling's solution or Benedict's solution, and 
the presence of a reducing substance identified. The 
specific gravity is then noted. A piece of yeast the 
size of a filbert, or two or three pieces according to 
the amount of urine utilised, is then added, and the 
urine is left for twenty-four hours, preferably at a 
temperature of about 77 Fahr. At the end of this 
time the urine is again tested, and if reduction no 
longer occurs fermentation is complete, otherwise the 
urine is left for a longer peripji, ^Vhen fermentation 


has been completed, the specific gravity is again taken. 
The rationale of the experiment is that owing to the 
decomposition of the sugar the specific gravity falls, 
and it has been found that every degree of specific 
gravity lost represents (accurately enough for clinical 
purposes) 1 grain of sugar per ounce ; or, if 100 c.c. 
urine have been utilised, the difference in specific 
gravity X 0*23 gives the percentage of sugar. 

It is possible to calculate from the amount of alcohol 
formed or the volume of C0 2 evolved, but the reduction 
in specific gravity which is far simpler is sufficiently 

The property possessed by sugars of rotating the 
plane of polarised light affords a method of differentiat- 
ing sugars from one another according to the direction 
of rotation and also of calculating the percentage of 
sugar, but this is not a method which could be regarded 
as clinically convenient. Another method, however, 
may be mentioned which on special occasions may be 
of use in differentiation, the phenylhydrazine test. 
In a test-tube are mixed together 15 c.c. of urine and 
sufficient of phenylhydrazine hydrochloride and of 
sodium acetate to lie on a sixpence. The mixture is 
boiled for ten minutes, employing a water-bath rather 
than the naked flame. After allowing to stand for 
half an hour, the deposit is pipetted off and examined 
microscopically with the inch objective for " osazone 
crystals," which are not merely characteristic of sugar, 
but specifically characteristic for each particular sugar, 
both as regards appearance and as regards their melting- 
point. Any elaborate differentiation is hardly likely 
to be useful to the practitioner, but on occasion he 
may desire to know if a certain reducing substance 
found in the urine forms an osazone. 


Assuming now that the presence of glucose in the 
urine has been definitely established. The next step 
in investigation is to establish whether or no " the 
iron reaction " is positive. If positive, the presence 
of one or all of acetone, diacetic acid and /?-oxy- 
butyric acid is indicated. A positive reaction is 
the formation of a blood-red colour when the ferric 
chloride solution is added in excess. An exactly 
similar colour may be produced by the urine of a 
patient who has been given a drug belonging to the 
ealicylate group, but in the latter case thorough boiling 
does not abolish, but rather tends to deepen the colour ; 
on the other hand, if the colour is due to the presence 
of one of the acetone bodies, it will disappear, or 
at least be reduced, as these bodies are volatilised. 
The ferric chloride test is quite suitable for clinical 
purposes, but should a special test for acetone be 
required the following may be employed : 

A few drops of a freshly prepared saturated solution 
of sodium nitroprusside are added to a third of a test- 
tube full of urine with sufficient solution of liquor 
potassae to make the mixture alkaline. A ruby-red 
or amethyst colour which becomes deeper on the 
addition of glacial acetic acid indicates the presence 
of acetone. It should be noted that the iron reaction 
merely indicates " acidosis," and may be present in 
any condition when carbohydrate food is not being 
adequately utilised. So that in addition to diabetes 
mellitus, its presence may be expected in starvation 
when carbohydrate is not being ingested, in persistent 
vomiting when it is not being retained, and in diarrhoea 
when it is not being absorbed. But, naturally, in none 
of these circumstances would glycosuria be present. 

In any case of glycosuria it is of vital importance 
that the patient should be tested for hyper-glycsemia, 
the presence of an excessive quantity of sugar in the 


blood. Normally, blood contains (H % sugar ; in 
diabetes mellitus from O2 to 0'4 % may be encountered. 
The method of estimation need not be described, 
requiring as it does a thoroughly well-equipped labora- 
tory and frequent practice to ensure accurate technique. 
The same considerations apply to special tests for 
confirmatory evidence of pancreatic disease, which 
is usually the concomitant of diabetes mellitus. 
* * * * * 

In a contribution specially devoted to diseases of 
the urinary organs and abnormalities of the urine it 
is sufficient to have considered the practical import- 
ance of the phenomenon, glycosuria, but any details 
as to treatment would be quite out of place. The 
disease, diabetes mellitus, is, speaking generally, a 
disturbance of the internal secretion of the pancreas, 
and has no particular pathological connection with 
the organs of micturition. Quite apart from this 
circumstance, the elaborate details of the modern 
method of treatment could not possibly be sketched 
in this small work, and special text-books should be 




IT is doubtful if this condition has any real pathological 
importance, although it is usually identified with a 
person of nervous disposition and is popularly regarded 
as evidence of excessive wear and tear of the nervous 
system. How far this is so is doubtful, and whether 
some error of metabolism is present is equally a matter 
of opinion ; but there is at least no doubt that phos- 
phaturia in greater or less degree is exceedingly frequent 
in the neurotic and those suffering from functional 
disorders. Not infrequently the cloudy appearance to 
the urine which a quantity of phosphates may impart 
is a matter of alarm to a patient who interrogates 
his doctor accordingly, more especially as the sufferer 
is the type of person particularly prone to be morbidly 
observant as to peculiarities of his excreta. 

Clinically, the importance to the physician lies in 
distinguishing phosphaturia from albuminuria (or 
pyuria). A very simple test suffices. Phosphates of 
calcium and magnesium are precipitated by heat 
in alkaline urine, but the precipitate (unlike that of 
coagulated albumin) at once disappears on the addition 
of dilute acetic acid. 

4CaHP0 4 , on heating = Ca 3 (P0 4 ) 2 -f Ca(H 2 POJ 2 . 

The former precipitates out, but is very soluble in acid. 
After a big meal requiring an increased quantity of 



acid in the stomach, there is relatively a superabundance 
of bases set free, so that the monohydric phosphate 
exceeds the dihydrogen phosphate salt, and being 
less soluble precipitates out in the urine as small 
needle-like crystals. 

The triple phosphates of ammonium and magnesium 
may be produced by the ammoniacal decomposition 
of urea, and be recognised as knife-rest or coffin-lid 
shaped crystals. 

The method of recognising phosphaturia has been 
described. Whether or no any form of treatment 
might result in its disappearance it is certainly a 
condition which does not call for treatment other 
than reassurance of a patient who has himself observed 
the peculiarity. 


Oxalates appear in the urine in the shape of envelope 
crystals. Their presence is detected microscopically. 
When occurring in small quantities they cannot be 
regarded as pathological, and even when in compara- 
tively large quantities they denote merely a peculiarity 
of metabolism on the border-line of pathology 
akin to phosphaturia, which is considered above. 
Once again the nervous system has been invoked as 
a causal or at least an associated factor, and it is by 
no means unusual for phosphaturia and oxaluria 
to alternate in the same person. 

Oxalates may be both endogenous and exogenous. 
In the former case their presence is due to synthetic 
production ; in the latter, to oxalic acid yielding sub- 
stances in certain foods, particularly rhubarb, spinach 
and tomatoes, are responsible. Oxaluria is clinically 
of far greater importance than phosphaturia. Hsema- 
turia may be produced, and the existence of a renal 
or vesical calculus may be in question. In many 


of such cases irritation of the renal substance by the 
crystals alone may be the cause of the haemorrhage, 
and no aggregation is in existence. But naturally, 
should there be clinical evidence of stone (see page 114), 
the microscopical discovery of the typical crystals in 
the urine would be a valuable piece of confirmatory 

Persons with the " oxalic acid diathesis " will be 
wise to avoid those foodstuffs which are rich in oxalic 
acid yielding substances ; to avoid conditions which 
may lead to concentration of the urine ; and to keep 
the kidneys well flushed by drinking bland fluids, as 
otherwise in the course of time sufficient collection to 
constitute a calculus may occur. 

Clinically, oxaluria is also of importance in being 
credited with the production of enuresis in children. 
This subject is treated in detail at page 50, and 
although oxaluria is on the whole an unimportant 
factor in this connection, such an element might well 
be potent in initiating and perpetuating the disability 
in a predisposed subject. 


A milky appearance of the urine may be due merely 
to a large excess of phosphates spontaneously deposited. 
This condition is easily definable by the addition of 
dilute acetic acid, which instantly clears up the tur- 
bidity. But a rare condition of milky urine known as 
chyluria is due to the suspension of finely divided 
droplets of fat, which are not soluble in acetic acid 
(but soluble in ether), and the nature of which is at 
once clear on microscopical examination, especially 
if a drop or two of the familiar stains for fat, osmic 
acid or Sudan III, are added. 

The commonest cause of this condition is infection 
by the Filaria sanguinis hominis. Diagnosis is absolutely 


made by identification of the parasite in the blood 
examined at an appropriate period, although this is 
not always easily discovered, and as evidence in support 
may be mentioned the existence of elephantiasis and 
the presence of an excess of eosinophil cells in the blood. 
A non-parasitic cause of chyluria is also possible. 
In such cases blocking of the lymphatics must occur 
by pressure upon the thoracic duct, usually by secondary 
malignant glands. 


Urine containing bile has usually a characteristic 
appearance. Although the exact degree of colora- 
tion is variable, a yellowish -green iridescent element 
is always present, and on shaking the urine in a test- 
tube closed with cotton-wool, foam is readily formed 
and stains the cotton-wool yellow. Tests for bile 
depend on reactions with bile salts or bile pigments. 
The quickest and simplest test is to employ a 1% 
alcoholic solution of iodine and add an equal quantity 
of urine, diluted if necessary : an olive-green colour 
is a positive reaction. The test may also be performed 
by pouring the iodine solution gently on to the surface 
of the urine, when a green ring will be formed at the 

Gmeliris test relates to bile pigments. Fuming nitric 
acid (i.e. containing nitrous acid) is the reagent, and 
this may be added to the urine in a variety of ways. 
It may be poured carefully on to the surface of the urine 
in a test-tube, or better still the urine may be allowed 
to flow from a pipette upon the surface of the reagent, 
the test-tube being held in a slanting position. Alter- 
natively, a drop of the reagent may be brought into 
contact with a drop of urine on a porcelain slab or a 
piece of white blotting or filter paper. A positive 
reaction is a play of colours at the junction, yellow 


changing to red, then to purple and blue, and finally 
to green, the last named being the essential feature 
in the test, the formation of biliverdin. 

Pettenkoffer' 's test is due to the presence of bile 
salts. The reagents are cane sugar and concentrated 
sulphuric acid. A reddish-purple or deep purple colour 
is a positive reaction. 

Hay's -test depends upon the reduction of surface 
tension through the presence of bile salts, and is 
performed by sprinkling flowers of sulphur on the 
surface -of the urine. If bile is present, the sulphur 
particles sink through the fluid instead of remaining 
on the surface. 

For clinical purposes it is quite sufficient to employ 
the iodine test to determine the presence of bile. 

Urinary Deposits. 

A large variety of crystalline and amorphous sub- 
stances may be identified in the microscopical examina- 
tion of urine under various conditions : Some are 
relatively very rare and associated only with uncommon 
disorders of metabolism. The following include the 
substances most commonly encountered : 

Urea may precipitate out in very concentrated urine 
in the form of rhombic prismatic crystals. These are 
themselves white, but they almost invariably carry 
down with them in their precipitation uroerythrin, the 
pigment of urine which imparts a pink colour. 

(Urea is present in urine normally to the extent of 
2 % to 3 %, and in the blood from 0'3 to O'l %.) 

Uric Acid. Under certain conditions this is displaced 
from its combinations and crystallises out of the urine 
either in the calices of the kidneys, in the bladder, or after 
the urine is voided. The crystals may be recognised as 
of the shape of a whetstone or of a barrel and agglo- 
merated in masses : dumb-bell shapes are less frequent. 


The presence of pigment (urochrome) imparts a pale 
yellow or yellow-brown colour, which in bulk gives 
the " cayenne pepper " appearance to the naked eye. 

Identification of these crystals in urine is evidence 
in support of the diagnosis of calculus in a patient 
who has had renal colic, hsematuria and suggestive 
pain referred from the kidney, ureter or bladder. In 
such a case microscopical examination would probably 
show blood cells, and epithelium cells as well as the 

Precipitation of uric acid in the urine does not 
necessarily mean excess either in the tissues or the 
urine, but depends upon the absolute and relative 
proportions of phosphates and chlorides to uric acid 
and the absolute and relative amounts of bases present 
in the urine. Its origin is both exogenous from foods 
rich in nucleo-proteins and purins, and endogenous, 
the result of the subject's own metabolism. Its 
presence in large amount normally with a mixed diet 
0*025 to 0'065 % is excreted denotes that the meta- 
bolism of urea is arrested at the uric acid stage. It 
would not be feasible to dwell in detail upon its relation 
to gout. Many gouty persons pass no excess of uric 
acid, although an excess is present as a rule in gout, 
as well as in the conditions leukaemia and pernicious 
anaemia and in a variety of other diseases. 

Triple phosphates (of ammonium and magnesium) 
are usually transparent colourless prisms with bevelled 

Earthy phosphates (of calcium or magnesium) appear 
as a colourless amorphous deposit. 

Oxalate of lime usually appears in the form of " enve- 
lope " crystals, the actual structure being an octahedron, 
which viewed from above yields the familiar appearance 
owing to the octahedral angles crossing the quadrilateral 
outline diagonally. Other less common shapes are also 


seen, e.g. dumb-bell or hour-glass or as thin plates with 
rounded ends. 

The epithelial cells derived from various parts of 
the urinary tract display the characteristic appearances 
of the organ from which they arise, e.g. the cubical 
and columnar cells from the kidney, the large flat 
cuboid cells from the bladder. A small quantity of 
the latter' is not an evidence of a pathological condi- 
tion ; a large quantity denotes catarrh or inflammation. 


This rare peculiarity, gas in the urine, may arise 
in one of two ways, viz. : 

(1) In consequence of a fistulous communication 
of the bladder with some part of the alimentary canal, 
most commonly the rectum. 

(2) Through production of gas in the urine itself. 
(a) Fermentation may occur in the bladder of 

sugar-containing urine in diabetes by the action of 
yeast and the consequent evolution of C0 2 , or by 
bacteria, when both hydrogen and C0 2 may be formed. 

(6) In the case of non-saccharine urine by infection 
of the urinary tract by some gas-producing organism, 
e.g. Bacillus coli communis, or B. lactis aerogenes. 
In addition to C0 2 and hydrogen, marsh gas, nitrogen 
and sulphuretted hydrogen may be produced. 

The presence of a recto-vesical fistula could hardly 
be overlooked, even if the fistula were not sufficiently 
large to cause the passage of faeces per urethram. 
An appropriate examination of the urine (bacteriological 
if necessary) will readily explain the phenomenon in 
the other cases referred to. 

Treatment will obviously be that of the cause itself. 

NORMAL urination is of course a painless process 
necessitated periodically by a feeling of abdominal 
discomfort arising from distension of the bladder, 
which discomfort may become an acute pain if for 
any reason the desire to empty the bladder cannot be 
fulfilled. Whilst wide variations occur according to the 
amount of fluid ingested, the quantity of exercise taken, 
the activity of the skin, and, we may add, the degree of 
vesical distension to which an individual becomes 
habituated, the act of micturition occurs on an average 
five times in the twenty-four hours, so that from 8 to 
10 ounces are normally voided on each occasion. 

Considered as subjective symptoms, the following 
abnormalities of micturition occur : 

(1) Frequency. 

(2) Difficulty. 

(3) Pain. 

(4) Peculiarities in the stream. 

(5) Sudden stoppage of the flow. 

(6) Precipitancy. 

(7) Retention or absolute incapacity to micturate. 

(8) Incontinence. 

Suppression, though it must receive consideration, is 
not, of course, a disorder of micturition, but of urinary 


It is necessary to postulate here two distinct 
conditions : viz. increase in the number of times that 
micturition is performed and increase in the total 
quantity of urine passed. The former condition is 



correctly designated pollakiuria, the latter is true poly- 
uria. Polyuria is generally, although not invariably, 
associated with pollakiuria, either in actual if unobserved 
fact, or as an obvious subjective symptom : pollakiuria 
may or may not be associated with polyuria, e.g. the 
act of micturition may be performed several times 
in an hour, but only a few drops may be expelled on 
each occasion in such conditions as stricture or enlarged 
prostate. Frequency without polyuria is sometimes seen 
in early tuberculosis of the bladder. 

It is manifest that in any condition of increased 
frequency the total quantity of urine passed in twenty- 
four hours must come under review in order to exclude 
the possibility of the symptom being due to increased 
secretion of urine which occurs in a number of condi- 
tions. These are best considered at this stage before 
dealing with genuine increased frequency. 

Polyuria. Polyuria may be encountered as a tem- 
porary or transient phenomenon of no pathological 
importance, and often attributable to an obvious cause. 
Thus, after the ingestion of large quantities of liquid 
the passage of a correspondingly large amount of urine 
of low specific gravity is to be expected. Incidentally 
we must note that the polydipsia may itself be the 
result of thirst induced by diabetes insipidus. 

The association of copious micturition with nervous 
disorders of a functional character is a very familiar 
one. Thus the candidate for an examination, the 
applicant for life insurance, the nervous orator, the 
athlete just previous to a contest, exhibit the influence 
of an ordeal upon the secretion of urine and the desire 
to micturate. Nervous disorders which, although 
functional in character, possess certain features of 
organic disability, and which again are frequently 
accompanied by the passage of increased quantities 
of urine, are exemplified by attacks of spasmodic asthma, 
of angina pectpris, and of major epilepsy. Jn hysteria, 


too, very large quantities of urine may be passed, and 
an attack of paroxysmal tachycardia is frequently 
terminated by the same phenomenon, which is also 
encountered at the crisis of fevers. Finally, transient 
polyuria may be accounted for by the ingestion of an 
exceptional quantity of some substance with diuretic 
properties, e.g. caffeine or theine and alcoholic beverages. 
Sudden changes in the atmospheric temperature are in 
certain susceptible people similarly effective. 

In some diseased conditions of the heart or liver 
associated with anasarca, improvement of the functions 
of the diseased organ may be accompanied by a pro- 
nounced polyuria corresponding to the expulsion from 
the body of the fluid which had accumulated in the 
tissues and cavities. Thus a patient recently under the 
care of one of us suffering from myocardial degenera- 
tion and auricular fibrillation had extensive dropsy. 
He responded to rest and the action of digitalis, so that 
on the fourth day after the treatment was instituted 
he passed 70 ounces of urine (35 ounces on the previous 
day). On the fifth day he passed 110 ounces, on the sixth 
day 190 ounces, and on the seventh day 210 ounces. 
By this time the oedema had completely disappeared. 

The periodic evacuation of a hydronephrosis may 
account for transient polyuria, the diagnosis of which, 
apart from pyelography, could only be determined by 
the correlated condition of a tumour disappearing with 
the passage of the increased quantity of urine. 

To turn now to polyuria of continued character : 
it is encountered, first, in chronic inebriates. Just 
as an occasional polydipsia leads to a temporary 
polyuria, so the regular imbibition of large quantities 
of fluid leads to a regular polyuria, especially as in 
addition the persistent diuretic action of alcohol comes 
into play, and, after a time, the effect upon the kidneys, 
may be the production of a.!} interstitial nephritis, 


Polyuria is the rule in contracted kidney of whatever 
origin. This condition is treated as a whole at page 74. 

Polyuria is the rule in diabetes, whether of the type 
of insipidus or mellitus. In the former, enormous 
quantities of urine, even up to as much as 20 
pints in the twenty-four hours, are not an unusual 
feature. Some types of diabetes insipidus are dependent 
upon pituitary disturbance, and most diseases of the 
pituitary body, e.g. acromegaly, are accompanied by 
polyuria. Indeed, this symptom not infrequently aids 
a diagnosis of dyspituitarism, which may have been 
suggested by general symptoms, but not of an unmis- 
takable character. It is hardly necessary to add that 
so characteristic a condition as acromegaly requires 
no such diagnostic aid as a mere suggestive feature 
such as polyuria. The inter-relation of the ductless 
glands prepares us to expect polyuria in thyroid 
insufficiency, the compensatory overaction of the 
pituitary resulting in this symptom. 

Finally, large quantities of urine are generally 
secreted in lardaceous and cystic disease of the 

Diabetes Insipidus. As reference has been made to 
this condition, it will be as well to include at this 
stage the few words which may be regarded as appro- 
priate in a work of this nature. It is not always easy 
to distinguish mild degrees of what might without 
hesitation be described as diabetes insipidus from a 
polyuria, which, whilst overstepping the boundary of 
normality, can hardly be regarded as pathological. 
When as much as 10 pints of urine are passed in 
twenty-four hours, no hesitation need of course occur 
in labelling the condition which appears to be an 
incompetence of the kidneys to secrete urine of normal 
concentration. Differentiation may be afforded by 
the simple expedient of administering 20 grains of 
sodium chloride, which will ordinarily be followed by 


an increase in concentration, but not in any increase 
in the quantity of urine passed. In true diabetes 
insipidus, on the other hand, the concentration remains 
unchanged, but the quantity of urine is increased. 
For this reason there is no justification in withholding 
fluid which leads merely to desiccation of the tissues, 
since the organism must at any cost obtain water 
sufficiently to reduce the concentration of urine. 

Some cases of diabetes insipidus appear to depend 
upon syphilitic disease of the meninges at the base 
of the brain. In these, anti-syphilitic treatment is 
beneficial. Such treatment is of no service in other 
cases due to primary defect of the kidney with inability 
to secrete urine of normal concentration, nor in those 
for which disease of the pituitary is responsible. 
Pituitary extract has been recommended for the latter : 
in three cases so treated by one of the present authors 
no improvement was apparent, and in one of these 
cases intermittent attacks of glycosuria were present, 
indicating some relationship between the conditions 
of diabetes insipidus and mellitus. 

To turn now to cases where the total amount of 
urine passed is not excessive, but in which there is 
genuine increased frequency : as one would have 
expected, it is in affections of the bladder and prostate 
that this symptom is most often encountered, but in- 
creased frequency is also a familiar concomitant of renal 
disease, the bladder being in a perfectly healthy state. 

In the investigation of such a case the first care is 
to compare the nocturnal with the diurnal frequency. 
As a rule, the former predominates, as is particularly 
evident in cystitis and prostatitis, as well as in chronic 
interstitial nephritis (when increased secretion also 
occurs). In vesical calculus, diurnal frequency tends 
to predominate unless cystitis is also present. In 
carcinoma of the bladder, frequency has no particular 



It must be pointed out that increased frequency is 
often the first, and for some time the only, symptom 
of commencing hypertrophy of the prostate and also 
of renal disease, particularly tuberculosis and interstitial 
nephritis. When no abnormality of the urine is present 
to point directly to an explanatory lesion, the cause of 
such a symptom often calls for considerable investigation. 

In children, a local condition is generally the cause, 
e.g. phimosis or a congenitally small meatus. Thread- 
worms by reflex irritation from the rectum, and balanitis 
also as a reflex irritation, are to be included in this 
category. Appropriate treatment of any of these con- 
ditions leads to speedy amelioration. If, in a child, any 
such local cause can be excluded, some abnormality 
of the urine should be suspected, e.g. the presence of 
Bacillus coli communis or of oxalates, or even of 
excessive acidity. 

In an adult the commonest cause of increased fre- 
quency is cystitis, for which a large variety of causes 
may be responsible. The reader is referred to 
Chapter XIII. 

Incontinence of Urine. 

In infants, periodic reflex micturition independent 
of volition is invariable : at fairly regular intervals 
the bladder contracts automatically. With training, 
this act becomes influenced by the higher centres until 
control is established, when micturition becomes a 
voluntary act which involves contraction of the 
abdominal muscles to raise intravesical tension suffi- 
ciently to start the reflex process which is under the 
sway of the lumbar centre in the spinal cord. 

Voluntary control presupposes a condition of mental 
stability first to learn to associate the process of mic- 
turition with certain circumstances, and later to under- 
stand social obligations. In the large majority of 
infants this control is fairly easily accomplished, and 


such elementary education is, as is well known, possible 
also in the case of domestic animals. The degree of 
intelligence demanded is a comparatively low one ; 
so that although " dirtiness of habits " is a stigma fre- 
quently encountered in subjects of congenital mental 
deficiency, it is not impossible to train a child to 
cleanliness in this respect even if any form of academic 
education is impossible. 

On the other hand, quite apart from the basal intelli- 
gence, this controlling influence of the higher centres 
appears to be of a special character. In some children it 
is established later than in others, just as some children 
are slow in learning to speak ; the co-ordination is 
more slowly acquired. Since control is usually 
established by the age of two, the term " enuresis " 
is applied to those cases in which bed-wetting occurs 
after this age in spite of special training having been 
undertaken. Such cases appear to possess either a 
micturition centre in a hyper-excitable state, liable to 
be stimulated by impulses which in a normal person 
would be resisted, or higher centres which on unduly 
slight provocation are prone to send out impulses to 
relax the compressor urethrae. Since the dominating 
influence of the higher centres is more likely to be in 
abeyance during sleep, nocturnal incontinence is rela- 
tively much more common than diurnal incontinence. 

Most cases of enuresis are a persistence of the infantile 
condition, but it is not uncommon for this symptom to 
manifest itself between the ages of five and eight, the 
period of the second dentition, when nervous instability 
is likely to exert its influence as in the somewhat 
similar condition, stammering, another example of 
inco-ordination. So that apart from those cases of 
idiots who are mentally incapable of training, the 
candidate for enuresis is the fundamentally " nervy," 
over-excitable child. Unlike stammerers, however, 
boys do not preponderate, for the disability occurs 


on the whole equally in the sexes. Dr. Still quotes of 
200 cases that 102 were boys and 98 girls and this 
notwithstanding the existence in the male of more 
opportunities for reflex stimuli to micturition so often 
vaunted as exciting causes. 

The first care of the practitioner confronted with 
a case of enuresis is the exclusion of local causes, which 
may be an important item in the perpetuation of the 
condition. In passing, one may mention the possible 
existence of such congenital defects as epispadias or 
hypospadias, or even of a healed spina bifida, in which 
through involvement of the sphincter branch of the 
long pudic nerve incontinence of an incurable character 
may be present. But in connection with local causes 
reference may be made to rectal threadworms, vulvitis, 
a tight fore -skin, a pin-hole meatus, balanitis and 
pathological conditions of the urine (e.g. oxaluria). 
Dr. Still is sceptical as to the direct influence of the 
commoner reflex causes ; he is rather disposed to mini- 
mise the likelihood of direct reflex action, but to suppose 
that such causes tend to set up a general increase of 
nervous irritability in a child already predisposed. 
This, of course, does not deny the value of their elimina- 
tion, but merely emphasises what is undoubtedly the 
case, that the most important condition is the basic 
temperament. For similar reasons the influence of 
adenoids must not be too enthusiastically accepted. 
Their removal improves the general health, and has 
often a high psychical value ; their removal, then, is 
only one element in the treatment of the case. 

An obvious precaution to be adopted is the avoidance 
of any fluid two hours before bed- time. But this 
should not encourage too wholesale a restriction of 
liquid throughout the day, so causing a concentration 
of the urine, which is thereby rendered more irritating, 
and so likely to contribute to incontinence. Foodstuffs 
of a diuretic character, and those of strong or highly 


spiced flavours, or with excess of salt, are equally to 
be avoided. The urine and urinary tract should be 
examined for evidence of cystitis, of vesical calculus, 
or of pyelitis. (Cystoscopy can be performed after 
the age of five with reasonable ease.) It is well to re- 
member that the polyuria of diabetes (mellitus and 
insipidus) has been frequently overlooked, and cases 
diagnosed as " enuresis," when the failure of control 
may really be due to the rapid filling of the bladder. 
Even the possibility of organic disease of the brain 
and spinal cord should receive at least passing con- 
sideration as a possible factor. 

But, after all, the very great majority of cases fall 
into the category of want of co-ordination, of " weak " 
or " irritable bladder," so that, when all subsidiary 
forms of treatment have been completed, a definite 
attack upon the nervous system is necessary in the 
direction of special training towards periodic micturition. 

The first step is to establish a degree of confidence 
resulting from a sympathetic reception of the disability. 
Not infrequently the little boy has already been 
subjected to various methods of influence, ranging 
from promises and bribes, to threats, ridicule, and 
similar persecutions. An " anxiety neurosis " is very 
easily established if too much attention is brought to 
bear upon the condition, and even simple neglect in 
the hope that time alone will effect a cure is to be pre- 
ferred to the encouragement of an introspection. The 
realisation that it is of profound importance to produce 
a rapid cure of a condition which is causing the sufferer's 
parents much perturbation as to the future is quite 
sufficient to perpetuate the catastrophe, every repetition 
of which makes the subject more resistant to treatment. 

At first, elementary methods of training may be 
tried and found efficient. The child should be awakened 
every two hours in the night in order to empty his 
bladder. Gradually these intervals are made longer 


and longer, until eventually the bladder can tolerate 
a normal degree of distension. Such a process of 
training is best conducted away from the patient's 
own home, since the necessary discipline is far more 
easily enforced, whilst the psychical stimulus of an 
entirely strange environment is a very potent factor. 
The circumstance that nocturnal incontinence is so 
much more common than diurnal incontinence has 
encouraged psycho-pathologists to the view that the 
act of involuntary micturition has a sexual basis of the 
nature of a vicarious seminal pollution, and calls for 
psychical treatment of a special character. With this 
view we have no concern. 

It is by no means without question that such forms 
of treatment as intra-vesical electricity may not act 
by the suggestive effect they produce rather than by 
any actual organic influence. Some time ago an 
American investigator upon local anaesthesia for 
operation upon the rectum, which consisted in injecting, 
not into the spinal canal, but in the vicinity of the 
cauda equina, stated his faith in this procedure for 
the successful treatment of nocturnal incontinence. 
But it is very doubtful if any local action really occurs, 
for it has long been observed that cure of enuresis 
may follow any operation, and a fortiori if the operation 
is related to the bladder, e.g. cystoscopy. Such 
methods as intra-vesical electricity or the application 
of caustics may in all probability act only by their 
psychical influence, which can be just as easily produced 
without the infliction of suffering. 

We have used the term " anxiety neurosis " as 
likely to perpetuate the condition. A neurosis of 
another character may be established, as in a case 
recently seen by one of us in which the incontinence 
took the form of a " defence neurosis." A sympathetic 
conversation revealed the circumstance that the boy 
had been ill-treated at school, and had developed 


this "defence neurosis" in order to save himself the 
ordeal of further attendance, which was precluded by 
the existence of this symptom. This case is mentioned 
merely to point out that in a highly susceptible 
person a neurosis may be set up, the germinating cause 
of which may be comparatively easily detected by any- 
one acquainted with the ordinary circumstances of a 
boy's life and the possibilities which may arise therefrom. 
Whether psycho-analysis might prove of value in more 
obstinate cases said to demand such analytical investiga- 
tion we do not feel competent to express an opinion. 

Turning now to the use of drugs. Many have been 
recommended for their specific effect, but it does not 
appear that any one has a really selective action. 
On the contrary, it is the experience of all physicians 
accustomed to treat such cases that success with one 
may result after total failure of all others to produce 
any improvement, whilst in another case an entirely 
different drug leads to success. Belladonna is the drug 
most likely to do good, and it should be administered 
in large doses children tolerate it well up to as 
much as 10 or 12 minims of the tincture three times 
a day for a child of five. The liquid extract of Rhus 
aromatica, thyroid extract, nux vomica, ergot, phena- 
zonum and the bromides, are other drugs which have 
gained a reputation, and any one of these may prove 
to be the most serviceable for any individual case. 

Incontinence arising in adult life must be separated 
into two conditions, viz. true incontinence, in which 
urine dribbles as fast as it enters the bladder, and 
" false incontinence," which is due to distension of 
the bladder, and in which the incontinence is of the 
nature of an overflow. The former is necessarily due 
to paralysis of the vesical sphincter ; the latter is asso- 
ciated with some mechanical obstruction, particularly 


an enlarged prostate, when the over-distended bladder 
has finally become flaccid and atonic. (See Ch. XV.) 

In tabes, true dribbling may occur from anaesthesia 
of the bladder. Nocturnal incontinence is a common 
preliminary. By the time urinary symptoms are 
present the familiar concomitants of Argyll-Robertson 
pupils and absence of reflexes should be also present. 
The cystoscopic appearance is typical. The bladder wall 
exhibits changes unlike any other lesion but primary 
atony. As a rule the incontinence is intractable, how- 
ever rigorously the parasyphilitic condition is treated, 
and the patient is compelled to wear a portable rubber 
apparatus, or a De Pezzer tube is inserted. (See Chap- 
ter XV.) In disseminated sclerosis and other diseases of 
the spinal cord and cauda equina, dribbling may result 
from flaccidity of the bladder and atony of the sphincter. 

In transverse lesions of the spinal cord the first effect 
upon the bladder is that of retention of urine from 
contraction of the internal sphincter. Should this 
distension be neglected, overflow incontinence will 
ultimately result, and the same condition will occur 
in coma when accumulation of urine has been permitted. 
But if, as is usually the case, regular catheterisation 
is undertaken, the bladder recovers its contractile power, 
and as Riddoch and Head have pointed out (Brain, 
1918, vol xl., pp. 149-263, and the Lancet, Decem- 
ber 21, 1918, p. 839), the " primitive mass reflex " of 
the infant re-appears, so that contraction of the bladder 
can be elicited by cutaneous stimulation of the thigh, 
and a paraplegic patient can in this way utilise his 
reflex incontinence to empty his bladder when it has 
reached a sufficient degree of distension. 

It may be added that true incontinence does not 
occur in hysteria, although frequency combined with 
carelessness may result in a state of perpetual wetness 
which may be mistaken for actual incontinence. 

If urethral stricture is the cause of incontinence, there 


will be a history of progressive difficulty and the passage 
of a small stream. The lesion is demonstrated by the 
passage of bougies and by urethroscopy. (See Ch. XVI.) 

Primary atony of the bladder appears between the 
ages of twenty-five and forty. The cause has not been 
discovered : there is no evidence of organic nervous 
disease, although cystoscopically a similarity is presented 
to the appearance of the tabetic bladder. The disease 
is progressive, and from partial loss of control eventually 
micturition becomes completely involuntary. 

Incontinence in Women. The preceding causes for 
adult incontinence must be supplemented in the case 
of women by special causes incidental to parturition, 
during which injury may be caused to the compressor 
urethrse by pressure of the foetal head, or actual 
tearing of the peri-urethral tissues may result. The 
condition of prolapse, too, may be responsible for some 
degree of incontinence, which will naturally be aggra- 
vated by increase of intra-abdominal pressure, as in 
sneezing or coughing or violent exertion, and when 
an abdominal tumour develops, e.g. in pregnancy or 
pathologically. Such conditions of partial incontinence 
vary from a trivial discomfort increased by nervousness 
or morbid anticipation up to a considerable degree 
of disability demanding the use of a portable urinal. 
Local contributory causes such as prolapse must 
receive appropriate treatment. 

Marion has devised an operation for the cure of in- 
continence in women for which he claims considerable 
success . 

Difficulty in Micturition. 

Difficult and painful micturition are frequent 
concomitants, but either may be present independently 
of the other, although, naturally, confusion in 
the patient's mind as regards these two distinctly 
different sensations is likely to arise, and may be disso- 
ciated only by detailed cross-examination. 


Difficulty in micturition must necessarily involve 
a mechanical cause, either obstruction to the passage 
of the urinary flow or interference with the nervous 
mechanism which governs the act of micturition. 
Obstruction in the urethra is far more frequent 
in the male. In this sex, stricture is a common sequela 
of gonorrhoea, and is the commonest cause of difficulty 
in micturition. In the female, stricture (from gonor- 
rhoea) is very rare. Similarly, the less frequent but 
well recognised form of difficulty arising from calculus 
impacted in the urethra so as partially to obstruct it, 
is almost entirely restricted to the male. 

Thirdly, prostatic disease (whether simple hyper- 
trophy, carcinomatous enlargement, or inflammatory 
change) is of course restricted to the male. Here again 
a mechanical obstruction to urination results see the 
detailed consideration of prostatic disease, page 15. 
In the female, occlusion of the urethra arises in an 
entirely different fashion, viz. from dragging and pressure 
of a pelvic tumour, most frequently a fibroid or a re- 
tro verted gravid uterus. Such conditions are diagnos- 
able by routine pelvic examination, which is naturally 
undertaken in any disorder of micturition in the female. 
Partial occlusion of the urethra may also occur by exten- 
sion into its walls of a carcinomatous mass in the vagina. 

Turning now to the bladder. The prostate has 
already been considered ; other vesical causes are 
common to both sexes. The vesical orifice of the 
urethra may become occluded by blood-clot after an 
extensive haemorrhage from the bladder mucous 
membrane. An infiltrating growth of the bladder may 
eventually extend into and obstruct the urethral 
orifice, but in both these conditions retention of urine 
rather than difficulty only is likely to arise (q.v.). 

The diseases of the nervous system associated with 
difficulty in micturition are tabes and transverse 
myelitis. In the latter the innervation of the bladder 


itself may be cut off, so that urination is impossible : 
in the former difficulty may be experienced in various 
ways, although actual control of the act may not be 
lost. In disseminated sclerosis, a special form of 
difficulty known as stammering micturition is some- 
times encountered. 

Difficulty in micturition of a purely functional 
character is not unknown. From interference with 
its sympathetic nerve-supply, a condition of atony of 
the bladder may result ; whilst the psychical difficulty 
experienced by nervous individuals who are requested 
to micturate for the special purpose of examination 
is too familiar to need further mention. (See also 
Retention of Urine, which more particularly applies 
in this consideration.) 

Painful Micturition. 

Excluding conditions of peritoneal inflammation in 
which pain is felt locally upon emptying the bladder 
on account of the tension upon the peritoneum, pain 
on micturition always results from some disease of 
the urinary tract, or some pathological state of the 
urine itself. The last named as a possible cause can 
be rapidly dismissed. In a few instances a hyperacidity 
of the urine may cause a stabbing pain along the urethra 
during the act of micturition and for a short time after- 
wards. In cases where a large number of oxalate 
crystals are being passed in a concentrated urine the 
friction against the urethral mucous membrane may 
lead to the same sort of painful sensation. 

Pain in the urethra during micturition is in the male 
most frequently due to acute inflammation, especially 
gonorrhoea in the first few days of an attack. Rarer 
forms of urethritis of non-venereal character may occur, 
but clinically their occurrence is overshadowed by the 
far greater preponderance of gonococcal infection. 

In the female, painful urethritis is less frequent, 


and when it occurs is not of so intense a character. 
Urethral pain on micturition in the female is generally 
due to the existence of a caruncle. 

Pain experienced immediately after micturition and 
referred to the tip of the penis is traditionally identified 
with vesical calculus, but it may arise from any condition 
in which, there is inflammation of the trigone of the 
bladder, e.g. cystitis, prostatitis, malignant disease, as 
well as calculus. 

As a rare cause of this sort of pain must be mentioned 
a calculus impacted at the vesical end of a ureter. 

Pain during micturition may be referred not to the 
urethra, but to the perineum, as a peculiar dragging 
sensation felt after as well as during the passage of 
urine. Prostatic disease should be suspected in such 
a symptom, although it is also encountered in vesical 

Oliguria : Suppression o! Urine. 

Reduction in the quantity of urine secreted is en- 
countered as a physiological phenomenon as well as 
in pathological conditions of the urinary organs. When 
secretion becomes reduced to a minimum so that 
insufficient collects to distend the bladder to a degree 
which excites the normal reflex of micturition, the 
condition known as suppression occurs, although it 
must be added that suppression may have a purely 
mechanical cause (vide infra). 

Oliguria is present in most febrile states. The 
secretion, too, is proportionately reduced whenever there 
is loss of fluid from the body in other ways, as for example 
in persistent diarrhoea and vomiting. The same effect 
is produced if whilst the fluid is not actually lost from 
the body it accumulates under the skin or in the body 
cavities, as in ascites or hydrothorax. The secretion of 
urine may be much "reduced in cardiac failure and in 
any condition accompanied by a low blood-pressure. 

The commonest pathological condition in which oli- 
guria is a feature is acute Bright 's disease (q.v. page 71). 

When true suppression occurs the bladder will 
naturally be found empty when a catheter is passed. 
Any mechanical obstruction leading to suppression 
must be on the proximal side of the bladder, as e.g. 
a carcinomatous growth of the bladder extending into 
and blocking the ureteral orifices. Such a condition 
of suppression will almost certainly be preceded by 
evidence of malignant disease of the bladder, e.g. fre- 
quency and pain on micturition, hsematuria and pyuria. 
Cystoscopic examination will reveal the growth in situ, 
whilst a rectal or pelvic examination will lead to the 
discovery that the base of the bladder is infiltrated. 

Similarly, double calculus of the kidney might 
produce the same effect at the upper openings of the 
ureters. This occurrence, though possible, is rare ; 
more frequently the anuria results from blockage of 
the ureter of a solitary functional kidney. It follows, 
too, that anuria would result from removal of a 
kidney when the remaining organ was functionally 
impaired, for which reason surgeons are always at 
pains to ascertain that the other kidney is functioning 
satisfactorily before the performance of a nephrectomy. 
One kidney, too, might be congenitally absent. 

As non-obstructive causes of suppression must first 
be mentioned the possibility of simulation in hysteria 
and in deliberate malingering when it has been main- 
tained that no urine has been passed. The bladder 
may be empty at the time of examination, but if a 
careful watch on the subject be kept and surreptitious 
micturition made impossible, it will be found that the 
bladder fills in the usual way. 

A somewhat alarming suppression occasionally 
follows an abdominal operation as a reflex phenomenon ; 
and unless it is realised that such a condition is by 
no means unfamiliar, considerable perturbation may 


be excited. It calls for- no active treatment other 
than cupping or hot applications to the loins. It must 
of course be distinguished from the retention, which, as 
is mentioned below, sometimes follows operations, 
especially herniotomy and appendicectomy. 

Turning now to pathological conditions of the 
urinary organs, suppression is most commonly seen 
in such diseases of the kidney as acute nephritis, 
poly cystic disease and pyelonephritis. It may also 
result from the ingestion of a poison, the excretion of 
which through the kidney excites inflammation and 
impairment or abolition of its function, e.g. cantharides, 
turpentine, mercury, phosphorus. In all circumstances 
such as these, and others when the kidney's normal 
activity is in abeyance, uraemia is imminent, and the 
characteristic phenomena of drowsiness, with headache, 
convulsions, dyspnoea and vomiting gradually develop. 
For further consideration of uraemia see page 73. 

Anuria may follow the passage of a catheter to 
relieve a much over-distended bladder in cases where 
obstruction is of long standing and the kidneys have 
from back pressure become distended and septic. 
Such anuria is more likely to arise if the distension is 
very rapidly relieved, and to obviate such an occurrence 
care is always taken to empty the bladder slowly in 
such cases. 

Retention of Urine. 

This condition has already been distinguished from 
anuria suppression of urine. 

Retention may arise, as in the case of difficulty, 
from a mechanical cause, or from some disturbance 
of the nervous innervation. In this connection one 
may regard retention as due to a more extreme degree 
of a condition which in a less pronounced form causes 
difficulty. As commonest causes, then, of retention 
must again be mentioned urethral stricture and prostatic 


enlargement. Complete occlusion of the urethra may 
result from an impacted calculus or from the free 
portion of a pedunculated tumour of the bladder 
having become washed into the vesical orifice by the 
urinary stream. 

Nervous Causes of Retention. Retention will result 
from interference with the spinal centre for micturition, 
as in compression paraplegia, or transverse myelitis 
of inflammatory or degenerative origin. The situation 
of the lesion will have an influence upon the condition, 
a difference resulting according as a portion of the 
cord above the lumbar centre for micturition or that 
portion which itself contains the centre is affected. 
In the latter, retention does not occur. (See Incon- 
tinence of Urine, page 56.) 

Retention frequently arises reflexly after operations 
as an immediate (and temporary) condition, particularly 
in operations upon the rectum and for hernia, although 
it may ensue upon any laparotomy. 

As a special cause of reflex retention may be 
instanced the voluntary retention as an instinctive 
defensive mechanism in any condition in which mic- 
turition is painful. 

In neurotic persons, retention may quite spontane- 
ously occur in the absence of any disease, from what 
is termed spasmodic contraction- of the sphincter 
vesicse. In such cases a catheter can be easily passed, 
with the aid of anaesthesia, and it is evident that the 
condition may be an active spasm as much as a 
defective relaxation of normal tonicity. A more 
correct term therefore would be achalasia vesicse, 
analogous as it is to the " cesophagismus," occasion- 
ally witnessed at the cardiac orifice of the stomach. 

As a variety of retention, the peculiarity of sudden 
stoppage of the flow of urine has obvious causation. 
A small movable calculus in the urethra, which when 
impacted leads to retention, may become impacted 


during the passage of a stream which began in normal 
fashion. A similar phenomenon is afforded by the 
sudden occlusion of the vesical orifice of the urethra 
by a villous tumour of the bladder. Again, the con- 
dition of achalasia above referred to may exhibit 
an intermittent activity with alternating intervals 
of normal flow and of retention. In the same way, 
nervousness when asked to urinate may not lead to 
absolute retention, but to a sudden termination of the 
flow after micturition has started. 

Peculiarities in the Urinary Stream. 

(1) In such developmental defects as hypospadias, 
epispadias, ectopia vesicae, a normal urinary stream 
is of course impossible. 

(2) In urethral stricture great variability in the 
character of the stream may be seen. It may be 
persistently small and of feeble projectile power ; 
sometimes, in fact, no proper stream is ever passed, but 
the urine merely dribbles away. On the other hand, 
the bladder may hypertrophy at first to overcome 
the resistance, so that a very good stream may be 
passed. In such cases urgency is a prominent feature, 
and the patient suffers from what is known as precipi- 
tate micturition. On the whole, the typical history 
of stricture is of gradual and progressive narrowing, 
with increasing difficulty in micturition and feebleness 
of stream. (See Chapter XVI.) 

(3) In prostatic disease. Changes in the stream 
are associated with difficulty in micturition and occa- 
sional retention. 

(4) Nervous diseases. We have already referred 
to disorders of micturition due to defective innervation 
of the bladder, and no further description is necessary. 
Changes in the character of the stream are naturally 
associated with variations in vesical distension. 

THE estimation of the renal efficiency, i.e. the selective 
capacity of the renal substance to pass or restrain 
various substances with their corresponding appear- 
ance in the urine, is of advantage both to the physician 
and the surgeon. The damage which the renal cortex 
has sustained by some infective or degenerative condition 
(so called " medical kidney ") can be assessed to a 
degree upon which a prognosis can be accurately based. 

In other conditions, such as urethral stricture or 
enlarged prostate, judgment as to the suitability of 
an operation may be influenced by similar tests which 
indicate how far the kidney has suffered from the 
lesion in the lower urinary tract. 

Although inefficient action of the kidneys will 
produce extensive constitutional disturbances and 
alterations in the character of the urine, the clinical 
signs will more certainly demonstrate the true condition 
of the patient when supported by chemical evidence. 
Therefore, when studying the state of the kidney, 
it is necessary to consider (1) the general condition 
of the patient, (2) the changes in the urine, and (3) 
the result of certain chemical tests. 

(l) The General Condition of the Patient. When 
the kidney first fails to excrete a normal urine, the 
regular functions of other organs are disturbed. 

Functional gastric disorders are to be expected. 
The appetite is impaired, the tongue is dry, and 
complaint of thirst is made. Flatulence is very 



frequent, and vomiting occasional. The skin loses 
its elasticity and is abnormally dry. 

In acute nephritis, the result of back-pressure, the 
complexion becomes muddy and sallow and the face 
slightly drawn. On the other hand, in chronic tubular 
nephritis the face is white and puffy. There is a gradual 
loss of energy, accompanied by headache and drowsi- 
ness. These changes are not to be noted at the same 
time, but the skilled clinician will be able to interpret 
their meaning in association with his other observa- 
tions. Hiccough is a late sign of renal failure, and 
indicates a very grave condition. A persistent 
subnormal temperature is another disquieting pheno- 

(2) Changes in the Urine. Reference is made in 
another chapter (page 71) to the character of the urine 
in nephritis, and it will here suffice to emphasise the 
meaning of certain changes as indicative of the extent 
of the altered renal function. 

The onset of renal failure is denoted by a polyuria, 
a urine of low specific gravity, with a trace of albumin 
and decreased urea excretion. A large quantity of 
albumin in the urine does not necessarily mean that 
the renal activity is failing unless it is associated with 
a failing urea excretion ; but the decrease in the out- 
put of urea is sure evidence of extensive disease even 
when the urine is otherwise normal. 

(3) Chemical Tests for Renal Efficiency. The prin- 
ciple upon which the tests for renal efficiency depend 
is the administration of some inert substance which 
is excreted in the urine and can be conveniently identi- 
fied and estimated both as regards the velocity and 
extent of its excretion. The substances used have 
been aniline dyes, such as indigo-carmine and methylene 
blue and phenol phthalein. By means of a colorimeter 
it is possible to detect how much dye has been excreted 

in the urine in a given time, but apart from their 
difficulty the above-mentioned tests are unreliable. 

Another substance which has been employed is 
phloridzin, but it damages the renal tissue and increases 
its permeability for sugar, so that it is too variable 
to be of any value. 

The estimation of urea in the blood is a valuable 
and accurate renal test, but is too complicated for 
anyone but a laboratory worker to perform. 

The familiar estimation of urea in the urine can 
be recommended as one which does not make any great 
demand upon the time, or the laboratory resources, 
of a busy practitioner, and is yet productive of results 
which serve for all practical purposes. The sample 
of urine to be tested should be taken from the total 
passed in twenty-four hours. The normal percentage 
of urea excretion in twenty-four hours is on an 
average 2*2. A reduction to 1 % or under will denote 
inefficiency of the renal function. The sodium hypo- 
bromite test is recommended as the simplest. 

The rationale depends upon the decomposition of 
urea by sodium hypobromite with the liberation of 
nitrogen, the estimation of which is proportional to 
the amount of urea 

CO(NH 2 ) 2 + SNaBrO = 3NaBr + 2H 2 O + C0 2 + N 2 . 

Various pieces of apparatus are procurable, some of 
such convenience that from the volume of nitrogen 
formed the percentage of urea can be directly read off. 
In practice a solution of sodium hydroxide is used, 
and bromine is separately added at the time of the 
experiment, since hypobromite solution itself is not 
stable. This is placed in a conveniently shaped flask, 
into which is carefully introduced a small test-tube 
containing 5 c.c. of the urine to be estimated. The 
flask is closed with a rubber stopper, through which 


runs a piece of tubing connected up to a measuring- 
tube containing water, with suitable arrangement for 
its displacement. The measuring tube is filled with 
water, and when the apparatus is tightly closed the 
urine is allowed gradually to come into contact with 
the hypobromite solution by inclining the generating 
flask. 'Gentle agitation ensures the complete decomposi- 
tion of the urea. The nitrogen forces down the column 
of water in the measuring-tube, the apparatus is left 
to cool, when the final reading of the displaced water 
column is read off after making suitable adjustment 
of the level. The volume of nitrogen is then read off, 
and from this the percentage of urea is either directly 
seen or calculated according to the above formula. 

Recently Maclean has recommended that urea be 
given by the mouth previous to its estimation in the 
urine. Fifteen grams of urea are dissolved in 
100 c.c. of distilled water flavoured with tincture of 
orange. This solution is taken on an empty stomach, 
preferably on rising in the morning. The bladder 
should then be completely emptied. Two hours later 
the patient micturates, and the concentration of urea 
in the urine is determined. After an interval of another 
hour the urine is once more collected and the per- 
centage of urea again estimated. If in both specimens 
it falls below 1'5, the renal function is considered to 
be below normal. If the first specimen gives a per- 
centage below and the second above T5, the renal 
function is approximately normal. 

This test is simple and can be performed by the 
busiest man : the results are satisfactory and rarely give 
misleading information. 

The Diastase Test. Diastase is absorbed from the 
intestine, and is normally excreted in the urine to a 
degree which is measured as 10 to 22-2 units. It is not 
necessary to explain the rationale of the estimation, 


which consists briefly in using graduated dilutions of 
the urine, and ascertaining the most dilute which can 
still exert a diastatic action as measured by the con- 
version of starch into dextrin and maltose. Iodine 
is used as an indicator, and the production of the 
familiar blue coloration denotes that conversion has 
not occurred. 

In nephritis the diastatic index is reduced to perhaps 
5 units, or even lower, and this low value persists even 
after albumin may have disappeared from the urine. 

It cannot be too often emphasised that these tests 
per se must not be the only guide to the condition 
of the kidneys. The picture is only complete when 
chemical tests, changes in the urine, and the general 
condition of the patient are placed in their proper 


Acute Nephritis. 

TYPICALLY, the onset is acute, and follows exposure 
to cold and wet or the ingestion of some substance 
irritating to the kidney, such as catharides or turpentine. 
The toxins in the diseases scarlet fever, diphtheria, 
and pneumonia and others already alluded to are 
similar irritants. The acute exacerbations which occur 
apparently spontaneously in subjects of chronic 
nephritis are also the result of some less virulent toxin, 
perhaps autogenous, which would not affect a kidney 
of normal structure and vitality. 

Trench nephritis demands special mention. A large 
variety of setiological causes have been suggested, 
such as the excessive protein diet on active service, 
the ingestion of particles of metal from the cooking 
utensils employed in the field, the unmasking through 
lowered vitality of a number of cases of previously 
existing but unrecognised nephritis. But without 
recounting the evidence contradictory of the above- 
mentioned hypotheses, or in favour of the one now 
generally held, trench nephritis has been shown to 
be a true acute nephritis in many respects closely 
resembling that of scarlatinal origin, in which suscep- 
tibility seems to play a part, and cold and exposure 
to be predisposing factors, but the actual cause of 
which is an infective agent, not a recognisable micro- 
organism but of ultra-microscopic type, or a toxin. 

Characteristically, fever of variable degree with 
rigors and vomiting is present, and complaint may be 



made of pain in the lumbar region or indistinctly local- 
ised in the abdomen. (Edema is often present, the 
face and ankles particularly being affected, but oedema 
is by no means invariable, and will especially be absent 
if the patient has already been confined to bed for 
some time suffering from one of the acute diseases 
with which nephritis is associated. In such cases 
only a routine examination of the urine would lead to 
the discovery of nephritis, since nothing symptomatic 
to point to an affection of the kidney may be present. 
In all probability, many such cases become overlooked, 
subsequently to manifest themselves as chronic nephritis. 
In the last influenza epidemic, nephritis was shown to be 
of very frequent occurrence, yet the typical symptoms of 
acute nephritis were not at all evident. Similarly, the 
occurrence of pyrexia with unaccountable dyspnoea, un- 
accountable that is to say in the absence of disease of 
the heart or lungs, may be the presenting condition. 

The urine will be reduced to 12 ounces or even less in 
the twenty-four hours, and sometimes there is complete 
suppression. It is of high specific gravity. Its colour 
will be dark, either from concentration or from the 
admixture of blood the quantity of which will produce 
variations, from a light pink almost to blackness. 
Albumin is present often in considerable amount, urea 
is much reduced, and chlorides are diminished. On 
examining the deposit of a centrifugalised specimen 
microscopically, casts (hyaline, granular, epithelial), 
blood cells and epithelial cells are seen. 

Hypertrophy of the heart and raised blood-pressure 
will be present if, as is frequently the case, an acute 
exacerbation has supervened upon a chronic condition. 
In a primary acute attack, arterial changes are not 
to be expected, but a history of some recent condition 
which suggests scarlet fever is a valuable aid in the 
diagnosis. Cases are sometimes sent to hospital as 
" acute nephritis," which are really a manifestation 


of scarlet fever, and during their treatment in hospital 
a recurrence of the fever is not uncommon. 

Pallor is often a marked early feature, with gradually 
increasing anaemia. 

TREATMENT. The treatment of acute nephritis falls 
under the following headings : First, directly to 
diminish the work thrown upon the kidneys, which will 
include the reduction of nitrogenous foodstuffs and of 
extractives. Since the production of oedema appears 
to be in some way associated with the retention of 
chlorides, salt in the food should be withheld as far 
as possible. The orthodox diet is 3 pints of milk 
daily, and, indeed, even this bland diet has objections, 
inasmuch as the albuminous constituent therein is 
considerable. Furthermore, the frequent occurrence of 
nausea and vomiting demands the avoidance of any but 
simple digestible foodstuffs. It may be well to restrict 
the nourishment in the acute stage to fruit juices, so 
that practically nothing but water and a little sugar are 
being taken. With improvement in the general condi- 
tion and in the local condition, as demonstrated by the 
disappearance of casts and reduction of albumin in the 
urine, the diet can be gradually extended. 

Secondly, indirectly to conserve the kidney, reducing 
its work by promoting and encouraging excretion 
through other channels, the bowels and the skin. 
To this end the passage of copious watery stools is 
ensured by the administration of hydragogue cathartics, 
of the type of pulvis jalapss compositus, or of concen- 
trated salines. The action of the skin is promoted 
by diaphoretics, such as liquor ammonii acetatis and 
spiritus aetheris nitrosi, and by the stimulating influence 
of the hot pack or the vapour bath, preferably the 
former. Pilocarpine is generally regarded as unde- 
sirable ; its sudorific action is accompanied by lachry- 
mation, bronchorrhcea, and respiratory embarrassment, 
which oppose serious objections to its application. 


Cupping of the loins may be regarded as an attempt 
at direct local treatment to relieve congestion of the 
inflamed organs by counter-irritation. 

Thirdly, the treatment of oedema. In most cases 
the treatment above described, which succeeds in 
promoting the excretion of water through other 
channels, will be sufficient to obviate any more direct 
measures. In addition, an excess of fluid is to be 
avoided as contributing to the causation of oedema, in 
which connection the reduction of salt must again be 
mentioned. In some cases, aspiration of a pleural cavity 
may be necessary to reduce a degree of hydrothorax 
which is embarrassing the heart by its mechanical in- 
fluence, or paracentesis abdominis may be performed. In 
the case of the limbs Southey's tubes will be requisitioned. 

Fourthly, the treatment of uraemia. This is a toxic 
state which is probably due to the formation and 
retention of some product of disordered metabolism. 
(The retention in the blood of the normal urinary 
constituents is apparently incapable of producing 
acute uraemia, for this condition does not necessarily 
result from suppression of urine.) An attempt to 
eliminate the toxins should be made by venesection, 
accompanied by intravenous saline infusions. Con- 
vulsions must be checked by the administration of 
hypnotics, particularly bromides and chloral. Lumbar 
puncture is frequently recommended, although we 
cannot claim to have seen any benefit definitely and 
with certainty result from its employment. 

Finally, after-treatment will be of a tonic character, 
particularly with the exhibition of iron in doses as 
large as the digestive system will tolerate. Arsenic, 
whilst an excellent haematinic, is irritating to the 
kidney. The diet must be regulated with due regard 
to the state of the urine. But in this connection it 
is necessary to formulate some ruling as to the condi- 
tion of continued albuminuria, which is the legacy of 


nephritis, and which persists in the absence of all 
other signs or symptoms. It is the fashion to regard 
these subjects as suffering from a severe renal lesion 
which demands complete rest and a rigid diet. Grant- 
ing the absence of symptoms, there is nothing to be 
gained by such procedures. In many cases a careful 
estimation of the amount of albumin shows that the 
loss is really comparatively small, even 1 % albumin 
in 50 ounces of urine amounts to ^ ounce only, an 
amount contributed by an extra pint of milk or the 
whites of two eggs ; in other cases, again, systematic 
estimation at intervals shows that the albuminuria 
tends to become gradually reduced in the absence of 
dietetic treatment. But in any case rigid treatment of 
such cases is gratuitous ; the most scrupulous care 
will not alter the underlying condition. On the other 
hand, neglect to diet strictly is not likely to precipitate 
uraemia. Such patients should be encouraged or 
persuaded to live a normal healthy life, obviously 
avoiding exposure to cold and excesses of any kind, 
and to continue taking iron preferably in the form of 
the liquor ferri pernitratis. 

Chronic Nephritis. 

In the majority of cases the patient will not be 
identified by his complaint of urinary symptoms, nor 
may the condition of the urine be a signpost towards 
diagnosis. In fact, many cases are in existence for a 
comparatively long time without symptoms of any 
kind, or with symptoms so trivial that no complaint 
is made until the development of acute uraemia and 
rapidly ensuing death. 

The first indication may be an apoplectic attack 
due to cerebral haemorrhage. Haemorrhages may 
occur elsewhere, most commonly epistaxis or haema- 
turia. A routine examination of the fundi occasionally 
leads to the discovery of retinitis, demanding a rigid 


investigation for the possible existence of chronic 
nephritis. An experience of one of us is a case in 
point. A patient was referred from an oculist to 
explain the retinitis which had been discovered during 
a routine ophthalmoscopic examination the patient's 
refraction was being undertaken for military purposes. 
No general condition to explain the lesion was dis- 
covered, but twelve months later the patient again 
came under observation, on this occasion with acute 
nephritis, evidently superimposed upon a long-standing 
chronic condition. 

In pregnant women, the vascular changes associated 
with chronic nephritis may affect the placental vessels, 
and miscarriages not infrequently occur in consequence. 

The typical associations of a chronic nephritis which 
should be looked for in any suspected case are a large 
left ventricle and a heaving apical impulse, with per- 
haps a systolic murmur ; a ringing (accentuated) aortic 
second sound. Anaemia of chlorotic type may be 
present, and almost invariably the blood-pressure, 
both systolic and diastolic, are raised, the former to 
180 mm. or higher. There may be a history of haemor- 
rhages, e.g. epistaxis, and their presence should be 
looked for particularly in the retina. 

Symptoms of which complaint may be made are 
headache, insomnia, and a feeling of weakness ; breath- 
lessness is common and giddiness frequent. Polyuria 
may be the presenting symptom. 

The relation of the circulation to the renal condition 
is such that it is frequently impossible to decide which 
is primarily responsible. In general, one regards the 
sufferer with " chronic nephritis " as one with " cardio- 
renal disease," and the two systems as inter-related, 
although associated signs of high blood-pressure, of 
albuminuric retinitis and of the characteristic urinary 
condition (see below), on the one hand, or of precordial 
pain, irregularity of the heart and shortness of breath, 


on the other, denote that the renal or myocardial factor 
respectively predominates. 

The urine in the condition granular kidney (chronic 
intestitial nephritis) is of low specific gravity (1005- 
1012). The quantity passed is increased and the 
percentage of urea is lowered, although the total out- 
put of .urea is not as a rule diminished. Usually the 
amount of albumin present is very low, and microscopical 
examination reveals the presence of very few casts 
the condition being one of degeneration rather than 
inflammation. In a later stage, especially with cardiac 
failure, the amount of albumin increases. 

TREATMENT. The condition of chronic nephritis is 
not one of a slowly progressing inflammatory process 
which is still active, but an effect produced by an 
original activity which has subsided and by the replace- 
ment of the normal kidney substance by fibrous tissue. 
Any attempt therefore at direct treatment of the kidney 
is useless, and care is directed towards conserving the 
kidney, the relief of symptoms as they arise, and the 
institution of safeguards against complications. 

The first consideration will be met by 

(1) The removal of any possible causal factor. 
The influence of such irritants as lead, alcohol, syphilis 
and gout in the production of granular kidney is pro- 
blematical, and in any case when the lesion has developed 
the mischief is irreparable. Still, such causal factors 
should be looked for and the possibility of any further 
influence eliminated, most of all perhaps as regards 

(2) Reduction of strain upon the renal function. 
The diet should contain a minimum of extractives, 
so that meat should be taken in small quantity only, 
and such substances as contain purins in excess 
avoided. Alcohol, too, must be taken sparingly. 
Sweetbread, liver, beef, pork, mutton, chicken, veal, 
salmon are relatively rich ; whilst oatmeal, vegetables, 


milk, eggs, cheese, butter, sugar, are free from or rela- 
tively poor in purin bodies. Tea, coffee, cocoa and malt 
liquors again contain purins which are deficient in 
wines and spirits, although the latter are inadmissible 
from the large proportion of alcohol they contain. 

It is evident that the traditional selection of white 
meat as opposed to red is unjustified if the avoidance 
of purins is the important consideration, since as regards 
the purin content there is little to choose between them. 
In general, too, it may be said that in the regulation 
of the diet for a chronic nephritic it is the avoidance of 
excess of any kind of food which should be the chief 
indication, since oxidation of proteins (which appears 
to be the aim of most regimes), whilst achieved by 
lessening the total intake of proteins, will be defeated 
by an increase of protein sparers, e.g. carbohydrates. 
It is more important to restrict the quantity of food 
taken than to eliminate certain constituents. 

As an average daily diet, that suggested by Dr. 
Langdon Brown may be quoted. It consists of bread 
16 ounces, butter 2 ounces, mutton or fish 3 ounces, 
potato 6 ounces, green vegetables 4 ounces, one egg and 
one pint of milk. Such a dietary yields 2,690 calories. 

Secondly, the work of the kidney may be reduced by 
increasing elimination through the other channels, the 
bowels and the skin. 

For the regulation of the bowels saline aperients or 
hydragogue cathartics, such as pulvis jalapae compositus, 
should be taken every morning or at fairly frequent 
intervals. The skin is kept gently active by regular 
exercise, which demands only a moderate degree of 
exertion, and in this way, too, elimination through 
the lungs is encouraged. If the patient's condition 
permits, a weekly Turkish bath may with advantage 
be taken. Flannel, or a mixture of wool and silk, 
should be worn next the skin. 

Thirdly, general hygiene. The sufferer from chronic 


nephritis should be regarded as a perpetual convalescent, 
and appropriate treatment includes, in addition to 
dietetic regulations, care of the skin and selection of 
suitable clothing, as already referred to, the avoidance 
of chill and of undue fatigue. Naturally such patients 
are always at their best in an equable climate, when- 
ever such residence is possible. The regular adminis- 
tration of iron is to be recommended whenever the 
condition of the digestion permits. 

(3) SYMPTOMATIC TREATMENT. (a) The blood-pres- 
sure. It is doubtful how far it is possible perma- 
nently to reduce a raised blood-pressure and how far 
such reduction if possible is advisable. But whilst 
in many cases no inconvenience appears to arise there- 
from, in certain cases distressing symptoms do appear 
to be definitely related to a high blood-pressure, and 
mtro-glycerine in full doses, or a mixture of sodium 
nitrite, 2 grains, and sodium nitrate, 10 grains, may 
be administered. The traditional employment of 
potassium iodide acquires additional interest in view 
of the influence of syphilis in the production of 
arterio-sclerosis and the relation between this condition 
and granular kidney. The great reputation which this 
drug has quite deservedly obtained may really be due 
to its anti-syphylitic action. 

(6) Headache, whether the result of high blood-pres- 
sure or of a mild degree of chronic toxaemia. Sir John 
Rose Bradford recommends pilocarpine in small doses 
for this condition, and if the headache is particularly 
troublesome at night and prevents sleep, the best hyp- 
notic is cannabis indica 20 to 30 minims of the tincture. 

In later stages oedema may develop and demand a 
more rigid regulation of the diet, and particularly 
the reduction so far as possible of sodium chloride 
(" salt-free diet " ). The skin will require more rigorous 
stimulation, as by vapour or hot-air baths or the hot 
wet pack. Pilocarpine in sufficiently large doses to 


produce a considerable degree of perspiration is not to 
be recommended, on account of the distressing effect 
upon the lungs, etc., it is liable to cause. As diuretics, 
caffeine, theobromine and diuretin are sometimes of 
value, and the well known diuretic pill (Pulv. digitalis 
gr. i. Pulv. Scillae. gr. i., Pil. hydrarg. gr. i., Extr. hyoscyam 
gr. i.) may be given once or twice a day. Notwith- 
standing such methods, it may be necessary to relieve the 
oedema directly as by aspiration of the chest or abdomen, 
or by employing Southey's tubes in the case of the legs. 

Later still uraemic symptoms may progress with 
vomiting and diarrhoea. The latter is best left un- 
checked. (See also page 75.) 

In the treatment of chronic nephritis the specific 
use of renal extracts has sometimes been recommended. 
The chief objection to their employment, empirical 
at any rate, is that there is no evidence of the kidney 
possessing an internal secretion. At the present day 
this therapeutic measure appears to possess no pro- 
minent supporters. 

Decapsulation for chronic nephritis, which has been 
for many years under consideration, has of recent date 
been brought into prominence by several investigators, 
who quote examples of cases greatly benefited, and in 
certain instances even cured, by the operation. It 
is difficult to select the class of case likely to be 
succesful. It is generally agreed that a young subject 
with oedema, polyuria, or oliguria, and one who is pass- 
ing considerable quantities of albumin, is the most 
favourable, and that cardio-vascular changes are a 
centra-indication, although cases with high blood- 
pressure who have benefited have also been reported. 

The operation appears to afford an additional passage 
for lymph to flow out of the kidney, so ensuring better 
drainage of the toxic elements, which are otherwise 
not eliminated. 


THE formation of pus in the kidney may be the result 
of primary disease in that organ, or it may be secondary 
to diseases of the lower urinary tract. The diagnosis 
is determined by symptoms referred to the bladder, 
by cystoscopy and by changes in the urine. Skia- 
graphy assists by demonstrating the size of the 
kidneys and the presence or absence of abnormal 
shadows, e.g. those of stone and patches of caseation. 

Reference must be made to certain hsematogenous 
infections of the kidney which closely resemble in 
their symptoms the so-called medical kidney, but in 
which the cause can be definitely traced to certain 
organisms, the most common of which is strep- 
tococcus. In these cases the amount of pus excreted 
may be small, simulating in this respect the urine seen 
in pyelitis of Bacillus coli origin. The disease affects 
one or both kidneys. 

Treatment of primary pus-formation, e.g. strep- 
tococcal nephritis, calculous pyonephrosis and tubercu- 
lous pyonephrosis should be referred to the surgeon 
at the earliest possible moment, and catheterisation 
of the ureters is necessary in order to draw off urine 
from each kidney for the dual purpose of estimating 
the renal function and determining whether one or 
both organs are diseased. Removal of one kidney 
is contra-indicated unless it is established beyond 
doubt that the other is quite healthy and functioning 
normally. Palliative treatment, such as local appli- 
cations to the loin and the internal administration 


of drugs, should only be resorted to when there is 
unavoidable delay in operative interference or the 
disease is bilateral. A turpentine stupe applied to 
the loin will relieve the aching pain common to these 
cases. A popular remedy is a very pliable rubber hot- 
water bottle which will fit closely round the loin ; this 
is equally efficacious as an analgesic, and possesses an 
added advantage since it can be indefinitely renewed. 
Aspirin and morphia may be given if the pain is severe. 

One of the more common primary infective diseases is 
pyelitis, which is due to infection by a coliform bacillus. 
Treatment usually rests with the practitioner. The 
patient should drink large quantities of non-alcoholic 
fluids e.g. Vichy, Contrexeville or barley water. In 
order to render the urine alkaline and thus prevent 
further growth of the organisms, sodium or potassium 
bicarbonate in doses of not less than 30 grains must 
be given four-hourly. Additional treatment is lavage 
of the renal pelvis with a weak solution of silver 

Stock and autogenous coliform vaccines are considered 
by some to do much good. Small doses should be 
given once a week in the early stages of the disease, 
e.g. two million bacilli, and in the later stages as large 
a dose as 200 millions. In the opinion of the authors 
they do no harm, and as little good. Best and warmth 
are essential, and the patient should remain in bed for 
at least forty-eight hours after the complete disap- 
pearance of both pain and fever. In pyelitis, operative 
measures are fortunately seldom required, but attacks 
of pain or fever or both are liable to recur, even at 
long intervals. No alarm need be felt at the continua- 
tion of night sweats for many weeks after the disap- 
pearance of the more acute symptoms, but the patient 
must be careful to avoid chill until they have gradually 
ceased. The symptoms of the adult form of this disease, 



which is chiefly observed amongst pregnant women, 
are remarkable for their similarity to appendicitis ; 
and although they may return with each succeeding 
pregnancy, permanent damage to the kidney is unlikely. 
Prophylactic doses of potassium bicarbonate should be 
given at the commencement of pregnancy. 

When the suppurating condition of the kidney is 
caused by an ascending infection from the lower 
urinary tract, as, for example, cystitis, due to either en- 
largement of the prostate or stricture, great credit will 
reflect upon the practitioner if he prove successful 
in relieving the more acute symptoms. It must, how- 
ever, be borne in mind that an ascending infection of 
the kidney can never be ameliorated or cured unless 
the cause of the obstruction in the lower urinary tract 
is removed, but temporary relief can be obtained by 
carrying out the following treatment. Both for en- 
larged prostate and stricture, as large a catheter as 
will pass the obstruction should be tied in, and the 
bladder irrigated twice daily with a weak antiseptic 
solution (silver nitrate 1 in 5,000, potassium perman- 
ganate 1 in 5,000, or oxycyanide of mercury 1 in 5,000). 
Should the urethra be intolerant to the retaining of 
a catheter for some days, the urologist must be con- 
sulted with a view to draining the bladder above the 
pubes (suprapubic cystotomy and insertion of the 
De Pezzer tube, see page 106). 

The golden rule, that whenever there is pus-for- 
mation in the body it should be immediately evac- 
uated, holds good in the case of suppurative lesions 
of the kidney. By tying a catheter into the bladder 
the whole urinary tract is drained freely. Besides 
free drainage we must be sure of free irrigation, in 
order that the lower urinary tract may be cleared of 
septic material. 

Irrigation of the upper urinary tract, that is the 


kidneys and ureters, may be carried out by increasing 
the flow of fluids through the kidneys. There are 
four ways by means of which this can be effected ; by 
the mouth, by the rectum, by subcutaneous and 
intravenous injections. 

If the condition is not very serious, the administration 
of large quantities of fluids by the mouth will suffice. 
One of the best and most pleasant for the patient is 
Contrexeville water, of which at least 4 pints should 
be drunk in twenty-four hours. Another excellent 
beverage for these cases is parsley tea. This may 
readily be made by pouring boiling water on chopped- 
up parsley. The solution should be concentrated, 
and the quantity given the same as in the case of 
Contrexeville water. 

Where uraemia is threatened or actually exists, 
fluids by the mouth are insufficient. Physiological 
saline at body temperature must be given, either by 
the rectum or intravenously, slowly and cautiously 
until 6 pints have passed into the circulation. After 
an interval of four hours another 3 pints may be 
given by the same method. Thus patients who at 
first sight appear to be moribund often recover in 
a remarkable manner. The only drug of value to be 
given by the mouth is hexamine (5 grains, four-hourly). 
Hot-air baths are strongly recommended by some 
authorities to reduce toxaemia by profuse sweating ; 
but the artificial production of sweating puts undue 
strain upon the heart, and may prove extremely 
dangerous. In conclusion, the treatment by the 
general practitioner of suppurative lesions of the kidney 
caused by an ascending infection may be summarised 
in four words : " Free drainage, free irrigation." 


THIS term must be restricted to the presence of 
organisms in urine freshly voided, since a perfectly 
healthy sterile urine may eventually exhibit the 
presence of micro-organisms if allowed to stand un- 
covered for a variable period, depending upon the 
external temperature and other circumstances. 

It is obviously necessary before a diagnosis of 
pathological bacteriuria is made that a specimen is 
collected by catheter with all aseptic precautions, since 
the urethra normally contains a variety of organisms 
of non-pathogenic character. 

Assuming, however, that a definitely infected urine 
is under consideration, the cause may be a generalised 
infection or a local lesion, by which is meant infection 
from some part of the urinary tract. For example, 
the kidney may contribute organisms of which the 
commonest are Bacillus coli, the tubercle bacillus, 
Staphylococcus aureus, pneumococcus. The same organ- 
isms may be derived from the bladder, the prostate 
and the urethra, with the addition, in the case of the 
two latter, of the gonococcus. These conditions are 
considered elsewhere. 

But the chief interest in bacteriuria lies in the possi- 
bility of a general infection without disease of the 
urinary organs. In such cases the contamination 
necessarily arises from some source of sepsis external 
to the urinary tract. Sometimes such a source is 
ascertainable, e.g. a carious tooth or a septic tonsil, 
but frequently no such focus of infection can with 



certainty be detected, and it would appear, particularly 
in infection by the Bacillus coli, that the normal denizens 
of the intestine acquire pathogenic properties and 
induce a generalised infection in which the organisms 
can be isolated from the urine, if not from the blood- 
stream. An infected appendix may be at the bottom 
of the mischief. 

In such cases we are often confronted with an illness 
displaying profound constitutional disturbance, pyrexia, 
perhaps vomiting and rigors, but without physical 
signs of any description. The nature of the illness 
is only elucidated by a routine examination demon- 
strating a pathological urine. The latter may be 
normal in appearance, but generally it exhibits a 
turbidity which is not dispersed by filtration. In 
some cases blood may be present, and impart its 
characteristic appearance. The reaction is usually 
acid. Frequency of micturition is generally, although 
not invariably, present. 

TREATMENT. Any source of infection must, if 
ascertained or suspected, be removed. The colon 
is disinfected by the administration of calomel and 
the injection of large enemata. The patient is confined 
to bed during the stage of acute illness and placed 
upon the bland diet commonly employed in cases of 
fever. The drug par excellence to be employed is 
urotropin, in doses of 10 grains given three times a 
day with a tumbler of water. Urotropin is efficient 
only in an acid urine, so that before this drug is adminis- 
tered care must be taken to ensure a suitable reaction 
in the urine. It is often far from easy to render an 
alkaline urine acid, and the only drugs which are utilised 
to this end are benzoic acid and the acid sodium 
phosphate, more usually the latter. Considerable con- 
troversy has arisen as to the principle of administering 
this salt together with urotropin, and until com- 


paratively recently such a practice was held to be bad 
in the expectation that the effect of the acid would be 
to liberate formaldehyde from the urotropin in the 
mixture, and not, as is desired, at the time of contact 
with the acid urine. But it does not appear that as 
a matter of fact formaldehyde is thus produced by 
the hydrogen-ion in acid sodium phosphate, and it 
is nowadays a common practice to administer the 
two simultaneously if it is desired to render the urine 

An alternative measure to disinfection of the urine 
is to render it alkaline by the administration of large 
quantities of sodium bicarbonate with citrate of potash, 
and so provide a milieu in which the Bacillus coli 
cannot flourish. 

Bacteriuria may be a very chronic, long persisting 
condition, and it is neither desirable nor necessary in 
the absence of definite indications to persist in a rigid 
treatment as regards restriction of diet and advice 
to refrain from occupation and other activities. A 
very efficient form of treatment in all urinary infections 
is vaccine-therapy. Although a stock vaccine may be 
employed, particularly in the case of coli-infection, far 
better results will be obtained by the use of an autogenous 
vaccine prepared by the cultivation from a catheter 
specimen of the patient's own urine. 


TUBERCULOUS affections of the genito-urinary organs 
most commonly appear between the ages of eighteen 
and forty years. The primary lesion is situated in one 
or both kidneys or in the genital organs. The bladder 
is always secondarily affected by direct spread of the 
infection from above or below. With affections of the 
genital organs we are not immediately concerned, but in 
all cases where the tubercle bacillus has been found in 
the urine it is important to examine the testicles, prostate, 
and seminal vesicles as a possible source of infection. 

So insidious is the onset of renal tuberculosis that 
symptoms of the disease rarely manifest themselves 
before the bladder becomes infected. Hsematuria 
without any other vesical symptoms is so rare as only 
to merit a passing comment. The common symptom 
of a tuberculous lesion is frequency of micturition due 
to cystitis. The complaint may be made of painful 
micturition when, owing to the development of urethritis, 
the passage of urine causes a sensation of soreness. 

In a young man, pale and thin, who complains of 
disturbance of his night's rest due to a frequent desire 
to micturate, suspicion should be at once aroused 
that tuberculosis is the cause of his ill health. A 
bacteriological examination must be made of the urine, 
and if on the first occasion the tubercle bacillus is 
not found, another examination should be made at a 
later date, for the organism is not readily discovered 
in this medium. Pus and sometimes blood are also 
constituents of a tuberculous urine. Even if tubercle 



bacilli are not found in the urine the diagnosis should 
not be rejected until cystoscopy has been performed. 

The patient should be cystoscoped and both ureters 
catheterised in order to ascertain whether, if present, 
the disease is unilateral or bilateral. It is possible 
to detect the presence of tubercles in the bladder 
mucous .membrane ; still more valuable evidence may 
be obtained by comparing the appearance of both 
ureteric orifices. Subsequently the urine from each 
ureter is bacteriologically examined, and thus a definite 
diagnosis can be made. 

If one kidney only is diseased, surgical interference 
is indicated, and the patient should be subjected to 
nephrectomy. Evidence of the presence of the tubercle 
bacillus in the genitalia as well as in one kidney does 
not contra-indicate this operation, for experience shows 
that it results occasionally in complete cure, and 
invariably in improvement of the disease in these 
organs when they are secondarily infected. 

After removal of the primary focus it is necessary 
to treat the tuberculous cystitis. This consists of 
(1) dietetic restrictions, (2) the administration of 
urinary antiseptics by the mouth, and (3) tuberculin 

(1) Dietetic Restrictions. This subject is discussed 
at the end of the chapter under the treatment for 
bilateral tuberculous disease of the kidneys. 

(2) Urinary Antiseptics. There are only a few 
drugs to be taken by the mouth which act as 
urinary antiseptics. The more important are urotropin, 
boric acid, and sandal wood oil. The first named 
has the greatest antiseptic power ; boric acid has 
the least. In a certain percentage of cases, urotropin 
increases the frequency of micturition by irritating 
the mucous membrane of the bladder. Sandal wood oil 
in capsules of 5 minims is an excellent substitute in 


such cases, and should be given every four hours, and 
continued for a period of three months. 

(3) Tuberculin Injections. See page 90. 

Secondary infection of the tuberculous bladder 
with other organisms is a serious complication the 
risk of which can be obviated by avoiding intra-vesical 
manipulation such as lavage. For the same reason 
the passage of urethral instruments should be rigidly 
restricted to those occasions when they must be 
employed for diagnostic purposes. 

Inoperable Urinary Tuberculosis. 

Whilst there are definite surgical indications, such 
as pyonephrosis, acute paroxysmal pain and continued 
pyrexia, as well as the prospect of eradicating a limited 
focus of infection as in one kidney, the practitioner 
is sometimes confronted with the treatment of a case 
in which both kidneys are involved, or in which the 
renal affection is accompanied by evidence of tuberculous 
disease elsewhere in the body. It may be stated that 
the presence of cystitis is no centra-indication to 
nephrectomy, since improvement of the bladder will 
ensue upon the removal of the primary focus. 

But where operation is clearly out of the question, 
the treatment must be a compromise between the 
attempt to deal with a tuberculous subject upon general 
lines and the limitations imposed by the existence 
of a renal lesion. Whilst restrictions are inevitable, 
the position adopted aims at regarding the patient 
as a tuberculous rather than as a renal subject. 

Medical treatment must be considered under the 
headings of climate, food, general hygiene and drugs. 

A great deal of controversy has arisen respecting the 
most desirable climate for such a patient. There is 
pretty general agreement that a maximum of sunlight 
is preferable, but whereas much may be said in favour 


of a cold dry atmosphere for phthisical patients gene- 
rally, the renal subject will be best suited by a relatively 
temperate climate at sea level, the Mediterranean 
littoral offering perhaps the best advantages, provided of 
course the patient can tolerate the necessary travelling. 
Otherwise the west and south-west coast in this country 
are to .be recommended. 

As regards food, indigestible materials and such 
constituents as are liable to over-burden the renal 
function, e.g. the heavier kinds of meat and fish, are 
to be avoided, as well as those vegetables, such as 
asparagus, which contain salts known to irritate the 
kidney. Alcohol, too, must be forbidden. On the 
whole the diet should consist largely of milk and 
vegetables. Cod liver oil, which is both a drug and a 
foodstuff, is given, as in most cases of tuberculous 

Hygienic considerations for the most part comprise 
a maximum of fresh air, with a due proportion of rest, 
with exercise strictly graduated to the patient's capa- 
bilities. Sanatorium discipline is desirable, but without 
arbitrary regulations which are not adapted to 
individual requirements. In other words, residence 
in a sanatorium itself is not to be recommended. 
Flannel should always be worn next the skin. In 
addition to cod liver oil, which has already been 
mentioned, and perhaps arsenic, only such drugs 
will be given as are necessary to combat or relieve 
symptoms as they arise. 

Tuberculin injections require mention, since they are 
frequently recommended as of special value in the 
treatment of tuberculosis of the genito-urinary organs. 
They are administered subcutaneously once a week, 
the dosage commencing at ^^ milligram, increasing 
gradually to ^ milligram. Such treatment must be 
continued for at least two years. 


THE origin of bladder inflammation may be found 
in a blood infection or secondary to some lesion of 
the urinary tract, e.g. the kidney or urethra, or an 
affection of the bladder itself, such as a stone, tubercu- 
losis, or a growth. 

Cystitis due to Blood Infection. 

Cystitis of haematogenous origin is a condition which 
occurs in both sexes, but more frequently in women. 
The organism commonly responsible is the Bacillus 
coli, but the streptococcus, the staphylococcus and 
the pneumococcus have also been recorded as infecting 
the bladder via the blood-stream. 

The disease is ushered in with a sudden attack of 
haematuria, followed by a rise of temperature and 
frequency of micturition. The quantity of blood 
passed varies with the severity of the inflammation. 
Occasionally the first indication of acute cystitis is 
limited to a rise of temperature, which may possibly 
cause a mistaken diagnosis of influenza, but after twenty- 
four hours the bladder symptoms assert themselves, 
and the correct interpretation of the condition becomes 
obvious. Besides the vesical symptoms to which 
reference has already been made, there is a sensation 
of smarting along the urethra during the passage of 
urine, and a feeling at the end of the act of micturition 
that evacuation of the bladder has been incomplete. 
Strangury is also present. Examination of the urine 
will reveal the presence of blood, pus, albumen and 



micro-organisms ; the - diagnosis of primary inflam- 
mation of the bladder will be confirmed by cys- 

TREATMENT. The patient should be confined to 
bed until the temperature has remained normal for 
at least forty-eight hours. 

A rubber hot-water bottle applied to the supra- 
pubic region will relieve the strangury, but if the latter 
is very severe J grain of morphia should be given 
hypodermically. Drug treatment will vary according 
to the nature of the organism. If infection is by the 
Bacillus coli, potassium bicarbonate, 30 grains every 
four hours, must be given by the mouth. If by one of 
the cocci group, urotropin 10 grains and tincture of 
hyoscyamus 1 drachm four-hourly. Vaccines are useless 
during the acute stage, and bladder lavage is obviously 
contra-indicated. Under this treatment the inflamma- 
tion disappears in the majority of cases, but occasionally 
the disease passes into the chronic stage, and it is then 
that vaccines and bladder lavage are useful. An 
autogenous vaccine commencing with very small 
doses, which are gradually increased, should be given 
once a week. A catheter should be passed weekly, 
and the bladder irrigated with 1 in 10,000 silver 
nitrate, which, after the lavage has been carried out 
two or three times, may be increased in strength 
to 1 in 5,000. Search for a primary focus in cases of 
hsematogenous infection of the bladder must never be 
neglected. A focus can rarely be found, but that is no 
excuse for neglecting to make the attempt. Boils, car- 
buncles, tonsillitis, pyorrhoea and chronic constipation 
are recognised as possible causes of infection, all of 
which should receive appropriate treatment ; but there 
will always be a large number of cases in which the 
source of infection is never determined, 


Cystitis Secondary to a Lesion of the Kidneys. 

Bacterial infection of the kidneys commonly spreads 
down the ureters to the bladder and sets up a localised 

Examples of this spread of infection are observed 
in the pyelitis of pregnancy, acute pyelonephritis and 
renal tuberculosis. 

A certain case is recalled when recurrent attacks 
of fever were associated with slight frequency of 
micturition. The urine was examined and found to 
contain the Bacillus coli and a few blood and pus cells. 
Cystoscopy revealed an area of acute inflammation 
around the left ureteric orifice, but no change on the 
right side. The left kidney was tender on deep pal- 
pation. The signs and symptoms pointed, therefore, 
to a unilateral pyelonephritis, with a secondary localised 
cystitis. Treatment by rest in bed while the fever 
persisted, and the administration of large doses of 
potassium bicarbonate (30 grains four-hourly) by the 
mouth, resulted in rapid disappearance of the symp- 

When symptoms point to an attack of cystitis being 
secondary to a renal lesion, not only should the urine 
be examined for bacteria, but radiography of the whole 
urinary tract is recommended, to exclude the presence 
of stone. 

It must not be forgotten that a stone may form 
and remain in the kidney " silent " and unsuspected 
for a number of years, but all the while damaging 
and undermining the vitality of the renal cells. Owing 
to the lowered resistance these tissues become infected 
and cause an attack of fever and a localised cystitis. 
In a few days the symptoms pass off, and again the 
stone is " silent." 


Cystitis due to Direct Spread from the Urethra. 

Urethritis of gonococcal origin, if treated during 
the acute stage of the disease by such severe local 
manipulation as the passage of bougies, catheters, etc., 
may spread to the bladder and give rise to an acute 
cystitis. So acute may this inflammation become that 
actual gangrene of the mucous membrane may occur. 

A fatal case is on record in which an attempt had 
been made to abort an attack of acute urethritis by 
means of instrumentation. Gangrenous cystitis was 
caused, resulting in the whole bladder wall sloughing, 
and death taking place from gonococcal septicaemia. 
Such cases are rare ; but cystitis due to the gono- 
coccus in the initial stages is always severe, and 
causes profuse haematuria. 

This condition is prone to become chronic and prove 
very intractable, pyuria persisting for many years. 

Local treatment consists of lavage with 1 in 10,000 
silver nitrate, potassium permanganate 1 in 5,000, 
and hydrogen peroxide. 

Infection of the bladder through neglect of aseptic 
precautions in instrumentation is unfortunately a 
familiar occurrence, and occasionally even the most 
scrupulous preventive measures cannot eliminate in- 
fection when the bladder has undergone degenerative 
changes, the result of stricture of the urethra or 
disease of the prostate. 

Cystitis Secondary to Vesical Growth. Pus-forming 
organisms find in malignant disease an excellent soil 
on which to multiply, and in no part of the body is 
this more pronounced than in the bladder. In fact, 
the first indications of the presence of a vesical growth 
are usually the symptoms of cystitis. It is this com- 
plication which terminates the patient's life by spreading 
the infection to the kidneys. 

Cystitis due to tuberculosis is separately considered 
in the chapter on " Tuberculosis of the Urinary Tract." 


THE examination of a patient in whom the symptoms 
point to disease in the urinary tract can never be 
complete without the aid of the cystoscope, and in 
no lesion is this more apparent than in growth of 
the bladder. The cystoscope will reveal whether the 
tumour is a papilloma or a malignant neoplasm, and 
in respect of the latter whether advanced or in the 
early stages of growth. 

A painless intermittent hsematuria is the usual 
symptom of simple villous or papillomatous dis- 
ease, but with respect to vesical cancer, apart from 
haematuria, there may be cystitis and pain in the 
suprapubic region. 

The treatment of simple tumours has in recent 
years undergone a marked change, for whereas it was 
customary to remove these growths by open operation, 
it is now possible to destroy them by the action of the 
diathermic current. The electrode is passed into 
the bladder with the aid of the cystoscope, several 
applications of the current being necessary before 
the patient is cured. 

The treatment of malignant growths may be 
considered from the pre-operative and post-operative 
aspects, and in the application of suitable methods 
to inoperable cases. 

(1) PRE-OPERATIVE TREATMENT. Much may be done 
by the patient's medical attendant to reduce his dis- 
comfort to a minimum before he comes under the care 
of the surgeon. Attacks of pain and haemorrhage 



require immediate treatment during the pre-operative 
period. Pain, which is of the nature of a strangury, 
is relieved by repeated doses of tincture of hyoscyanus 
given by the mouth. Less than drachm doses three 
times a day will be found ineffectual. 

It occasionally happens that portions of growth are 
cast off free into the bladder, or that large blood-clots 
form, causing such acute pain as to necessitate a 
hypodermic injection of morphia. When this occurs 
operation should not be delayed. 

Haemorrhage from a growth of the bladder will often 
tax the practitioner's ability and patience. The 
bleeding may be persistent or intermittent. In the 
former case, usually the less severe, a catheter should 
be passed and the bladder irrigated with a solution of 
silver nitrate 1 in 5,000, at a temperature of 120 Fahr. 
This should be carried out daily. 

In passing a catheter the strictest aseptic precau- 
tions must be adopted, for the introduction of 
sepsis into the bladder, the seat of the growth, is a 
serious complication. Numerous drugs have been 
recommended for the arrest of persistent haemorrhage. 
Of these the better known are ergot, calcium lactate 
and iron salts. The authors have seen no good what- 
ever result from their administration. 

The patient should be warned against the severe 
bleeding that will ensue from all violent exercise, such 
as horse-riding, running, etc. ; also of the danger of 
increased blood-pressure caused by high living and 
indulgence in alcohol. 

The treatment recommended for persistent bleeding 
must in no way be considered to replace or cause 
any delay in operative interference. When blood is 
found in the urine, expert advice should be obtained 
at the earliest opportunity. In cases of intermittent 
haemorrhage, the bleeding is often so profuse as to 


result in extensive clot-formation with retention of 
urine. An attempt may be made to relieve the more 
acute symptoms by evacuating the clot with Bigelow's 
evacuator, but blockage usually results, and at best 
it is a purely temporary measure. In such cases 
immediate surgical interference is required. 

(2) POST- OPERATIVE TREATMENT. Following removal 
of a bladder tumour and healing of the suprapubic 
wound, the patient should be instructed to report 
every six months for examination of the urine. Recur- 
rence of growth is insidious in its onset, and if he is 
wise the practitioner will send his patient at least once 
a year to an urologist for cystoscopic examination. Thus 
only is it possible to detect an early return of the 

that the practitioner's efforts to relieve pain and dis- 
tress are severely tested. All such cases should be 
submitted to an expert examination with a view to 
treatment by fulguration, radium, or a permanent 
suprapubic cystotomy. If haemorrhage is severe, or 
there is such frequency of micturition as to prevent 
the patient from getting a good night's rest, an urologist 
should be called in with a view to performing a per- 
manent suprapubic cystotomy. Irrigation of the 
bladder via the urethra may become impossible owing 
to blockage of the internal meatus by growth, or 
cause such pain as to render the patient exhausted. 
The experience of the authors is that all inoperable 
cases eventually require a suprapubic cystotomy. 
Following this operation the patient will again pass 
into the hands of his usual medical attendant, who 
will be expected to advise how the skin around the 
euprapubic fistula may be prevented from becoming 
excoriated, and what dressings will be necessary. 
The application of an ointment consisting of zinc 



and castor oil in equal parts thickly spread over the 
whole of the skin of the suprapubic region will keep 
it in a healthy condition. The urine from this fistula 
can best be drained by a rubber tube passed through 
an indiarubber flange into the bladder, the other 
end being attached to a portable urinal. Between 
the flange and the skin should be placed a layer of 
gauze smeared with castor oil and zinc ointment. The 
gauze must be changed daily. 

For pain, various drugs may be used. That which the 
authors favour most is aspirin, which should be given 
in doses of not less than 15 grains three times daily. 
Morphia and its preparations should only be resorted 
to when the patient has become resistant to all other 
analgesics or in the very last stages of the illness. 
In order that the analgesic effect of aspirin may be 
prolonged it should be given alternately with phenacetin. 
It should not be forgotten that the effects of repeated 
doses of morphia are to cause marked constitutional 
disturbances of such a character as to produce a condi- 
tion of mental degeneration in the patient which results 
in great distress to those around him. 



THE most common cause of inflammation is an attack 
of gonorrhoea, but cases are recorded where there is no 
history of such infection, and the organisms isolated 
in these cases are the Bacillus coli and staphylococcus : 
the tubercle bacillus may also be responsible, associated 
with a secondary infection, in which case the primary 
focus is in the testicles or kidneys. 

Gonococcal Infection of the Prostate. 

In 80 % of cases of gonorrhoea the prostate becomes 
involved, resulting in definite constitutional disturb- 
ances, which necessitate special treatment. A rise of 
temperature, pain in the back, and increased frequency 
of micturition in an attack of gonococcal urethritis, 
indicate that the inflammation has spread to the 
posterior urethra and prostate. Rectal examination, 
by demonstrating tenderness of the prostate on pal- 
pation, confirms the diagnosis. 

The patient should be made to realise that his con- 
dition is serious, and must immediately take to his bed. 

TREATMENT consists of hot baths twice daily, 
the administration of hexamine, 5 grains, three times 
daily by the mouth, and free purgation. Urethral 
irrigation is contra-indicated. In a mild case, ten to 
fourteen days will see a complete cessation of the 
acute symptoms, after which the patient must be 
submitted to prostatic massage and irrigation of the 
posterior urethra with weak antiseptic lotions. Some- 



times pus will develop in the prostate, producing a 
large abscess, which causes pain both on micturition 
and defascation. Under the treatment recommended 
for acute prostatitis, the abscess will in the majority 
of cases empty itself by bursting into the urethra. 
In such an event the patient obtains immediate 
relief and rapidly recovers from the acute symp- 
toms. In a few cases the symptoms are extremely 
severe, and the patient becomes so ill that surgical 
interference is a necessity. An incision is made in the 
perineum between the bulbo-cavernosus and the anus, 
and the swollen prostate felt behind the urethra. 
The abscess is opened and drained, care being taken 
to avoid injuring the urethra when plunging the knife 
into the prostate. On no account should the abscess 
be opened by the rectal route, to avoid the danger of 
infecting the peri-prostatic tissues with the Bacillus coli. 
For the treatment of chronic prostatitis of gonococcal 
origin the reader is referred to the literature on venereal 

Non-Specific Infection of the Prostate. 

The prostate when infected with organisms, other 
than the gonococcus, becomes what may be termed 
" irritable," that is to say, the inflammation is of a 
low degree, causing irritative phenomena in connection 
with micturition and sexual desire. There is frequency 
of micturition both by day and night and an abnormal 
sexual appetite. The diagnosis is made by bacterial 
examination of the prostatic secretion, posterior ureth- 
roscopy, and rectal examination. 

The patient, while strenuously denying exposure 
to specific infection, will admit a slight muco-purulent 
discharge from the urethra, and unless careful examina- 
tion be made, the tendency will be to doubt the veracity 
of his statement, 


By massaging the prostate, and then instructing 
the patient to pass the first ounce of urine into a sterile 
bottle, a specimen of the prostatic secretion is obtained, 
which, when subjected to bacteriological examination, 
will demonstrate the presence of the tubercle bacillus, 
Bacillus coli, or other non-venereal organism. 

Posterior urethroscopy shows inflammatory changes 
around the verumontanum and prostatic ducts ; and 
finally palpation through the rectum reveals nodules in 
the gland and thickening of the seminal vesicles. 

The treatment will depend on the type of organism 
isolated by the bacteriologist. If the tubercle bacillus 
is found, thorough examination of the genitalia and 
kidneys must be conducted in order to demonstrate 
the site of the primary focus. Treatment then consists 
in removal of the primary focus, followed by a course 
of tuberculin injections, fresh air and tonics and 
general hygienic precautions. The prostatic lesion is 
made worse by urethral instrumentation or irrigation. 

TREATMENT, if the disease be caused by the Bacillus 
coli, staphylococcus, etc., must be on the following 
lines : The organism is isolated, and from it an auto- 
genous vaccine is made, which is injected into the 
patient subcutaneously, commencing with small doses 
(e.g. 50 millions), and gradually increasing at intervals 
of a week to 500 millions. Associated with this treat- 
ment, massage of the prostate must be undertaken, 
followed by irrigation of the posterior urethra with 
weak antiseptics, such as potassium permanganate 
1 in 10,000 and oxycyanide of mercury 1 in 10,000. 
The prognosis is good. 

Simple Enlargement of the Prostate. 

With the introduction of total enucleation by Freyer 
in 1901, the treatment of enlarged prostate under- 
went a radical change. Until then this condition had 


been treated either by drugs " to reduce the conges- 
tion," by the constant passage of a catheter, or by an 
operation, which consisted in picking away portions 
of the organ with scissors, scoops and forceps. 
Vasectomy was also employed as an indirect method 
of reducing the size of the gland. For a time this 
procedure was popular and commonly practised at 
St. Peter's Hospital prior to Freyer's epoch-making 

The necessity of removing the prostate before second- 
ary changes occur in the bladder, ureters, and kidneys, 
cannot be too strongly insisted upon. In all cases 
the percentage of deaths occurring under expert 
operative treatment is low, but it would be consider- 
ably lower were those cases eliminated when the 
operation has been undertaken as a measure of urgency. 

So insidious is the deviation from the normal associated 
with an enlarged prostate that the patient generally 
regards such changes as the natural consequence of ad- 
vancing years. He finds that he is obliged to break his 
night's rest by rising to micturate once, perhaps twice ; 
moreover, with the desire comes an urgency for relief. 
Besides this lessening of control a slight strain is always 
required to expel the urine. All of these symptoms 
may not be manifest at once, and in the early stages 
of the disease the layman seldom observes more than 
one, but the prudence of the medical practitioner he 
consults should elicit further evidence. 

Although years may pass between the onset of the 
symptoms and the condition when life becomes a 
burden, the gradual increase in discomfort necessitates 
medical advice. 

Commencing enlargement of the prostate can be 
recognised by two methods of examination palpation 
of the gland per rectum and cystoscopy. As stricture 
will give rise to symptoms similar to those of com- 


mencing enlargement, urethroscopy may be necessary. 
Thus other possible causes of nocturnal frequency, 
straining and precipitancy of micturition, are excluded. 
The quantity of residual urine, that is, the amount of 
urine remaining in the bladder, after the voluntary 
attempt to expel the whole contents has been made, is 
in the early stages of prostatic enlargement between 
1 and 3 ounces. 

The gland enlarges principally in two directions, 
superiorly into the bladder and posteriorly towards 
the rectum. When the main enlargement is towards 
the bladder there may be little or nothing abnormal 
palpable per rectum, the projection of the prostate 
being chiefly intravesical. This latter is always a 
pathological condition, and is confirmed by the appear- 
ance of the internal meatus in both ante- and post- 
mortem examinations. Moreover, it is when the gland 
enlarges superiorly that the urinary symptoms present 
themselves most quickly. 

With the aid of the cystoscope it is possible to detect 
the presence of prostatic growth within the bladder, 
but if the abdominal wall is flaccid, occasionally this 
projection can be detected by means of bimanual 
examination, viz. one finger in the rectum and pressure 
of the other hand above the pubes. 

When enlarged towards the rectum the gland is felt 
as an elastic swelling and is mobile bimanually. Thus 
when investigating a case of suspected prostatic en- 
largement the following procedure must be adopted : 

The patient passes all the urine he can into a glass 
receptacle in the presence of his medical adviser, so 
that the latter may study any alteration in the urinary 
stream and the appearance of the urine. A rectal 
examination is then made, and followed by a bimanual 
one. A Coude catheter is passed in order to estimate 
the amount of residual urine. 


Should the catheter meet with an obstruction in the 
anterior urethra, urethroscopy is required to exclude 
the presence of stricture. Finally, cystoscopy may be 
necessary to confirm the diagnosis. 

TREATMENT. The correct treatment for this disease 
is removal of the whole gland by operation. Cathe- 
terisatipn as an alternative measure is a dangerous 
practice and should be discouraged, for however 
careful in the sterilisation of the instrument the patient 
may be, cystitis is certain to occur, owing to the de- 
generative changes in the bladder wall. If renal failure 
is present at the time of examination of the patient, 
preliminary suprapubic drainage of the bladder is 
necessary to relieve the more urgent symptoms. At 
a later date, if the kidneys recover their function, 
the surgeon can proceed with the operation of total 
enucleation of the gland. 

Carcinoma of the Prostate. 

One of the most insidious and chronic forms of 
malignant disease is that which attacks the prostate 
gland. Two clinical types are recognised, the scirrhus 
variety and the adeno-carcinomatous ; but the latter 
manifests itself as a simple enlargement in the early 
stages, and is with difficulty diagnosed as cancerous 
without the aid of the microscope. 

The presence of malignant cells in a certain number 
of enlarged prostates, which clinically are simple, is 
strong evidence in favour of removal by operation of 
the gland as soon as it interferes with the normal 
function of micturition. 

Patients suffering from malignant disease of the 
prostate universally complain of pain a symptom 
absent in simple enlargement in the region of the 
perineum, especially on pressure, such as when sitting 
on a hard seat. As the disease progresses, pain may 


be referred to the external genitalia and thighs. The 
stream of urine on micturition is observed to get 
smaller, and there is an increasing strain to empty 
the bladder. Thus in the early stages the subjective 
symptoms are few, and the general condition of the 
patient remains good, but with the spread of the 
disease to the base of the bladder and the glands of the 
pelvis, cachexia and loss of weight manifest themselves. 

Palpation of the gland per rectum will establish 
the diagnosis, although the additional examination of 
passing a catheter will help to exclude simple enlarge- 
ment, for the quantity of residual urine in early 
malignant disease is negligible. 

The gland, as felt per rectum, is stony hard, and, 
when the disease is advanced, immobile bimanually, 
and found to merge into the tissues and organs around. 
Owing to the narrowing of the prostatic urethra a full- 
sized catheter cannot be passed. 

TREATMENT. If the disease is discovered early and 
the gland is movable bimanually, operative interference 
leads to some measure of success, and should therefore 
be the treatment of choice. The growth can be re- 
moved by the perineal route or suprapubically through 
the bladder. 

If, on the other hand, the gland is fixed, little hope 
can be entertained from the results of removal by 
the knife. In radium we have a remedy that is worthy 
of trial in all cases which are considered inoperable. 
The radium is inserted into the growth via the peri- 
neum, and must be applied with meticulous care and 
with an exact knowledge of the effect of irradiation 
upon the normal tissues of the body. Therefore, so 
long as the disease has not spread beyond the capsule 
of the prostate, removal of the growth by operation 
is the correct procedure ; but when it has infiltrated 
the surrounding tissues, e.g. the base of the bladder 

and the vesiculse seminales, the use of radium is indi- 
cated. Retention of urine is a not uncommon feature 
in extensive carcinoma of the prostate, and in those 
cases where removal of the growth by operation is 
contra-indicated, it will be found necessary to make a 
permanent opening in the bladder above the pubes. 
The method of suprapubic drainage, as introduced by 
one of the authors, consists in the insertion of the 
self -retaining tube invented by M. De Pezzer. The 
operation is a simple one, and can be performed with- 
out difficulty by a practitioner in a cottage hospital, 
or other convenient place. The steps of the operation 
are as follows : 

The bladder should be distended with at least 
16 ounces of boric lotion at body temperature. An in- 
incision of about three-quarters of an inch is made just 
above the pubes. The sheath of the rectus is then cut ; 
with the tip of the finger the fibres are separated and 
the bladder wall felt beneath. A trocar and cannula, 
the latter fitting a No 28 De Pezzer tube, are then 
plunged through the bladder wall. The trocar is 
removed ; the tube, guided by a stilette, is passed 
through the cannula into the bladder. The cannula 
is withdrawn and then the stilette, leaving the tube 
in the bladder. The end of the tube is mushroom- 
shaped and plugs the orifice securely, automatically 
flattening out with the rise of urine ; moreover, the 
hole in the bladder is exactly equal to the size of the 
tube, so that leakage is impossible. 

After the wound has healed (usually about forty- 
eight hours later), a wooden stopper is inserted into 
the distal end of the tube, and the patient is able to 
walk about in comfort without fear of wetting his 
clothes. A rubber garter round the thigh holds the 
tube in position. So simple and practical is this 
device that when the patient desires to micturate 


he can slip the tube from under the garter and remove 
the wooden stopper, thus relieving Nature by the 
artificial means as easily as by the natural. 

In order to keep the urine sweet and the tube free 
from mucus and phosphates, the patient should be 
provided with a glass syringe and instructed to wash 
out the bladder morning and evening with potassium 
permanganate 1 in 8,000. Acid sodium phosphate 15 to 
30 grains four times daily should be given to keep the 
urine acid. 

The tube should be removed about once a month 
and replaced by a new one. This is easily done with a 
stilette, which straightens out the proximal end, so that 
it can be inserted into the bladder. 

Patients find the utmost relief from this method 
of bladder drainage ; they carry on their work and 
experience no discomfort or inconvenience apart from 
washing out their bladders. 

The operation is also successfully used for cases 
requiring suprapubic drainage of the bladder owing 
to deficient excretion of urea, prior to prostatectomy. 
As local anaesthesia is usually sufficient, the patient 
undergoes a minimum of shock. Well does the urologist 
know that the shock of a preliminary cystotomy in 
cases of threatened renal failure in consequence of 
an enlargement of the prostate will often cause death. 
So simple a procedure as the insertion of the De Pezzer 
tube reduces the shock, and, should the kidneys recover 
their full function, it permits the removal of the prostate 
without the difficulty caused by the scarring of the 
abdominal wall. 

PROSTATE GLAND : see chapter on calculi of the 
urinary tract (page 116). 

IN the male, narrowing of the lumen of the urethra 
is usually due to trauma or inflammation ; occasionally 
it is congenital in origin. Stricture of the urethra 
seldoms occurs in the female. 

The severity of the injury varies from complete 
rupture of the urethra to a slight tearing of the mucous 
membrane. Immediately after the accident, the 
patient is seized with pain, and, attempting to micturate, 
passes a little pure blood. Whether the rupture is 
complete or partial, fibrous tissue forms, and is ulti- 
mately followed by a variable degree of stricture. 
In the female injury to the urethra is sometimes the 
direct consequence of labour. 

Gonococcal inflammation is responsible for the 
highest percentage of strictures ; tuberculous urethritis 
and intra-urethral chancre are other causes. The 
history of a blow on the perineum or penis followed 
at a later date by increasing strain and difficulty on 
micturition suggests stricture. Other characteristic 
signs are changes in the urinary stream : pain 
on micturition is not usual. 

Urethroscopy will confirm the diagnosis except in 
an elderly patient, when such an examination may 
give a negative result. The obstruction is then prob- 
ably due to prostatic disease. An advantage of ureth- 
roscopy is the elimination of spasm of the compressor 
urethrae, a condition which is found in certain nervous 
individuals, and causes difficulty of micturition and 
even retention of urine. Malignant disease of the 



urethra in its early stages exhibits the typical symp- 
toms of stricture, and can only be diagnosed by 

TREATMENT. If diagnosed early, urethral stricture 
of inflammatory origin should never need operative 
interference. Treatment must be undertaken with 
bougies and urethral sounds so as to restore as far as 
possible the "normal passage of the urethra. For 
successful handling gentleness is a sine qud non, other- 
wise repeated damage to the mucous membrane will 
cause increased scarring and therefore tighter stricture. 
Excessive bleeding, extravasation of urine, and fatal 
syncope are other complications which may result from 
rough manipulation with urethral instruments. Finally, 
cystitis may result from the neglect of aseptic 

The treatment of a ruptured urethra must be prompt. 
If a catheter can be passed it should remain tied in 
for a week. Should this be impossible a suprapubic 
cystotomy must be performed, and subsequently ex- 
ternal urethrotomy with excision of the lacerated 
portions of the urethra. 

Early Stricture. 

An effective method of treating an early stricture 
is detailed as follows : 

In order to ascertain the degree of contraction, a 
graduated whip bougie should be passed. When 
resistance is offered to the passage of this instrument 
the position should be noted and the bougie withdrawn. 
A second bougie, the exact size of that part of the whip 
which is gripped by the stricture, must then be passed. 
This suffices for the first treatment. A week later 
two bougies should be passed, one the same size as 
at the previous treatment, the second a size larger. 
At intervals of seven days this should be continued, 


gradually increasing 'the size of the bougies until 
No. 22 French size can be passed. From this time 
onwards metal sounds are substituted at intervals of 
a fortnight, two only at each treatment, until the 
urethra will admit a full-sized sound. The intervals 
should then be gradually lengthened until treatment 
takes place every six months. 

Provided that the patient leads a healthy life and 
reduces the amount of alcohol he takes to a minimum, 
no complication need be feared ; but it must be im- 
pressed upon him that the passage of a full-sized in- 
strument every six months is a necessary precaution 
against further contraction of the stricture. 

Neglected Stricture. 

Such a condition is often complicated by numerous 
false passages, occasioned by careless instrumentation 
and by ulceration behind the stricture. To those accus- 
tomed to handle urethral instruments a stricture is rarely 
impassable, although much patience may be necessary 
to pass even a filiform bougie. Retention of urine is 
often produced by a high degree of contraction. 

TREATMENT. The patient should rest in bed with 
the filiform bougie tied in : urine can then pass along- 
side it. Twenty-four hours later an attempt should 
be made to pass a larger instrument. If this operation 
is successful, the patient can get up, and after three 
days another and slightly larger instrument should 
be passed. The initial passage of a filiform bougie 
is facilitated if a number of filiforms are first inserted 
into the false passages. 

Thereafter the patient should be treated on the lines 
indicated previously for early stricture. 

When a filiform bougie is the only instrument which 
can be passed, and further dilatation of the lumen seems 
impossible, the operation of internal urethrotomy is 


recommended. The stricture is cut from within the 
urethra, and provided that the post-operative treatment 
is carefully regulated the subsequent results are 

In cases where no instrument can be passed, external 
urethrotomy should be performed. If the facilities for 
this operation are not immediately available and re- 
tention of urine is complete, the patient should be 
relieved temporarily by suprapubic cystotomy. 

POST- OPERATIVE TREATMENT. After internal ureth- 
rotomy a catheter should be tied in the urethra for 
three days. Haemorrhage is prevented by the pressure 
of the instrument against the cut surface. The bladder 
should be washed out twice daily with a weak anti- 
septic, such as potassium permanganate 1 in 10,000. 

On the fourth day the catheter is removed ; on the 
fifth, if there is no rise of temperature, a bath should 
be given. At the end of a week the patient can leave 
the nursing home. For one month from the date 
of operation no further treatment is required, but two 
to three sounds should be passed at the termination 
of this period. 

A considerable percentage of permanent cures are 
effected, but the passage of a large sound every six 
months is a wise precaution. 

After external urethrotomy, a catheter must be tied 
in until the wound of the perineum has healed, after 
which the same post-operative treatment as for internal 
urethrotomy is required. 


All instruments should be boiled and placed in an 
antiseptic solution, such as carbolic acid 1 in 80 or 
formalin 1%. It is most important to keep all urethral 
instruments dry when not in use, both for the purpose 
of preservation and asepsis, A satisfactory way to 


keep bougies and catheters always sterile and ready 
for use is in a glass tube, at the open end of which is 
a metal perforated stopper containing formalin powder. 
Thus the contents of the tube are surrounded by 
formalin vapour. 

Extravasation of Urine. 

When this condition is not the result of trauma 
to the urinary organs, it is a complication of urethral 
ulceration associated with stricture or peri urethritis. 
It may be the practitioner is required to see a patient 
who has been seized with a rigor when in apparent good 
health, and who complains of no subjective symptoms 
of urinary disease. 

Perhaps the patient is unobservant, and has failed 
to notice a gradual narrowing of the urinary stream, 
and although closely questioned will not assist in 
discovering whether urethral stricture be not the cause 
of the sudden fever. If a primary focus in any other 
part of the body and such a disease as malaria can be 
excluded, it is wise to examine the urethra as the 
possible site of the infective process. Should a stricture 
be discovered, it is reasonable to suppose that either 
ulceration has taken place behind it allowing extravasa- 
tion of urine, or an ascending infection of the kidneys 
is manifesting itself. A rigor, tenderness on pressure 
of the perineum, and slight oedema of the skin, will be 
the signs and symptoms of commencing extravasation. 

Treatment must be prompt. Under general anses- 
thesia the stricture is fully dilated and an incision made 
in the perineum so as to expose the area of extravasation. 
All necrosing tissue should be excised and the wound 
packed with gauze. When forty-eight hours have 
elapsed, and the patient has recovered from shock, 
treatment on the principle adopted in cases of septic 
pelluljtig in other parts of the body should b undertaken. 


For one hour every day the patient is lifted into a 
hip bath containing water at body temperature. If the 
case is very septic a few drops of sanitas are added. 
While soaking in the bath the wound should be freely 
exposed, all dressings being removed. On returning to 
bed the perineal wound must be repacked. 

Chronic extravasation with multiple fistulse is treated 
differently. Before attempting to deal with the local 
condition the urine must be drained away through 
a tube inserted into the bladder above the pubes. 
The fistulse in the perineum are excised, and at a later 
date the recommendations for the treatment of stricture 
carried out. The urine should be drained suprapubic- 
ally until the wounds in the perineum have healed. 

A STONE may form in any part of the urinary tract, 
and unless its composition consist of pure uric acid will 
give a shadow to the X-rays. Skiagraphy, therefore, 
must be an essential part of the examination in all 
cases where a calculus is suspected. Cystoscopy is 
equally important, for thereby a stone in the bladder 
or in the vesical end of the ureter can be detected. 
If a skiagram demonstrates a shadow in the line of the 
ureter further investigation is necessary to determine 
its cause, for a calcified gland, lying on, or adjacent 
to, the duct, will give a shadow to the X-rays indis- 
tinguishable from that produced by a calculus. In 
order to clear up this point a bougie which is opaque 
to the rays must be passed up the ureter, and which 
therefore, in a skiagram, will give the anatomical 
relationship between it and the shadow. 


The symptoms caused by stones in the urinary 
organs vary according to their position, their size, and 
the presence or absence of suppuration. 

Pain. A dull ache in the loin, difficult to distin- 
guish from lumbago, increased by lateral movements 
of the trunk and violent exercise, persisting intermit- 
tently for many months, and causing no marked con- 
stitutional disturbance, is suspicious of the presence 
of a calculus in the substance of the kidney. As a 
rule there is no renal tenderness on palpation. 

When, however, the stone lies in the renal pelvis, 


the pain is of a colicky nature, sharp and stabbing, 
causing nausea and even, in some cases, vomiting. 
During the attack the kidney is tender on palpation, 
but this sign is absent in the intervals of pain. 

While a stone in the ureter is stationary, pain will be 
absent, but as soon as forcible contraction of the ureteric 
muscle occurs, the patient will be seized with a colicky 
pain situated immediately over the stone, and thence 
referred along the course of the duct to the genitalia. 

Appendicular and ureteric colic are so similar that 
one is often mistaken for the other, but the former 
is a more superficial pain, and is never referred to the 
external genitalia. 

When the stone is in the bladder or the urethra, pain 
is referred to the tip of the penis, and in the case of 
calculi in the prostate gland the patient will complain 
of aching in the perineum. 

Changes in the Urine. 

Stone in the Kidney. The changes that occur in the 
urine if the stone is in the cortex or silent area of the 
kidney, can only be recognised by microscopic examina- 
tion. The urine then contains an increase in the number 
of crystals, phosphatic, oxalate, or uric acid, according 
to the chemical constitution of the calculus. If the 
stone is situated in the calyx or pelvis, hssmaturia is 
a common symptom. Pus will also be present, its 
amount depending upon the degree of infection. 

An observant patient will sometimes draw the atten- 
tion of his medical attendant to the alteration in the 
quantity of urine passed before and after an attack of 
renal colic. Previous to the onset of pain the amount 
of urine passed will be small, but following the attack 
there will be a sudden escape of urine from the pelvis 
of the kidney which is followed by polyuria. 

The condition known as anuria or cessation of the 


flow of urine occurs when both kidneys are damaged by 
the presence of calculi in the urinary tract. 

Stone in the Ureter. Much depends upon the size 
of the stone in this situation with regard to the changes 
in the urine. 

If the stone is of such a size as to obstruct the free 
flow of urine, infection of the kidney takes place, and 
a considerable quantity of pus will be voided on mic- 
turition. After an attack of ureteric colic, hsematuria 
may be a prominent sign. 

On the other hand, a small stone, should it remain 
stationary, may give rise to no alteration in the urine. 

Stone in the Bladder, Prostate or Urethra. Pyuria 
and intermittent hsematuria are the changes nrted 
when a stone lies in the bladder or is lodged in any 
part of the urethra, whereas if the calculus is in the 
substance of the prostate gland, haematuria will be 
absent or inconspicuous. 


Kidney. Operative treatment is indicated in all 
cases of renal calculus, unilateral or bilateral, with the 
one exception of a single small stone lying in the cortex. 
The latter case should be treated on medical lines, and 
skiagrams taken at intervals in order to observe any 
change in the size or position of the calculus. 

Ureter. A large stone should always be removed 
by operation, but a small calculus can be left for six 
months in the hope that it may be passed during mictu- 
rition. If at the end of this time the stone, as shown 
by a skiagram, has not changed its position, operative 
interference is advisable. Small stones lying in the 
vesical end of the duct can be dislodged by dilating the 
ureteric orifice with the aid of the operating cystoscope. 

In those cases where immediate removal is not decided 
upon, in order to assist the stone in its passage down the 


urinary tract, large quantities of fluid, such as barley 
water, Imperial drink and Contrexeville, must be taken. 

The Bladder. The stone should be removed by 
the operation of litholapaxy at the earliest possible 
moment, unless it is very large, lying in a diverticulum, 
or associated with an enlarged prostate. In such 
cases the stone is removed by suprapubic cystotomy. 

The Prostate and Urethra. If the stone lies in the 
prostate gland, the bladder must be opened above the 
pubes, and, with the patient in the Trendelenburg posi- 
tion, both gland and stones are removed at the same 

Should the stone be in the urethra, an attempt may 
be made to remove it by means of crocodile forceps 
passed down the urethra. If this procedure fails, 
access to the calculus is obtained by the operation 
of external urethrotomy. 

It is a not unusual question for a patient to ask, 
after a stone has been removed from some portion of 
his urinary tract, how the formation of another calculus 
can be avoided. 

First, he should be warned against living in a climate 
where most of the body moisture escapes via the skin. 
In other words, concentration of urine predisposes to 

Secondly, vegetables containing oxalic acid, asparagus, 
strawberries, beetroot, etc., must be excluded from his 

And lastly, it is important that no alcohol be taken, 
and that he drinks large quantities of barley water, 
Contrexeville or Imperial drink. Hard water must 
also be avoided. If a cause for the formation of the 
stone is discovered, e.g. chronic cystitis, treatment for 
such must not be neglected, 


Acetone in urine, tests for, 36 
AchalnsJa vesicso, 63 
Acidosis, 36 

Adolescent albuminuria, 9 
Albuminuria, 7, 73 

adolescent, 9 

after exercise, 10 

alimentary, 10 

in fever, 11 

in pregnancy, 11 

in renal disease, 12 

tests for, 7 

in venous congestion, 12 
Albumosuria, 9 
Alimentary albuminuria, 10 
Alimentary glycosuria, 30 
Alkaptonuria, 3 
Anurin, 114 
Appendicitis, 85, 115 
Arterio-sclerosis, 17, 25 

Bacillus coli, infection by, 23, 44, 
50, 80, 81, 84, 86, 91, 92, 99, 

Bacteriuria, 84 
Bcnce Jones albumosuria, 9 
Benedict's test, 32 
Benzidin test for blood, 16 
Bile in urine, 3, 41 

tests for, 41 
Bilharziosis, 24 
Black urine, 3 
Blackwater fever, 26 
Bladder, atony of, 56, 57 

calculus of, 24, 49, 115, 117 

haemorrhage from, 21 

malignant disease of, 49, 61, 94, 

papilloma of, 19 

tuberculosis of, 46, 87 

tumours of, 95 

Blood diseases and heematuria, 25 
Blood in urine, see Hsematuria 


Blood pigments in urine, 3 
Blood pressure in nephritis, 78 

Calculus, 21, 39, 43, 113 

of bladder, 24, 49, 115, 117 

of kidney, 64, 93, 113 

of prostate, 115, 117 

of ureter, 115, 116 

of urethra, 20, 63, 115, 117 
Casts, 7, 13, 71, 113 
Choluria, see Bile in urine 
Chronic nephritis, 74 
Chyluria, 2, 40 

Climate in treatment of tuber- 
culosis, 90 
Creatinin, 33, 34 
Cyclical albuminuria, 9 
Cylindroids, 13 
Cystitis, 23, 28, 60, 91 

tuberculous, 88 

Cystoscopy, 19, 21, 23, 24, 28, 
63, 56, 61, 88, 92, 95, 102, 
103, 104, 116 
Cystotomy, 97, 110, 117 

Decapsulation of kidneys, 79 
De Pezzer tube, 56, 82, 106 
Diabetes, 2, 4, 30, 48, 53 
Diabetes insipidus, 5, 46, 48 
Diastose test for renal function, 68 
Diathermy, 95 
Diet, in treatment of chronic 

nephitis, 76 
Difficulty in micturition, 57 

Endocarditis, 13, 18 

Enuresis, see Incontinence of 


Exercise, albuminuria after, 10 
Extravasation of urine, 112 

Familial albuminuria, 9 
Fehling's test, 32 



Pilariasia, 43 

Frequency of micturition, 23, 45, 

49, 87, 91, 99 
Functioned albuminuria, 9 

Gastric disorders in renal disease, 

GlycoBuria, 30, 44 

tests for, 32 
Glycuronic acid, 33, 34 
Gmelirfa test, 41 
Gonococcus, infection by, 1, 23, 

58, 59, 84, 94, 99, 108 
Gout, 43 

Granular kidney, 5 
Guiacum test for blood, 116 

Hsematuria, 15, 39, 61, 74, 91, 
94, 96, 108, 115, 116 

in blood diseases, 25 

causes of, 17 

tests for, 15 
Hsemin crystals, 15 
Hsemoglobinuria, 26 
Haemorrhage from prostate, 24 
Hay' a test, 42 
Better's test, 7 
Hydronephrosts, 47 
Hyperglycsemia, 36 

Incontinence of urine, 40, 50 
Indioanuria, 3 

Instruments, sterilization of, 111 
Intermittent albuminuria, 9 
Iron reaction in urine, 36 

Kidney, calculus of, 21, 64, 93, 114 
decapsulation of, 79 
infarction of, 13, 17 
lardaceous disease of, 14 
malignant disease of, 13 
uppuration of, 80 
tuberculosis of, 22, 60, 87, 93 
tumours of, 19 

Lactose in urine, 31 
Leaky kidneys, 9 
Litholapaxy, 117 

Malignant disease, se Kidney, 
Bladder, etc. 

Melanuria, 3 

Microscopical examination of 
urine, 21 

Micturition, disorders of, see Diffi- 
culty, Frequency, Inconti- 
nence, Painful, Precipitate, 

Mucin in urine, 8, 10 

Nephritis, 14, 49, 50, 62 

acute, 22, 69, 70 

chronic, 22, 49, 60 
Nervous diseases, urinary symp- 
toms in, 56, 58, 63 
Neuroses, 54 

Odour of urine, 4 
Oliguria, 6, 60 
Orthostatic albuminuria, 9 
Osazone crystals, 35 
Oxalates, 22, 39, 43, 50, 69 

Painful micturition, 57, 59 

Paroxysmal hsemoglobinuria, 26 

Pelvic tumours, 58 

Pentosuria, 31, 34 

Perinaeum, pain in, 60, 104 

Pettenkoffer'a test, 42 

Phenylhydrazine test, 35 

Phimosis, 50 

Phosphates, 13, 38, 39, 40, 43 

Physiological albuminuria, 9 

Pituitary disease, 48 

Pneumaturia, 44 

Pneumococcus, infection by, 99 

Pollakiuria, 32, 46 

Polyuria, 6, 32, 46, 53 

Postural albuminuria, 9 

Precipitate micturition, 64 

Prostate, abscess of, 100 
calculus in, 115, 117 
disease of, 24, 58, 63, 99 
hypertrophy of, 50, 82, 101 
malignant disease of, 104 

Prostatitis, 99, 100 
tuberculous, 101 

Pus in urine, 27 

Pyelitis, 81, 93 

Pyelonephritis, 93 

Pyuria, 27, 61,94, 115, 116 
causes of, 29 



Radium therapy, 97, 105 
Recto-vesical fistula, 44 
Renal extracts, 79 
Renal function, estimation of, 65 
Renal glycosuria, 31 
Renostaxis, 25 
Residual urine, 103, 105 
Retention of urine, 62, 106 

Salt free diet, 78 
Skiagrapliy, 114 
Spectroscopy of urine, 16 
Sterilisation of instruments, 111 
Stricture, 20, 68, 63, 64, 82, 103, 

Suppression of urine, 60, 61 

Tabes, urinary symptoms in, 56 
Transient albuminuria, 9 
Trench nephritis, 70 
Tubercle bacillus, infection by, 

84, 99, 101, 108 
Tuberculin infections, 90, 101 
Tuberculosis of bladder, 46 

of kidney, 22, 50 

of urinary tract, 87 

Urmia, 62, 73, 79, 83 
Urates, 2, 8, 13 
Urea, 42 

estimation of, 67 
Ureter, calculus in, 115, 116 
Urethra, calculus of, 63, 115, 117 

chancre of, 108 

hemorrhage from, 20 

Urethra, injuries to, 19 

malignant disease of, 108 

rupture of, 108 
Urethritis, 23, 59, 94 
Urethroscopy, 19, 28, 100, 101, 

103, 104, 108 
Urethrotomy, 110, 117 
Uric acid, 33, 34, 42, 43 
Urine, in acute nephritis, 71 

albumin in, see Albuminuria 

in bacteriuria, 85 

bile in, 3 

changes in, due to calculi, 115 

in chronic nephritis, 76 

colour of, 2 

in cystitis, 91 

deposits in, 42 

extravasation of, 112 

hyperacidity of, 69 

microscopical examination of, 

mucin in, 8, 10 

normal characteristics of, 1 

odour of, 4 

reaction of, 4 

retention of, 106 

specific gravity of, 6 

sugar in, see Glycosuria 

in tuberculous infection, 87 
Urochrome, 2, 43 
Uroerythrin, 42 

Vaccine therapy, 81, 86, 92, 101 
Yeast test for sugar, 34 

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