Volume 4 — DISEASES OF THE GENITO-URINARY SYSTEM. (continued 4)

While a majority of cases of malarial hæmaturia are intermittent, many are continuous, and of my eight cases only three were distinctly intermittent. One of these cases I published in a clinical lecture in the Philadelphia Medical Times as far back as September 1, 1871.

Negroes are not exempt from this milder form of the disease, as they seem to be from the more malignant form of the South. While writing this paper I was consulted by a negro thirty-one years old who had a true malarial hæmoglobinuria, which yielded promptly to the treatment by quinine. But this was the only negro out of seven cases.

The duration of the disease is very various, and if neglected may be indefinite. Stephen Mackenzie⁵ reports a case which lasted twenty-three years.

⁵ "On Paroxysmal Hæmoglobinuria," London Lancet, vol. i., 1884, p. 156.

PHYSICAL AND CHEMICAL CHARACTERS OF THE URINE.—The urine is usually acid in reaction when passed, sometimes neutral, rarely alkaline, and ranges in specific gravity from 1010 to 1028. It is always albuminous, and always tinged by blood coloring matters, the depth of color varying from the trifling degree known as smoke-hued to a dark-red or claret color. Sometimes it is even darker, and is often compared to porter, though this degree of coloration is more characteristic of the malignant form. The urine deposits a dark, reddish-brown sediment, generally copious, but varies in quantity with the degree of coloration of the urine. This sediment is made up chiefly of red blood-discs or the granular débris resulting from their disintegration.

Casts of the uriniferous tubules are also often present. They are usually made up of aggregated red blood-discs or the granular matter referred to; but they may also be hyaline or hyaline with a moderate amount of granular matter attached. Granular urates also at times contribute to the sediment and also adhere to the casts. Renal and vesical epithelium may occur. Crystals of oxalate of lime and of uric acid are sometimes present, while blood-crystals have been found by Gull⁶ and Grainger Stewart, and a hæmatin crystal once by Strong.⁷

⁶ Guy's Hosp. Reports, 1866, p. 381.

⁷ British Med. Journ., 1878, vol. ii. p. 103.

That red blood-discs are at times exceedingly scarce, and even totally absent at the very moment when urine is passed, is a well-recognized fact; while that the coloring matter present is still that of the blood, even though no corpuscles are present, is easy of demonstration by the production of Teichmann's hæmin crystals,⁸ by spectrum analysis, or by the guaiacum test.

⁸ Place a drop of the sediment upon a glass slide and allow it to dry. Mix thoroughly with a few particles of common salt and cover with a thin glass cover, under which allow two or three drops of glacial acetic acid to pass. Carefully warm the slide for a few seconds over a spirit-lamp, and when most of the acetic acid is evaporated, examine by the microscope. Hæmin crystals will be seen to crystallize out as the mixture cools.

In the matter of the presence or absence of blood-discs, it is to be remembered that these may be present at the moment the urine is passed, but disappear by subsequent solution if the urine happens to be alkaline or becomes so secondarily. It is an interesting fact, too, that colorless blood-corpuscles are often present intact, even when red discs are absent. While I have frequently examined urine sent me from the South in which the coloring matter of the blood and no corpuscles were present, only one of the cases coming under my own observations furnished urine of this character. The proportion of urea varies, and bears no evident relation to the condition itself.

PATHOLOGY AND MORBID ANATOMY.—The pathology of malarial hæmaturia consists, as yet, chiefly of theoretical deductions. We can only conclude that the malarial poison acts upon the blood and blood-vessels, impairing the integrity of both. This goes so far occasionally as to produce an actual destruction of blood-discs, and always so alters the capillaries that they permit the transudation of blood-elements ordinarily retained.

The morbid anatomy is scarcely more precisely defined. Ponfick⁹ goes so far as to say that the exudation of hæmoglobulin is not possible without the concurrence of marked diffuse nephritis. Recently Lebedeff¹⁰ has sought to investigate the more minute alterations of the kidney in hæmoglobin exudation, but without very definite results. These, however, on the whole, seem to confirm Ponfick's view as to the presence of an inflammatory process, as also do those of Litten¹¹ and Lassar.¹²

⁹ "Ueber die Gemeingefährlichkeit der essbaren Morchel," Virchow's Archiv, Bd. lxxxviii. S. 476, 1882.

¹⁰ "Zur Kenntniss der feineren Veränderungen der Nieren bei der Hämoglobinausscheidung," Virchow's Archiv, Bd. xci. S. 267, Feb., 1883.

¹¹ "Verhandl. des Vereins für innere Medicin," Deut. Med. Wochenschr., No. 52, Dec. 29, 1883.

¹² Ibid., No. 1, Jan. 3, 1884.

DIAGNOSIS.—The diagnosis of this condition is not usually difficult. We have first to determine whether the hemorrhagic discharge is from the kidney rather than the bladder or ureters. The former is the case when tube-casts are found. But tube-casts are not always present even when the hemorrhage is from the kidneys. The absence of clots and of vesical irritation, and of pain in the course of the ureters, is characteristic of blood from the kidneys. Finally, all hæmoglobinurias are renal.

It being certain that the blood comes from the kidney, we have to distinguish it from that due to cancer, to calculus-irritation, and to cachexias, as purpura and scurvy; or to grave forms of infectious disease, septicæmia, pyæmia, etc.; or, finally, to poisonous substances introduced into the blood, such as arsenic, iodine, arseniuretted hydrogen, carbonic acid and carbonic oxide gas, and even certain species of edible fungi.

The diagnosis is greatly aided if it is found we have to do with a hæmoglobinuria rather than a hæmaturia. For although the former condition is produced by toxic and septic agencies of another kind, the attending symptoms, when it is thus produced, are so characteristic that it is not likely that error can be made.

To aid in distinguishing it from cancer we have the history of malarial exposure, and often that of other forms of malarial disease; and, notwithstanding the seeming drain upon the system, none of the cases I have ever seen present the profound anæmia of cancer. The bloody discharge in cancer of the kidney is always a true hæmaturia; there are always blood-discs in the urine. There is often pain in the region of the kidney in cancer, but never in malarial hæmaturia.

In calculous disease there is almost always pain before or during the hæmaturic attack, and characteristic crystalline sediments often appear in the urine.

The disease, being comparatively rare in this latitude, is sometimes overlooked on this account. Of the 8 cases which I have noted during sixteen years, 5 originated in Pennsylvania, 1 in New Jersey, 1 in Delaware, and 1 in North Carolina.

TREATMENT.—The treatment is distinctly that of malarial disease, and I have seldom seen more brilliant and satisfactory results than have followed the use of quinine in a case accurately determined, although such success is not invariable; and I have known the disease to resist for a long time the most thorough and judicious use of anti-malarial remedies. Usually, however, I take hold of a case of this kind with considerable confidence. When there are distinct remissions my practice has been to administer 16 to 20 grains of sulphate of quinia in the usual manner of anticipation of the paroxysm in intermittent fever—from 3 to 5 grains every hour until the required amount is taken; the whole amount may be taken in two doses, or even in one dose. Where there is no distinct remission I more usually direct 3 to 5 grains every three hours, until the hemorrhage ceases or decided cinchonism is produced.

The advantage well known to accrue in malarial disease from the combination of mercurials with quinine applies to hemorrhagic malaria as well, although I usually reserve the mercurial until I have ascertained whether the simple quinine treatment answers the purpose. If the usual method fails, I give 8 or 10 grains of calomel in the evening, followed by a saline in the morning, before reinstituting the quinine treatment. In the case of the colored man alluded to who had malarial hæmoglobinuria 36 grains of quinine failed to break the attack; but the same quantity, given after 10 grains of calomel had acted, succeeded.

Where these means failed I have not found the other methods of treatment commonly resorted to in obstinate malarial disease to be any more efficient. I allude to the treatment by arsenic or by iron and arsenic. Indeed, in the only two cases in which, after failure with the quinine treatment, iron and arsenic were used at my suggestion, they failed absolutely. In the one case, under the care of James L. Tyson, this treatment was carried out most faithfully. After four weeks' treatment with quinine without effect, Fowler's solution was given, at first in 5-drop doses three times daily, subsequently increased to 10 and 15, along with 20- and 30-drop doses of tincture of the chloride of iron, until oedema of the eyelids occurred, when the arsenic was discontinued, but the iron continued. In two or three days the arsenic was recommenced in 3- and 4-drop doses for three or four weeks longer without effect. Fluid extract of ergot in 20-drop doses was then substituted for the iron, alternating with the arsenic for two weeks longer, when some slight favorable change was apparent, but it was temporary. Repeatedly throughout the treatment the patient complained of weariness and backache, cold feet and knees, headache and acceleration of pulse, and a feeling of utter wretchedness; and then again he would feel quite comfortable for a day or two, but with little or no change in the urine, except occasionally in the morning, when it would sometimes be quite light-hued, but after breakfast would again assume its bloody character. A sojourn at the seaside for two weeks was without effect.

It will appear from the above that ergot, which has been found useful in some forms of hæmaturia, is of little service here, as is attested by two other cases in which I tried it faithfully. At the same time, it is a remedy which should be tried in case of failure with others.

The usual astringents, mineral and vegetable, of known efficacy in the treatment of hemorrhagic conditions, should be used alone or in conjunction with the specific anti-malarial treatment after the latter has been found of itself insufficient. To this class of remedies belong the mineral acids, persulphate of iron, acetate of lead, alum, gallic acid, catechu, kino, the astringent natural mineral waters, etc.

Rest is certainly an important adjuvant in the treatment of this form of malarial disease. I have known a recurrence to take place after a long drive.

It is claimed for many natural mineral waters that hemorrhage from the kidneys is one of the affections cured by their use. Chalybeate and alum springs might be expected to be of advantage by the local action of these astringents in their transit through the kidneys, and they frequently are. The following case illustrates their efficiency: The patient was a lawyer who consulted me in June, 1881, at the suggestion of W. W. Covington of North Carolina. He had frequently had chills, and a congestive chill in 1873. Three months before I saw him he began to pass bloody urine. He had no other symptoms, except a soreness and weakness in the neighborhood of the sacrum, extending into the outer part of the left thigh. The urine passed for me at the time of his visit was dark reddish-brown in color, acid in reaction, had a specific gravity of 1028, highly albuminous, and deposited a sediment of almost tarry consistence, which was made up almost entirely of blood-corpuscles. There were no tube-casts. He had been a dyspeptic since seventeen years of age, and medicines disagreed with him; but he was treated faithfully with quinine, iron, arsenic, ergot, benzoate of lime, all without the slightest effect. At the end of about a year from the time he consulted me he heard of the Jackson Spring, located in Moore county, North Carolina, fifteen miles distant from Manly Station on the Raleigh and Augusta Railroad. He went there, and remained one week. He stated that for the first two or three days the water acted decidedly on his kidneys, and he voided a number of clots of blood. On the third day all traces of blood disappeared, and it recurred but once since, on a very cold day in November last, but again disappeared after a day or two in the house. Unfortunately, no precise analysis of this water seems to have been made, but from what my friend writes it evidently contains iron and sulphur, and magnesia is also said to be present. It is promptly diuretic. Since this occurred I have used the water of alum springs in other instances with advantage.¹³

¹³ See the report of a case treated successfully by Rockbridge alum-water by Radcliffe, Med. News, Jan. 12, 1884.

The following are some of the chalybeate and alum springs the waters of which may be expected to be of service in hæmaturia: Orchard Acid Springs, New York; Rockbridge Alum Springs, Pulaski Alum Springs, Bath Alum Springs, Stribling Springs, and Bedford Alum Springs, all in Virginia. In all of these waters iron and alum are both present, accompanied, in many instances, by free sulphuric acid, by which their efficiency is increased. In one of my cases the hemorrhage disappeared temporarily under the use of the water from the Bedford Springs, Penna., but again returned. These waters contain a little iron, but no alum. Subsequently, the same patient was promptly relieved by quinine, which had not been previously tried.

But the cases most promptly relieved by the alum waters are the non-malarial cases depending, upon hemorrhagic diathesis without other local disease. A remarkable instance of this kind was related to me by letter by J. Macpherson Scott of Hagerstown, Md. After enormous doses of quinine had been used under the supposition that it was malarial, it was promptly and totally cured.

Malignant Malarial Hæmaturia.

The second more serious form of this disease, as it occurs in the tropics and the southern part of the United States, is characterized by such increased intensity of all the symptoms that it may be well called malignant. Singularly, however, the disease has seemed to be much more prevalent during the last fifteen years. My attention was first called to it in September, 1868, when I received specimens of urine and the history of some cases from R. D. Webb of Livingston, Ala., who wrote also that it was not known in that part of his State prior to 1863 or 1864.

In this, as in the milder form, there is a distinct but more invariable history of malarial exposure, and the attack often begins as an ordinary case of chills and fever, there being often one or two paroxysms before the hæmaturia appears. At other times the hemorrhage ushers in the disease suddenly. The urine is often black and almost tarry in consistence, and passed in unusually large quantities—it is said as much as a pint every fifteen or twenty minutes until a couple of quarts have been passed, or one or two gallons in the course of twelve hours. But after twenty-four hours the quantity diminishes. Epistaxis sometimes occurs, but is not often profuse. Distressing nausea, and vomiting of bilious and even black matter, like that of black vomit, also occur. Intense jaundice rapidly supervenes—said to come on sometimes in the course of an hour, often in from two to six hours. The tongue is brown and dry. The bowels are at times constipated, and at others loose. Although the patient may be feverish at first, with a temperature of 104° to 106°, and the skin dry, the pulse rapidly becomes small and feeble until it is scarcely perceptible. Drowsiness and coma sometimes intervene, and at others the mind is clear until the moment of death, which frequently supervenes within twenty-four or sixty hours; or the symptoms may subside, to be repeated again the next day if not prevented by treatment. If recovery takes place, which it sometimes does, and lately more frequently, convalescence is slow and tedious, the patient remaining for weeks in an enfeebled and anæmic state.

In this form, especially, of the disease it often happens that the coloring matter and the débris of blood-discs only are found in the urine, very few and often no entire ones being discernible: in other words, we have a true hæmoglobinuria or hæmatinuria. The urine is of course albuminous. A specimen recently received from North Carolina and analyzed by Wormley contained no corpuscles, but revealed the spectroscopic band characteristic of hæmoglobin. It contained 2½ per cent. of urea. The specific gravity of the urine ranges between 1010 and 1020, being lower when it is copious.

As to the jaundice, it is evidently a hæmatogenetic, and not a hepatogenetic, form with which we have to deal. It is due, not to the retention of bile, but to the disintegration of blood-corpuscles and the solution of their coloring matter, which diffuses through the tissues and stains them yellow or yellowish-green. This form too, apparently, is more frequent in males, and negroes appear to be exempt. This is not the case with the milder form, for it will be remembered that one of my patients was a negro.

Autopsies reveal the same intense yellow coloration of internal organs—lungs, liver, spleen, stomach, kidneys—anæmia rather than congestion, while the blood is dark-hued and is indisposed to coagulate. The spleen is often enlarged.

The TREATMENT for the breaking of the paroxysm is pre-eminently quinine or quinine with mercurials, and although this does not always succeed, there seems to be no other remedy. The quinine may be given hypodermically. The nausea has been controlled by morphia and lime-water, by carbolic acid, and by creasote. In addition, restorative measures are necessary, including the free use of stimulants. Turpentine has been used in large doses (fluidrachm j), it is said with advantage, in Alabama.

CHYLURIA.

BY JAMES TYSON, A.M., M.D.

The term chyluria is applied to a condition of urine in which the secretion is admixed with fat in a minute state of subdivision, whence the urine acquires a milky or chylous appearance. The proportion of fat varies greatly between such as gives a mere opalescence to the secretion and that which makes it absolutely indistinguishable, in appearance, from milk, while even the characteristic odor and taste of urine are often wanting. The further resemblance of such urines to milk is found in the fact that, on standing, a cream-like substance rises to the surface. On the other hand, a spontaneous coagulation into a jelly-like substance containing fibrin proves an unmistakable relation to blood.

The chemical composition of such a urine, having a specific gravity of 1013 and neutral in reaction, is given by Beale,¹ as follows:

Water 947.4

Solid matter 52.6

Urea 7.73

Albumen 13.00

Uric acid 0.00

Extractive matter with uric acid 11.66

Fat insoluble in hot and cold alcohol, but soluble in ether Fat insoluble in cold alcohol Fat soluble in cold alcohol 9.20 2.70 2.00 13.90

Alkaline sulphates and chlorides 1.65

Alkaline phosphates Earthy phosphates 4.66

¹ Urinary and Renal Derangements and Calculous Disorders, Philada., 1885, p. 73.

Such urines are of course albuminous, as will have been seen from the table. They therefore coagulate when boiled or on the addition of an acid. They also exhibit a tendency to spontaneous coagulation more or less complete, which is apt to be followed by later disintegration of the clot. The proportion of solids is larger than in ordinary urines.

Microscopically, the urine is found to contain, in addition to its usual elements, immense numbers of molecular particles easily soluble in ether, and therefore fatty in their composition. It may be rendered perfectly clear by the addition of ether, and again approximately milky after evaporating the ether and shaking the residue; but now the microscope shows the oil in the shape of oil-drops and not molecules. Oil-drops are also sometimes sparsely present in the fresh fluid, but the fatty particle is commonly molecular. Indeed, the molecules are commonly so small that an aggregated mass of them appears like a delicate cloud under the microscope, rather than a collection of individual particles. Blood-corpuscles may also be present, sometimes in sufficient quantity to produce a distinct pink coloration, but no unusual proportion of leucocytes is common. The pink tinge, and even an almost bloody appearance, is very apt to precede the chyluria. This bloody character sometimes gradually increases until the chyluria has become a hæmaturia, so that we have sometimes a chyluria spoken of as a first stage of hæmaturia. Tube-casts do not occur. Chyluria is seldom constant, and a specimen of urine passed a couple of hours after one white as milk may be, again, perfectly clear and in all respects natural. Thus, a second specimen, passed by the same patient as that of which the analysis is given above, was almost clear. It had a specific gravity of 1010 and a slightly acid reaction, and contained a mere trace of deposit, consisting of a little epithelium, a few cells larger than lymph-corpuscles, and a few small cells, probably minute fungi. Not the slightest precipitate was produced by the application of heat or addition of nitric acid. The following is Beale's analysis:

Water 978.8

Solid matter 21.2

Urea 6.95

Albumen 0.00

Uric acid .15

Extractive matter with uric acid 7.31

Fat insoluble in hot and cold alcohol, but soluble in ether Fat insoluble in cold alcohol Fat soluble in cold alcohol .00

Alkaline sulphates and chlorides 1.45

Earthy phosphates .15

DISTRIBUTION OF THE DISEASE.—By far the largest majority of instances of the disease originate in tropical and subtropical climates. Thus, India, China, and South America—and in South America, Brazil, and Guiana—are countries in which it is common. It is said to be rarer on the coast of South America than in the interior; yet it is especially partial to insular countries, and most of the cases observed in this country originate in the West Indies—in Barbadoes and Cuba, in Bermuda and the island of Trinidad. Many cases occur in Bahia, Guadeloupe, Madagascar, the Isle of Bourbon, and Mauritius. Indeed, the first important study of the subject was based on cases observed in the latter island by Chapotin.² In Africa both Egypt and the Cape of Good Hope are favorite localities, and in Australia, Brisbane has furnished many cases.

² Thèse, Topographie médicale de l'Ile de France, 1812.

At the same time, cases do originate in temperate climates, and although the disease is rare in Europe and North America, Dickinson has collected five cases from his own practice or that of others, which undoubtedly originated in England. I know of but one case of certain North American origin, that of a woman reported by McConnell to the Medico-Chirurgical Society of Montreal, April 27, 1883. She was thirty-three years old, a native of the province of Ontario, and had had the disease eleven years. At the time of her death, which appears to have been from tubercular phthisis, there were cavities in the apices of both lungs.

SUBJECT'S ATTACKED.—There seems no election as to nativity, natives and foreigners being indiscriminately attacked in the countries in which it occurs. There is some difference of opinion as to whether the disease is more frequent in males or females; which is a reason for believing that it occurs with nearly equal frequency in both.

It is more common in middle life, but Prout reports an instance in a child eighteen months old, and Rayer one in a woman at seventy-eight years. She had had it, however, since she was twenty-five, or about fifty-three years. Dickinson was consulted with regard to a boy of five, and mentions a case fatal at twelve. Roberts says: "Chylous urine prevails mostly in youth and middle age."³ Of 30 cases collected by him, 3 were under twenty; 7 between twenty and thirty; 11 between thirty and forty; 6 between forty and fifty; and 3 over fifty.

³ Urinary and Renal Diseases, 4th ed., Philada., 1885, p. 344.

The subjects of the disease are apt to be pale and relaxed as to their tissues, but while this may be a possible result of the disease, it can hardly be regarded as a predisposing cause.

PATHOLOGY AND ETIOLOGY.—The precise mode in which chyluria is brought about is unknown. It is to be inferred, in view of our existing knowledge, that there has been produced, in some way, in each instance a communication between the urinary and chyliferous systems, although exactly where such communication is has as yet only been guessed at. It may be in the kidney itself, or its pelvis, or the ureter, or in the bladder. Cases originating in the tropics have been found associated with elephantiasis, but this is not very frequent. Dilatation of cutaneous lymphatics, producing cutaneous papules and vesicles and a discharge of lymph from them, has also been noted coincident with chyluria.

Prout,⁴ among the earlier writers on this subject, and more recently Bence Jones,⁵ Waters, Bouchardat, Robin, Bernard, and Egel, did not consider a positive lesion necessary, but ascribed the condition to a vice of nutrition and blood-making, accompanied by a slight consequent textural alteration in the blood-vessels of the kidney, through which the elements of the chyle transuded. Waters⁶ says that "the main pathological feature of the complaint is a relaxed condition of the capillaries of the kidney," which permits the transudation.

⁴ Stomach and Renal Diseases, 4th ed., London, 1843.

⁵ Lectures on Pathology and Therapeutics, 1868, p. 256.

⁶ Med.-Chir. Trans., vol. xiv. p. 221, 1862.

The results of examination of the blood, in cases of chylous urine, by Bence Jones, Rayer, and Crevaux, who found in certain instances an excess of fat, have been quoted in support of these views, but these examinations seem to have been microscopical and not chemical, and the results have not been confirmed by recent observers. Such views were also upheld on theoretical grounds by Bouchardat,⁷ based on the greater commonness of the disease in warm climates. He reasoned that when the heat-producing elements, whether absorbed from food or produced by metamorphoses of other proximate principles, are in excess, and an elevated external temperature does not favor their consumption, their elimination is attempted by certain organs, notably the liver and kidneys. The effort by the kidneys seems, however, to be attended by a structural change in the blood-vessels, as the result of which blood is eliminated with fat, especially at the beginning of the disease. Later the blood disappears, but the albumen remains some time longer, disappearing finally with the fat.

⁷ Ann. de Thérapeutique, 1862.

Bernard and Robin also compared the blood of such cases to that of geese artificially fattened, being that condition of blood which is normal after digestion but transient. Egel also held similar views, ascribing the imperfect elaboration to the effect of hot climates.

Gubler⁸ first suggested that chylous urine was due to a passage of chyle directly into the urinary passages, and that this was immediately preceded by a dilatation of the renal lymphatics similar to that known to occur on the surface of the body and attended by the local flow alluded to.

⁸ Gazette médicale de Paris, 1858, p. 646.

Vandyke Carter,⁹ of Bombay, suggested that the communication was between the lacteals and lymphatics of the lumbar region and those of the kidney. Those who have seen the semi-diagrammatic drawing of a dissection of the lymphatics as seen from behind, in the remarkable case of Stephen Mackenzie,¹⁰ cannot fail to be impressed with the probability of such communication.

⁹ Med.-Chir. Trans., vol. xlv., 1862.

¹⁰ Trans. Path. Soc. of London, vol. xxxiii. p. 394, 1882.

That a chylous urine is the direct result of a discharge of chyle into the urinary passages at some point between the kidney and the neck of the bladder, is further rendered likely by the experience of W. H. Mastin of Mobile, Alabama, with a case of chylous hydrocele: W. H. W., a native of Alabama, aged twenty-two, presented himself with a hydrocele. Mastin tapped the sac and drew off a white milk-like fluid, which was sent to me for examination. It was perfectly white and undistinguishable by the eye from milk. Upon microscopical and chemical examination, I found it presented all the physical and chemical characters of chyle. Six months later, the sac having refilled, Mastin evacuated eight ounces more of the same fluid—some of which was again sent to me—and then laid open the sac freely. Examining the cavity carefully, he found it smooth, polished, and pearly white, but at its upper portion, just where it began to be reflected over the testis, was a small, round, granular-looking mass about the size of an ordinary English pea. This he sliced off with a pair of scissors, and at once recognized the patulous mouths of three or four small vessels which did not bleed. These he dissected back for a short distance, and found that they passed into the connective tissue around the upper border of the testis. He then passed a ligature around the mass and brought the ends of the ligature to the outside, excised all the front wall of the tunica, and closed the sac. The patient recovered, and there was no return of the hydrocele. Although it is to be regretted that the patulous vessels were not watched for a few minutes, I do not think there can be any reasonable doubt that there was here a lymphatic varix, and that the chylous fluid in the tunica was the result of leakage through its walls. Since the patient had had gonorrhoea, Busey,¹¹ in his remarks on this case, suggests that the obstruction to the onward movement of the lymph, and the cause, therefore, of the dilatation and rupture, was inflammation attacking a single gland or an area of lymphatics.

¹¹ Occlusion and Dilatation of Lymph-Channels, by Samuel C. Busey: A series of papers reprinted for private distribution from the New Orleans Medical and Surgical Journal, from Nov., 1876, to March 1878.

If it be acknowledged, then, that in chyluria some direct communication must exist between the lymphatic and urinary systems, how is this communication brought about? Various causes have been supposed at different times to be responsible for this condition, among them traumatism in its various modes of occurrence, such as being thrown from a horse. Mental shock has also been held responsible. So, also, syphilis and hereditary tendency. But most cases still remained unaccounted for when, on August 4, 1866, Wücherer first detected in the chylous urine of a woman in the Misericordia Hospital at Bahia an unknown worm. In 1872 it was announced that Timothy R. Lewis had found in the blood, and also in the urine, of a person suffering with chyluria in Calcutta, a delicate thread-like worm about ¹/70 of an inch long and ¹/3500 of an inch wide. This observation was confirmed by Palmer and Charles. Lewis named it Filaria sanguinis hominis. Since then the filaria has been found in the blood and urine of many cases. Lewis found six in a single drop of blood from the ear, and estimated 700,000 as approximately correct for the whole body. But Mackenzie calculated that there were in the blood of his patient from 36,000,000 to 40,000,000 embryo filariæ. These minute nematodes, discovered by Wücherer and Lewis, proved to be, as was indeed early suspected, the larvæ of a larger filaria which was discovered by Bancroft of Brisbane, Queensland, Australia, in December, 1876, first in a lymphatic abscess in the arm, and afterward in the fluid of hydrocele of persons infested with the smaller worm. The parent worm is about the thickness of a human hair and three or four inches long. It was named, by Cobbold, Filaria Bancrofti. Lewis himself found, in August following, a male and female of the parent worm, in a scrotum infiltrated with chylous fluid, in a case of elephantiasis. The female contained ova with embryos precisely like those found in the blood and urine. The worms are viviparous, but abortions seem frequent, ova being frequently discharged unhatched.

It has been rendered highly probable, by the researches, first, of Manson in China, and later of Lewis in India and Sonsino in Egypt, that the filaria in its fully-developed form is introduced into the stomach and intestines of man with water. Thence it makes its way into the blood and lacteal system, where it reproduces the embryo filariæ. These embryonic or larval filariæ are taken from the human blood by a mosquito, in the body of which it undergoes further development, after which the perfect Filaria Bancrofti is deposited in water, through which it again reaches the stomach of man, and thus the disease is perpetuated.

One of the most singular features in the history of the filaria is its nocturnal habit. It is found in the blood only at night, unless, as Mackenzie has shown, night be converted into day—that is, if the hours of sleeping and waking be reversed. In Mackenzie's case the worms appeared about seven o'clock in the evening, increased up to midnight, and disappeared by eight or nine o'clock in the morning. What becomes of them at the time when they are undiscoverable in the blood is as yet unknown.

Acknowledging filariæ to be the essential cause of chyluria, the precise method in which they operate to cause the obstruction, dilatation, and rupture of the lymphatics is a matter of speculation. The embryo filariæ are so lithe and small that they move among the corpuscles apparently without harming them, but the ova in which the embryos lie coiled up, and which are often discharged unhatched, are large enough to cause obstruction in the smaller lymphatics and lymph-passages of the lymphatic glands, and thus cause the phenomena of chyluria, as well as of the other diseases of the lymphatic system with which it is often associated, or which may occur independently of it, such as elephantiasis, cutaneous lymph-vesicles with their chylous and lymphous discharges, lymph scrotum, chylous hydrocele, and other diseases of the lymphatics. Indeed, the total number of affections other than chyluria which are found associated with filariæ exceed those of chyluria. Among the diseases with which it is said to be associated is erysipelas.

It is evident, therefore, that notwithstanding the fact that the discovery of the Filaria sanguinis hominis has shed a flood of light upon the subject of chyluria, the fact must not be overlooked that not a few cases of the disease have occurred in which the most careful search has failed to find this parasite in the blood. Careful examinations, during waking and sleeping hours, have been made without result, so that we cannot deny altogether the possibility of the disease occurring independent of filariæ as the cause. It is common, therefore, to speak of parasitic and non-parasitic chyluria.

On the other hand, the filaria embryo is often found in the blood of persons apparently in perfect health. Manson tells us that out of every ten Chinamen taken at random, at Amoy, the blood of one will contain filariæ.

MORBID ANATOMY.—There can hardly be said to be any morbid anatomy of chyluria, unless we regard the lymphatic lesions which sometimes accompany it as a part of the disease. Again and again do we read the reports of autopsies at which the kidneys were found normal, and where lesions have been noted they were such as are found due to other causes, and the coincidence was accidental.

SYMPTOMATOLOGY.—Apart from the characteristic urine of the condition, there are no symptoms which can be regarded as in any way peculiar to the disease. The mode of onset is usually sudden, and yet many patients experience no symptoms whatever, and would be quite unaware that they were afflicted in any way, were they not aware of the fact that they are passing lactescent urine. Since the discharge is, however, a drain of very valuable nutrient and force-producing material, most patients sooner or later gradually grow weaker; and this symptom of weakness becomes sometimes very marked, so that they fall into a condition of extreme debility, even to fainting on exertion.

Another symptom sufficiently frequent to deserve mention is pain in lumbar region, sometimes very severe, sometimes on one side, at others on both.

Painful micturition, due to obstruction, is also a symptom traceable directly to the condition of the urine. The disposition of chylous urine to coagulate has already been alluded to. The coagulation taking place in the bladder, it is the clot which sometimes obstructs the urethra and makes urination difficult or impossible. Plugs of coagulum are ejected, sometimes with considerable force, after prolonged straining, and with this comes relief to the symptoms, which may be reproduced through the operation of the same cause.

Other symptoms which are occasionally present may have an accidental relation to the affection, while they may be due to it. Such are headache, nausea, and other gastric symptoms.

Mention has been made, too, of the concurrence of superficial lymphatic leakage, especially on the lower part of the abdomen, the thighs, and the legs. Such leakage is often from little vesicular elevations which are evidently dilated lymphatic vessels. The presence of such leakage should suggest the examination of urine for lesser degrees of chyluria. In like manner, the urine should be examined in case of elephantiasis, lymph-scrotum, and chylous hydrocele, with which also chyluria is sometimes associated.

The effect of intercurrent febrile states, whether symptomatic of local inflammation, as of the lungs, or whether the result of the idiopathic fevers, has often a singular effect on chyluria in causing its disappearance for a time. It would seem that states of high vascular tension, however induced, tend to make it cease.

While chyluria has made its appearance, for the first time, in a number of cases during pregnancy, this condition in other instances has caused it to disappear, especially toward the later months; whence it would seem that the pressure of the rising womb has a favorable effect.

The DIAGNOSIS of chyluria consists in the recognition of the chylous state of the urine. This, ordinarily very easily recognized, might be taken in its slight degrees for phosphatic or uratic or purulent conditions of the urine, and vice versâ. The disappearance of the first on the addition of acids, of the second on the application of heat or alkalies, will resolve any doubt, while the microscope will detect the pus-corpuscles in the last. None of the reagents named will dissolve the fatty molecules of a chyluria, while ether will cause the fluid to clear up completely.

The PROGNOSIS is usually favorable. Very rarely is an attack fatal, and when such is the case it is from exhaustion—from the drain to which the system is subject. Tubercular phthisis is therefore a not infrequent immediate cause of death.

TREATMENT.—On the supposition that filariæ are the essential cause of the disease, the rational indication would be first to destroy them by the introduction into the blood of some parasiticide; and, second, to repair the lesion of communication between the lymphatic system and the urinary passages. As yet no agent is known which would not be as fatal to the host as to the filaria, if used in sufficient quantity to destroy the latter; nor has it ever been possible to find the point of communication between the two systems, although treatment has been directed to producing closure of such communication, and with some show of success. Thus, in a case under his care Dickinson of London injected into the empty bladder twelve ounces of a solution of perchloride of iron, containing at first two drachms of the tincture to the whole quantity, gradually increased to four drachms. The solution was retained in the bladder for from eight to twelve minutes with little or no inconvenience. The operation was repeated almost daily for twelve days. The effect was always to check the milky flow and to substitute a clear urine. But after the operation had been repeated a certain number of times there was a decided rise of temperature, with headache, nausea, lumbar pain, hæmaturia, and albuminuria which continued a short time after the hæmaturia ceased. Singularly, too, with the subsidence of these symptoms, the chyluria remained absent for some time. The injections were resumed on its return, and each time were followed by relief. In the course of their use, however, the strength of the solution was increased to an ounce of the perchloride to twelve ounces of water, and the strongest solutions were retained in the bladder for as much as an hour, the weaker longer. Ultimately, however, the use of the injections became so painful that they had to be discontinued.

Another measure, employed by Bence Jones, was abdominal pressure by means of a belt. This also, in his experience, relieved the lumbar pain. In his case, which was about eight years under observation, Dickinson applied the pressure by a sort of tourniquet about an inch below the umbilicus. This lessened, though it did not stop, the pulsation in the femoral arteries. It also was successful at first, the chylosity lessening, and finally ceasing, but on the removal of the belt the chylous character gradually returned, and in sixteen hours was as bad as before. Repeated trials were followed by the same transient effect, but no cure. Under this treatment, however, combined with a liberal diet and rest, the patient gained many pounds in weight, and was able to leave the hospital and resume her occupation as dressmaker, the pursuit of which, and the absence of the favorable conditions of hospital-life, as invariably caused a return of the symptom and its resulting debility, which again caused her to seek admission.

Rest, therefore, and an abundance of good nourishing food, tend at least to counteract the exhausting effects of the disease, and even to cause the discharge to cease. Tonics, and especially chalybeates, are indicated for the former purpose.

As the relaxing effects of warm climates and warm weather seem to predispose to the condition and to aggravate it, removal to cooler latitudes and places is indicated.

Astringents, internally administered, naturally suggested themselves at an early date, and were used by Prout, Priestley, and Bence Jones. The latter especially thought gallic acid useful. He reports a case in which the disease did not return after its long-continued use. Goodwin of Norwich, England, also reports a case in which the chyluria was controlled by the gallic acid, but returned in four or five days after the remedy was discontinued. It again disappeared on resuming the drug, and the patient could at any time render the urine nearly normal in appearance by taking it. The case was lost sight of before it could be regarded as cured. Waters also reports a case which apparently recovered completely after nine weeks' treatment by gallic acid. He gave at first 30 grains a day, which were gradually increased to 135 a day, and then gradually reduced.

Other astringents which have been used are tannic acid, matico, or acetate of lead, nitrate of silver, the mineral acids.

Mangrove was successfully used in a case related by Bunyan of British Guiana. It was used in the shape of a decoction at the suggestion of a negress, an ounce being taken four times a day. In seven days the patient was so much relieved that the remedy was discontinued for two days, but the symptoms returned. They again disappeared when the drug was resumed, and two subsequent attacks were immediately cut short by the remedy. Roberts suggests that it may act as a parasiticide, and suggests larger and sustained doses of the iodide of potassium for the same purpose.

Retention of urine, when present, should be treated like the same symptoms under other circumstances, by catheterization, washing out the bladder with tepid water, warm fomentations, and similar measures. It has even been suggested to wash out the bladder with ether under these circumstances.

As it seems impossible for the embryo filariæ to develop in the human body into the fully-developed Filaria Bancrofti, it is evident that with the death of the latter, which must occur sooner or later, the production of embryos must cease, while those previously produced must sooner or later also die, and in this way a spontaneous cure take place—just as a person infested with trichinous disease will ultimately recover if the introduction of the trichinæ cease and he is able to survive the irritation caused by the presence of the parasite in his muscles. In this manner we may account for the spontaneous disappearance of the disease in so many instances where all treatment has proved unavailing.

DISEASES OF THE BLADDER.

BY EDWARD L. KEYES, M.D.

Inflammation.

The bladder is a patient organ, and rather slow to resent injuries from within or without. It never inflames on account of such general causes as the influence of cold, anæmia, cachexia, or a depressed state of the general system. Any of these causes may act as adjuvants, but alone they are not effective. Thus a chilling of the legs, inoperative upon an individual with a healthy bladder, is a prime factor in exciting inflammation in the bladder of an old man with an enlarged prostate; while the simple passage of a sound upon an individual suffering from anæmia might provoke a cystitis which the same traumatic cause would not have produced upon a patient in a thoroughly healthy condition.

Yet inflammation of the bladder is very common. It is sometimes a malady, more often a symptom produced by some other malady (stricture, prostatic enlargement, stone), and only to be overcome by detecting and removing its cause. The causes of inflammation of the bladder therefore include nearly all the maladies to which the bladder is liable.

The varieties of cystitis take name from that tissue of the viscus which is involved, and from the modality of the inflammation.

We have—

1. Cystitis mucosa Acute suppurative; diphtheritic; gangrenous.

Chronic catarrhal; membranous.

2. Interstitial cystitis, where the muscular coat of the bladder is involved.

3. Peri-cystitis, para-cystitis, where the peritoneal surface or surrounding structures are inflamed.

This short section upon a surgical subject, only being granted a few pages in a medical work, cannot include a description of all these conditions, or more than a general outline of acute and chronic catarrhal cystitis. Suffice it to say for the other varieties that interstitial cystitis depends upon mucous cystitis or peri-cystitis, and is an inflammation of the muscular coat of the bladder, sometimes culminating in abscess, sometimes in concentric hypertrophy—i.e. contracture of the bladder. Peri-cystitis and para-cystitis occur in connection with peritonitis and pelvic cellulitis, and the peripheral inflammation may extend inward and involve the muscular and later the mucous coat.

All these conditions are grave only in proportion to the intensity of the malady causing them and to which they are subordinate.

Gangrenous cystitis occurs after injury, and occasionally in profound septicæmic conditions (puerperal) or after intense cantharidal poisoning. It is fatal.

True diphtheria of the bladder occasionally, but very rarely, accompanies general diphtheritic conditions, and is a very grave malady. Membranous cystitis is less grave, may be partial or complete. I have a fibrinous cast of a female bladder which was extruded through the meatus. This malady occurs sometimes as a late complication of advanced chronic cystitis mucosa in the male. Recovery is quite possible.

Cystitis mucosa is a common disorder, constantly encountered by the physician as well as the surgeon. The irritable bladder, sometimes called cystitis, demands description here, as it may go on to become subacute or even acute cystitis of the vesical neck.

Irritability of the bladder is a neurotic and not an inflammatory condition, although it may lead to the latter state and terminate in it. The bladder is said to be irritable when the calls to urinate are too frequent, generally with little or no pain. As a rule, the urine is clear, containing no pus or a quantity entirely disproportionate to the frequency of the call to urinate.

In true irritability of the bladder the patient sleeps all night, although he may have to empty his bladder every hour or two by day. There is sometimes a sense of weight, heat, or throbbing, more or less intense, in the perineum; the desire to urinate is normal but imperious; the satisfaction after the act is complete, and no pain accompanies its performance.

This condition of things is generally either neurotic directly, or indirectly (reflex). In children it may be caused by a tight prepuce, especially if irritated by retained smegma, by teething, by the existence of intestinal worms; and it may accompany chorea. It gets well by lapse of time or is cured by removal of the cause. In the adult it is most common in young men and recent widowers, and is often an expression of sexual distress due to sexual stimulation without relief, to sexual excess, or to improper sexual hygiene. The irritation of acrid urine will also cause it, as well as such peripheral troubles as a narrow meatus urinarius, a tight prepuce, urethral stricture, moderately enlarged prostate, kidney irritation (stone in the kidney, etc.). It appears in old men, sometimes, apparently, as a forerunner of organic prostatic changes.

Such stimulation as a glass of wine or beer, pleasant company, absorbing occupation, may cause it to disappear temporarily. It is habitually better in dry, clear weather, and worse in damp seasons when the wind is east. Worry, anxiety, fatigue, depression of spirits, and similar causes aggravate the condition. It is better for the first twenty-four hours after sexual intercourse, and worse than it was before during the next following twenty-four hours.

The SYMPTOMS of pure irritability are simply a frequent desire to urinate during the waking hours, the act not being attended by pain and the urine being reasonably clear.

The PATHOLOGY of this affection is not definitely known. It seems to be an essential neurosis involving the sensitive nerves of the deep urethra and neck of the bladder, attended, if long continued, by surface congestion of the deep urethra and neck of the bladder, and ultimately the phenomena of inflammation; for the very mechanical act of allowing the bladder incessantly to empty itself too often, and to squeeze its own neck, will, in many cases, after a time, lead to traumatic inflammation of mild type.

TREATMENT.—Marriage is a very effective treatment of pure vesical irritability when there is a sexual element in the case.

If any peripheral or local cause exists (stricture, contracted meatus, dense acid urine), its removal will effect a cure. Alkaline diluents, notably the citrate of potassium in gr. v-xxx doses, administered midway between meals, copaiba, or cubebs in moderate doses, often gives relief. Tonics, the tincture of the chloride of iron, and arsenical preparations are often of great value. The tincture of hyoscyamus in minim x-lx doses may be combined advantageously with any of these remedies.

One of the most efficient of all methods of treatment is the use of the conical steel sound, as large as the urethra will admit without violence. The sound should be warmed, lubricated, and gently carried into the bladder at intervals of two to four days. The daily passage of the sound is objectionable, even if it gives relief at first, for it is liable to kindle a slow inflammation in a urethra unaccustomed to its use. When a sound is inserted it should not be left an instant in the bladder, but should be gently withdrawn as soon as it has been fully inserted. If left in the urethra, it does no good, and may act upon the cut-off group of muscles in the membranous urethra, causing them to contract spasmodically, as in the physiological performance of the coup-de-piston after urination. Such contraction bruises the sensitive mucous membrane of the urethra against the hard sound, and does mechanical damage.

The sound acts in three ways: It (1) mechanically distends the irritable contracted cut-off muscle and seems to quiet its contractile tendency. It (2) squeezes all the blood from the passively congested vessels of the irritated mucous membrane, thus ensuring a new supply of blood to the part and an improved circulation in the reaction which follows the irritation. It (3) mechanically, by contact, blunts the sensibility of the terminal sensitive nerves in the mucous membrane of the deep urethra. In this way the sound acts, and its effects generally last several days, often a week. Its good effect is also instantaneous. The slight feeling of weight and discomfort in the perineum which the patient has before its use is gone instantly, and replaced by a feeling of comfort. When this immediate sense of relief is not experienced, it is doubtful whether such a case will yield to the simple treatment by sounding.

It is a mistake to suppose that any ointments smeared upon a sound do good in this condition. Mercurial, belladonna, and other ointments are used, but they are all and entirely rubbed off the sound before it reaches the deep urethra, and their good effect probably resides solely in the imagination of the physician and the credulity of the patient. Ointments are undoubtedly of service in some obstinate cases, notably strong tannic-acid mixtures, and sometimes iodoform, but these cannot be carried to the deep urethra by being rubbed upon a sound. The cupped sound may be used to effect this very neatly, the little cups on the sides of the curve of the sound being filled with the ointment which it is proposed to carry down and apply to the affected spot. A few drops of a mild nitrate-of-silver injection also give decided good results in some cases. The solution should vary between two and ten grains in the ounce of water, and may be accurately applied by means of a Bigelow or an Ultzmann syringe, a few drops being thrown into the membranous urethra. After the application, which should be made only when the patient has a full bladder, urination will wash out the canal and good effects may be looked for—not immediately, as after sounding, but after the irritation produced by the stimulating application has subsided.

Acute Cystitis.

Acute cystitis sometimes involves only the neck of the bladder; in other cases the whole mucous lining of the bladder is included in the morbid process.

The causes of acute cystitis may be grouped under six heads:

1. Traumatic.—Under this head may be ranged all injuries from without, with or without fracture of the pelvic bones—wounds, rupture of the bladder, the pressure of the child's head during labor; injuries from within, as during the use of instruments, by stone, or pedunculated tumor. The list may be increased by such chemical traumatisms as those produced by ammoniacal urine in cases of atony or paralysis, by excessively acid urine in neurotic conditions of the neck of the bladder. Such chemical causes, it will be observed, commonly act in conjunction with another cause. Irritating injections without any co-operative cause are capable of lighting up acute cystitis.

2. Extension of neighboring inflammation—gonorrhoeal cystitis and that attending prostatic inflammation, pelvic abscess, pelvic cellulitis, peritonitis from neoplasms growing at the vesical neck, tubercle, cancer, etc.

3. Medicinal—from cantharides, sometimes cubebs or turpentine.

4. Specific—in diphtheritic, puerperal, septicæmic conditions.

5. The influence of cold when chronic inflammation already exists.

6. Neurotic—actual, from extreme and long-continued neuralgia of the vesical neck; reflex, from irritation at a distance, tight meatus, stricture, inflammation of the seminal vesicles, kidney irritations.

SYMPTOMS.—The symptoms of acute cystitis are (1) frequent painful urination by night as well as by day, the pain being greatest at the close of, and immediately after, the act, and the pain persisting more or less between the acts, radiating from the perineum; (2) moderate fever, sometimes announced by chill; (3) commonly great despondency and a depression of spirits totally disproportionate to the degree and significance of the local inflammation; (4) the urine invariably is milky, with pus: it may at first be acid and of normal odor; it is often tinged with blood, especially toward the end of the act of urination. In extreme cases the urine may contain membranous or sloughy shreds or gangrenous gases. The urine eventually becomes alkaline, and finally deposits lumps of pus and abundant triple phosphate crystals.

Complications occurring with the cystitis yield appropriate symptoms. Such possible complications are congestion and engorgement of the prostate, possibly going on to abscess; epididymitis, orchitis, inflammation of the seminal vesicles, inflammation running up the ureters, pyelitis, surgical kidney; abscess in the walls of the bladder or in the connective tissue about the same; very rarely peritonitis or suppurative phlebitis in the veins about the neck of the bladder.

The pathological changes produced by acute cystitis are similar to analogous changes upon the other mucous membranes: patches of more or less brilliant uniform or punctate redness, perhaps surrounding small ecchymotic areas; a softened, swollen mucous membrane; enlarged follicles near the neck of the bladder, perhaps ulcerated spots; possibly false or true diphtheritic exudations (such exudations have been especially noted in cantharidal cystitis); possibly interstitial abscess of the bladder-wall, or even suppurative phlebitis in the veins about the prostate and neck of the bladder, as observed by Walsham¹ in a case of cystitis due to over-distension. This last complication is happily exceptionally rare.

¹ London Lancet, May 10, 1879, p. 665.

The PROGNOSIS varies with the cause of the cystitis, and as the latter often cannot be entirely removed, the acute cystitis may only be moderated so as to be made to assume the chronic form. When the cause can be entirely removed, acute cystitis gets well and leaves the bladder absolutely sound.

TREATMENT.—Acute cystitis from whatever cause requires a uniform general line of treatment. Anodynes are essential both for the patient's comfort and to prevent the constant straining to empty the bladder to which the unremitting, painful desire to urinate impels him. Hyoscyamus is a favorite in the form of tincture in minim xx-drachm j doses, or any of the opiates by the mouth, or in suppository preferably combined with extract of belladonna in small dose. Sometimes quarter- or half-grain suppositories of extract of belladonna alone at intervals of six to eight hours keep the tenesmus more in check than anything else, but belladonna used too freely may bring on retention by causing spasm of the cut-off muscles. Camphor is useful, especially in strangury from cantharides. Rest in bed is essential in most cases, preferably with the hips raised. Heat in some form, as a hot poultice, fomentation, spongio-piline, hot-water rubber bottle, etc. over the hypogastrium preceded by a mustard plaster, gives great comfort. Hot-water hip-baths of short duration and frequently repeated are of service in most cases.

Alkalies are valuable, especially in the beginning of an attack—liq. potassæ minim v-xx doses, citrate of potassium gr. x-xx, combined with an anodyne or some demulcent drink.

Infusions and extracts of corn-silk, dog-grass root, buchu, pareira brava, uva ursi, etc. are of some assistance, but generally not so comforting as some of the bland diuretic waters—Bethesda, Mountain Valley, Poland, Glenn, Vichy, Wildungen, Buffalo Lithia. Distilled water or rain-water, especially if taken warm, is a good diluent diuretic. On the advent of acute cystitis all instrumentation upon the bladder should, if practicable, be postponed, all stimulating drugs (cantharides, turpentine, cubebs, alcohol) stopped, and stimulating foods avoided. Asparagus, coffee, salt, pepper, mustard, acids, and a highly nitrogenized diet are not allowable. The rectum should be kept empty and complications treated as they arise.

Chronic Cystitis (Catarrh of the Bladder).

Catarrh of the bladder is chronic inflammation of the mucous membrane of the urinary reservoir, with more or less thickening of the walls of the bladder. This malady, so apt to persist for years, is probably more commonly encountered by the physician than acute cystitis. Acute cystitis, however, frequently complicates the chronic malady by occasional outbursts of acute symptoms. Thus an attack of the stone is acute calculous cystitis interrupting the course of chronic vesical inflammation due to stone. Catarrh of the bladder may follow acute cystitis, or it may commence insidiously as a subacute disorder, and be catarrh, in the popular sense, from the first.

The causes of catarrh of the bladder are never single. It always takes two causes to produce true catarrh of the bladder—one mechanical, and one chemical. After a traumatism inflicted on a healthy bladder, with proper care the patient recovers entirely. If, however, he insists upon keeping up and about, continues to drink liquor, and does not avoid straining at urination, the membrane about the neck of the bladder, irritated by the ammonia from the decomposing urine, secretes an excess of viscid mucus, the pus becomes gelatinized by the ammonia, the constant straining leads to hypertrophy of the muscular coat, the nerves lose their acute sensitiveness, and the milder persistent malady, chronic catarrh, is set up, to continue perhaps for an indefinite period.

Infiltrations of the bladder-walls with tubercle or cancer, urinary calculus, and, notably, enlarged prostate, stricture of the urethra, tumors of the bladder, hernia of the bladder, exstrophy, over-distension of the bladder from stricture, spasm of the urethra, coma, paralysis, or other cause, may be the traumatic element, while the liberated ammonia from the alkaline decomposing urine furnishes the chemical element; and the two causes, if continued, occasion and maintain the condition known as chronic catarrh of the bladder. In coma or the delirium of typhoid fever or paraplegia or hemiplegia (sometimes) the bladder becomes over-distended and atonied, perhaps paralyzed. Here the use of the catheter appropriately, with great gentleness, may relieve the patient without even the intervention of acute cystitis; while, on the other hand, acute cystitis may come on and be cured, or, if ammoniacal urine be allowed to accumulate and the bladder be not washed out so long as it is unable to entirely expel its contents, chronic cystitis, catarrh, results. I have known several cases of partial paraplegia and other disorders in which the patient could void no drop of urine except through a catheter, where there never had been any chronic catarrh, no stringy mucus, hardly a pus-corpuscle, through long years of the disability, owing to intelligence in the attention to emptying and washing out the bladder instituted by the physician having first charge of the case.

As prominent among the causes of chronic catarrh in a purely medical aspect it may be well to insist upon the ease with which this condition is sometimes brought about by the physician himself. A man with a weakened bladder may carry a pint or much more clear urine in his bladder constantly during many years as a residual deposit which his weakened bladder cannot throw off. Excess over the fixed residuum produces a desire to urinate, and the patient, mainly by voluntary contraction of the abdominal walls, voids that excess. If now the physician finds this globular accumulation in the patient's belly, and in his zeal to do all that is possible forgets his caution, he may throw the patient first into an acute cystitis (if haply he escapes collapse), and then into chronic vesical catarrh—an affair perhaps of a lifetime. Surgeons have noticed, and especially Sir Henry Thompson has pointed out, that a dirty catheter may poison the urine and bring about a cystitis which otherwise might have been avoided; and observers from all time have noticed that the sudden entire evacuation of the contents of a bladder long accustomed to over-distension is in itself a grave cause of serious inflammatory disturbance to the mucous membrane of the bladder. Recently much attention has been called to this condition and its possible fatal termination by Sir Andrew Clarke, under the name of catheter fever.

The deductions from a knowledge of these facts are obvious: they are—(1) always to thoroughly cleanse, and then to disinfect, a catheter on each occasion before its use; and (2) never to empty entirely at a first sitting a bladder which has been long habituated to over-distension; and when, finally, the bladder is emptied, always irrigate it with a disinfecting solution (borax) after each emptying.

SYMPTOMS.—Chronic cystitis varies in grade, and its symptoms vary with the grade of the inflammatory process. There is probably no pain more intense than that endured by a man with severe general cystitis in its last stages, when the unceasing tenesmus wrings groans from his lips, the sweat from his body, doubles his frame in agony, and converts his facial expression into a distorted tragedy. The sight is pitiable and never to be forgotten. On the other hand, a man may continue about and at his work with a patient flabby bladder containing constantly more or less stringy mucus and ammoniacal urine, suffering little or no pain or tenesmus, and perhaps having no subjective symptoms except a slight sense of weight in his lower belly and a rather frequent desire to urinate.

Between these limits the symptoms range, but in a general way it may be said that the symptoms of chronic vesical catarrh are these: frequent calls to urinate, attended by more or less pain, especially toward and after the termination of the act. The sense of satisfaction normally felt after urination is generally absent. Motion, particularly jolting as in rough riding, causes pain. This pain is referred to the lower part of the belly, to the perineum, to the end of the penis, the urethra, the anus. The straining after urination may be absent or of the most intense character, leading to prolapse of the rectum and causing excruciating torture. The urine always contains pus scattered through it, and generally also more or less pus in that semi-solid condition known as stringy mucus. Stringy mucus is pus gelatinized by the ammonia of the decomposing urine. These clots of muco-pus contain gritty crystals of the ammonio-magnesian phosphate. More or less blood is to be found in the urine, especially during acute paroxysms. Pure blood sometimes follows the urine after each act of urination. Bacteria abound in the fluid, which varies in odor greatly in different cases, not always strictly in accordance with the severity of the actual inflammatory process. Thus, the urine may be simply sweetish in its odor, ammoniacal, flat, and stale, or be possessed of a putrid, sickening sweetness of indescribably nauseating power. Again, it may be rankly rotten. The bottom of the chamber in some cases becomes covered with a thick coating of the viscid muco-pus, which strings out and reluctantly follows the fluid when the vessel is inverted. Sometimes the urine contains shreds of false membrane or putrid masses of sloughy tissue.

PATHOLOGY.—In chronic cystitis the mucous membrane of the bladder undergoes gradual thickening, loses its pink salmon tint, and becomes gray in color. The thickening extends to the submucous layer, and more or less to the muscular walls as well. In cases of prolonged chronic cystitis attending atony of the bladder, notably with hypertrophied prostate, the cavity of the organ is large, its walls seemingly thinned and flabby, its internal coat roughened by the crossing of bundles of muscular fibres or perhaps perfectly smooth. In other conditions (concentric hypertrophy), where there has been a serious obstacle to the free outflow of urine without any atony of the muscular coat (stricture of the urethra, some cases of stone and of enlarged prostate), the walls of the bladder may be enormously thickened to the extent of an inch or more, the inside surface rough, perhaps ulcerated.

The thickening of the muscular bands within the bladder often causes them to stand out in bold relief, like the muscular bundles in the heart-cavity. These prominent bundles enclose spaces of various sizes and shapes, and from the bottoms of these spaces sometimes the mucous membrane protrudes between the muscular bands and forms pouches of varying size (sacculated bladder). These pouches consist of mucous membrane alone covered with peritoneum, and may become the seat of encysted stone.

If there has been a subacute grade of the surface inflammation before death, there may be livid spots on the mucous surface of the bladder, punctate or larger ecchymoses, reddened areas from which the epithelium is more or less detached, ulcers with or without sloughs or diphtheritic covering, perhaps perforations of the bladder and infiltration of urine, enlarged mucous follicles, granulations, fungosities, etc. Heterologous deposits, tumor, cancerous and tubercular ulcers, cysts, stone, complete the possibilities of what may be encountered in the bladder at an autopsy upon a patient with chronic cystitis.

The chronic like the acute varieties of cystitis may involve the whole of the inside of the bladder or only a portion of it.

The PROGNOSIS, like that of acute cystitis, varies mainly with the cause. If the latter can be entirely removed (stone), the bladder gets perfectly well. Not so, however, unless all the causes are removed. Thus, a phosphatic stone may grow in a bladder as a result of enlarged prostate and chronic cystitis. The presence of the stone excites the chronic cystitis, and subjects the patient to a crisis of acute cystitis from time to time. The removal of such a stone will by no means cure the chronic cystitis; its removal is only one step in the treatment of the cystitis.

As far as life is concerned, the prognosis of chronic cystitis is good. A patient may live many years with chronic cystitis, particularly if he treats his bladder properly. Although, as generally encountered, chronic cystitis is not curable, few maladies yield results to treatment more gratifying to the physician and the patient than the one under consideration.

The legitimate ultimate termination of chronic cystitis is by chronic inflammation of the ureter and pelvis of the kidney on both sides, interstitial kidney changes, and finally death by suppression. Generally, this end may be almost indefinitely postponed by well-directed efforts of palliative treatment.

TREATMENT.—The acute outbursts of inflammatory disturbance occurring during the course of chronic cystitis require the same means for their relief as those already indicated when considering the treatment of acute cystitis—all the prohibition of stimulants, the use of bland mineral waters, demulcent decoctions, infusions, and alkaline draughts. The anodynes, the rest, the heat, the hip-bath, are all indicated here for the acuter symptoms, just as they are in the acute malady, but very much more can be done both in a prophylactic and in a curative way. A milk diet, even an exclusive milk diet, is an element of great value in cases of chronic cystitis. I have two patients, both old men, now under observation, one of whom recovered entirely from cystitis with complete atony, necessitating the constant use of the catheter, by means of an exclusive milk diet. He takes one gallon of milk a day, and nothing else, and lives among his fellow-men at his work and amusements in entire contentment. He has remained absolutely well on this diet during many years. The other patient could not take milk after fair trial, but gradually emerged from the very jaws of death, due to prolonged chronic cystitis and double pyelitis, by the free use of koumiss, which his wife daily prepared for him. Vichy and milk in equal parts, taken cold, is another form of using the milk diet, and the more modern peptonized milk another.

Light white and red wines, or even a little gin or old brandy, are of decided advantage in the majority of enfeebled old men with chronic cystitis. The patient should be clothed with the utmost care. The feet and legs should be clad in wool unless in the very hottest season, and flannel should constantly encase the belly and loins. Nothing is more detrimental to chronic cystitis than chilling the legs.

Another word is necessary in favor of the internal use of alkaline remedies. Even where the urine is alkaline, ammoniacal, putrid, if the stomach will take an alkaline medicine kindly the effect is generally beneficial, for the urine, especially in old men who are prone to these maladies, is quite certain to be acid at the fountain-head. And even if the urine is immediately altered by chronic pyelitis through ammoniacal decomposition before it enters the ureter, yet it will generally irritate the pelvis of the kidney and the ureter and the bladder less if it be secreted in a bland alkaline state than if it be discharged into the irritated area full of uric acid.

Turpentine, copaiba, cubebs, and the muriate of iron are of service in selected cases, but ordinary astringents seem to possess little or no value. Benzoic acid, in ten-grain doses in capsules, sometimes improves the ammoniacal condition of the urine, but the stomach often rejects it. Boracic acid, which has of late been much talked about, in five- to ten-grain doses in water, three or four times a day, is of value occasionally. Quinine is serviceable where the nerve-force is failing. I have been unable to procure any very decided advantage from the use of salicylic acid or the salicylate of sodium by the mouth.

The most important general surgical principle in connection with chronic vesical catarrh is that which concerns emptying the bladder thoroughly and ensuring its cleanliness. In many, perhaps most, conditions of chronic inflammation of the bladder from atony, paralysis, obstruction, or other cause the bladder fails to empty itself entirely. There remains, therefore, a fixed residuum always in the bladder; and although this is diluted and partly evacuated at each act of urination, yet some of the pus, the bacteria, the ammoniacal ferment, remains constantly in the bladder ready to contaminate each new portion of urine as it descends from the kidneys. This must be disposed of, and the bladder washed out, if a permanently satisfactory treatment is to be instituted.

The soft-rubber catheter is to be preferred where it will pass, otherwise the woven silk or the French Mercier instrument, and the bladder should receive attention at least once in the twenty-four hours, and oftener if required. The last drops of urine should be drawn off and the bladder washed with water at about 100° F., in which is dissolved some borax—a heaping teaspoonful to the pint—or other substance capable of disinfecting the contents or mildly stimulating the circulation of the bladder.

Carbolic acid has not yielded good results in my hands. A host of remedies have been employed, but it is doubtful whether anything can do more good than the water mechanically, borax as a disinfectant, dilute nitric acid, minim i-x to the pint, as a stimulant, or, in some cases, nitrate of silver, gr. ½-x to the ounce, used with caution. The injections should be practised through the catheter which withdraws the urine, and repeated according to their effect. For cleansing purposes an injection of simple warm water may be used at each introduction of the catheter. A fountain syringe with two-way stopcock is the most convenient instrument to use for the purpose of simply washing the bladder, because the wash may be repeated indefinitely until it returns clear, without readjusting the nozzle in the catheter.

Very extreme, long-protracted cases of chronic vesical catarrh justify the performance of lateral cystotomy for their relief, or the modification quite recently proposed by Thompson²—a median perineal incision involving only the membranous urethra, through which a large soft-rubber catheter is passed and tied in for a few days or longer.

² Brit. Med. Journ., Dec. 9, 1882, p. 1131.

Neurosis of the Bladder.

The most common vesical neurosis is neuralgia of the neck of the bladder, with or without the accompaniment of irritability of the bladder, spasmodic stricture, or vesical spasm. Irritability of the bladder has been already considered at the beginning of the section on Cystitis. The other neurotic conditions are always more or less interwoven with each other, and they may each and all of them complicate inflammatory states of the deep urethra, prostate, and vesical neck.

The CAUSES of this set of affections are most varied, and range from irregular sexual hygiene (the most common of all) through inflammatory local conditions, peripheral irritations (the most obstinate of which is chronic inflammation of the seminal vesicles, with or without true spermatorrhoea), up to organic changes in the spinal cord and brain.

The PROGNOSIS in neurotic states varies with the cause. Some cases are easily controlled; others absolutely defy all and every treatment of which I have any knowledge.

The TREATMENT involves a removal, if possible, of the cause. Local measures which have been found most effective in subduing the deep urethral irritation are—(1) the gentle passage of a soft bougie or conical steel sound into the bladder at intervals of one to seven days. The instrument should be removed at once. Sometimes it is necessary to cut a narrow meatus or a stricture in the pendulous urethra in order that a sound of large-enough size may be employed to put the sensitive deep urethra sufficiently on the stretch. (2) The application to the deep urethra and prostatic sinus of pastes of tannin or iodoform with the cupped sound or other apparatus, or the injection of the deep urethra with strong solutions of tannin or mild solutions (gr. i-x to ounce j) of nitrate of silver. (3) In the most extreme cases, those furnishing all the symptoms of stone, even cystotomy is justifiable. It nearly always furnishes a temporary, sometimes permanent, relief.

Medical measures include all the bland diluent mineral waters, alkaline and tonic remedies, already considered in discussing Irritability of the Bladder.

Atony and Paralysis.

Atony of the bladder is more or less lack of expulsive force, due to failure in power of the muscles of the bladder, the nerves remaining sound. Paralysis is the same condition perhaps more pronounced, but due to central origin. A patient may be unable to pass water in more than a dribbling stream, but if he has true organic stricture or spasm of the deep urethra, the muscular coat of his bladder may perhaps not be to blame for his imperfect urination. The question of atony may be decided in such a case by introducing a catheter of any size that will pass. If there is atony, the stream flows sluggishly from the mouth of the catheter, and toward the end is influenced by the breathing of the patient. If there is no atony, the stream rushes through the catheter, and maintains its force until the last drop flows away. In paralysis and extreme atony the influence of the descent of the diaphragm during inspiration is noticed during the whole course of the flow of the sluggish stream through the catheter.

The CAUSES of atony are over-distension of the bladder, voluntary (by persistently neglecting the call to urinate), involuntary retention (from fever, coma, stricture, large prostate), and a certain intrinsic, sometimes inherited, tendency to weakness on the part of the bladder, noticed by some people during their entire lives.

Atony is most common, often a part of their malady, in old men with enlarged prostate. Paralysis of the bladder accompanies certain organic changes due to injury or disease in the spinal cord or brain. Both in atony and in paralysis the bladder may be constantly distended to a certain extent, perhaps to its utmost limit, as a passive sac, and the excess of urine over this uniform residuum may dribble away involuntarily (false incontinence), or may be expelled in small portions by repeated acts of urination performed in the ordinary way or by the aid of great straining and assistance from the voluntary contractions of the muscular walls of the abdomen. No condition of incontinence of urine can be considered proved until demonstrated by the passage of a catheter. Both atony and paralysis may get well under proper treatment in favorable cases. Many cases are incurable, but the discomfort they tend to cause may be almost entirely counteracted.

TREATMENT.—Under all circumstances where the bladder cannot empty itself, the catheter should be used, and the bladder should be washed out, kept clean, and disinfected. All the suggestions laid down for catheterization and vesical injection in the section on Chronic Cystitis are applicable here and need not be repeated. It is particularly necessary to disinfect the catheter on each occasion before it is introduced. This is best effected by washing the catheter outside and inside with a 5 per cent. solution of carbolic acid in water, and finally washing it outside with clean water, before its introduction. If the bladder is over-distended, it should not, as a rule, be entirely emptied at the first introduction of the catheter, for fear of possible collapse, or, what is more to be dreaded, setting up acute cystitis by suddenly taking off all the internal pressure from the vessels in the walls of the weakened bladder, to which pressure the circulation has become accustomed. If, therefore, the bladder is emptied inadvertently, it is better to inject a few ounces of warm water containing borax in solution (a teaspoonful to the pint), and leave it in until the next catheterization. The quantity left in may be reduced at each sitting. By careful attention to these means most cases of over-distension due to atony or paralysis may be relieved without the intervention of cystitis, or with so little that it does not become a serious factor in the case.

The medical treatment of these cases is less important than the mechanical. Under the latter alone and improvement in general health curable cases often get well. Milk diet is of service, and iron and tonics of considerable value in proper cases. Electricity has not yielded satisfactory results in my hands, and I have not derived the advantage from ergot which is often claimed for it. In cases of atony I think I have seen good results sometimes follow the use of strychnine internally in pretty full doses. The same remedy under the skin acts more promptly and more effectively if it is to do any good at all. In true paralysis of central origin the cure of the bladder depends upon relief of the original disease and local treatment to the bladder.

Hysterical women sometimes feign paralysis in order apparently to secure the sympathy and personal attention of the physician. The application of the actual cautery above the pubes, and entrusting a female nurse with the function of catheterization, is generally effective treatment in these cases.

Hemorrhage from the Bladder.

After all sorts of wounds and injuries to the bladder, and in cases of rupture of the viscus, blood is found in the urine. In certain medical conditions, in scurvy, hemorrhagic eruptive diseases, cases of vicarious menstruation, it has been noticed. In strangury due to cantharides, or in any condition of acute or chronic cystitis with considerable spasm of the bladder, the urine contains more or less blood. Especially is this true if ulceration exist at or near the neck of the bladder, as in tubercular or cancerous cystitis.

In cases of stone in the bladder one of the cardinal symptoms is vesical hæmaturia, while in villous growth often the only symptom of the malady is repeated attacks of more or less profuse bleeding from the bladder coming on unexpectedly, without obvious exciting cause, and showing no regularity in the length of the intervals between the hemorrhages or the intensity or duration of the latter. Outbursts of unexpected hemorrhage are not uncommon in connection with some cases of enlarged prostate and chronic cystitis, while these outbursts are the rule, sooner or later, in most cases of true cancer of the bladder.

The DIAGNOSIS is often very important—that is, in a given case to decide whether the blood comes from the bladder or from the kidney. This may usually be ascertained by a very simple manoeuvre, especially when the flow of blood is not excessive: a silver catheter of short curve is introduced and the urine drawn off, the bladder gently washed several times without moving the catheter, and the shade of red in the wash noted. Now, the bladder being slightly distended with warm water, the point of the catheter is moved somewhat roughly in all directions and made to touch different portions of the wall of the bladder. The water is now allowed to escape, and its deepened color will decide that the hemorrhage has a vesical origin, for manipulations of a silver catheter in a healthy bladder will not occasion a flow of blood. In doubtful cases on two occasions I succeeded in locating the point whence the blood escaped as follows: In one I passed a soft catheter, and washed the bladder until the wash escaped nearly clean; I then withdrew the catheter until the point reached the membranous urethra (the bladder having been left full of clean water), and immediately passed the instrument again and withdrew the contents of the bladder, which were now brilliantly colored, thus locating the bleeding point in the prostatic sinus. In the other case, that of a young man with moderate stricture, whose urine was nearly solid with blood, I noticed that no blood escaped by the meatus between the acts of urination; therefore the bleeding point was posterior to the membranous urethra. Was it in the prostate, the bladder, or the kidney? To decide this I passed a soft catheter and washed the bladder until the wash flowed clear. I then injected some warm water, withdrew the catheter, and caused the patient to empty the bladder. The flow was brilliant with blood. In both these cases I effected a cure by one application of solid nitrate of silver through the urethra to the prostatic sinus.

The TREATMENT of vesical hæmaturia is the treatment of the cause, which, if possible, must be ascertained. For the symptom itself the internal use of iron, turpentine, opium, gallic and tannic acids, are of service. I have not derived any advantage from ergot. Locally, rest in bed, ice over the region of the bladder, and avoidance of straining at urination are generally all that is necessary. I have had good results from injecting the bladder with a solution of alum, gr. i-ij to ounce j of warm water, and cures have been effected by injecting nitrate of silver in solution. It is not well to inject iron in solution, since this substance makes a hard clot, and a soft clot is preferable. When the bladder fills up with a solid clot of blood, the best treatment, according to my experience, is to administer opium freely and diluent drinks. The urine slowly dissolves the clot, which has already arrested the hemorrhage, in most cases by its pressure, and the blood flows away as a dark coffee-ground material, sometimes nearly black. If the catheter is used, the clot broken up or dissolved with pepsin or other substance, and washed or pumped out, a new clot is apt to form at once; and although this treatment is based on high authority, and is often practised successfully, it is a question whether the patient would not in many cases do as well, or better, by being let alone, soothed by opium, until the urine dissolves the clot and nature relieves him.

New Growths in the Bladder.

These belong strictly to the province of surgery, but they fall also under the notice of the physician. Tubercular disease may involve the whole mucous surface or only the neck of the bladder; cancer may infiltrate its walls or grow out as a solid tumor in the vesical cavity; fibrous, sarcomatous, and myomatous new formations, polypi, and cysts, simple and hydatid, have been encountered; villous growths, both benign and cancerous, may occur. These morbid deposits give rise either to recurrent hemorrhage or to varying grades of chronic cystitis. The diagnosis is often difficult, the treatment generally palliative. Much has been done of late in an operative way for the relief of tumors of the bladder, and some brilliant results have been secured by operations through the perineum as well as above the pubes. A tumor of moderate size may be detected by the searcher within the bladder, and often may be grasped in a lithotrite and measured. Such a tumor can generally be plainly felt by conjoined palpation in a thin subject, one hand pressed firmly down behind the pubes and two fingers of the other hand passed into the rectum. Recently, Sir Henry Thompson has advocated vesical exploration for purposes of diagnosis through a median incision in the perineum, as for median lithotomy, and has practised it a number of times with a large measure of success. I have made the same exploration several times, and have encountered and successfully removed one tumor. The expedient is worth bearing in mind for use in any obscure cases. It is probably less objectionable and more likely to yield valuable information than the exploration by introducing the whole hand into the rectum (Simon's method).

SEMINAL INCONTINENCE.

BY SAMUEL W. GROSS, A.M., M.D.

DEFINITION.—By the term seminal incontinence, which is synonymous with involuntary or abnormal seminal emissions, pollutions, and spermatorrhoea, is meant the involuntary discharge of semen beyond the limits of health. Although usually described as a distinct disease, it is symptomatic of, and, as a rule, primarily dependent upon, weakness or exhaustion, along with exaggerated irritability, excitability, impressibility, or mobility of the centres which preside over erection and ejaculation. Hence it should be regarded as a motor neurosis, and not as a functional disorder of the testes.

CLASSIFICATION.—Involuntary seminal losses embrace three conditions, which constitute as many varieties of the affection, and which may exist separately, or pass into one another, or be combined. These varieties are, first, nocturnal losses or pollutions, which occur during sleep, and are generally attended with an erection, erotic dream, and pleasurable sensation; secondly, diurnal pollutions, which take place when the patient is awake, are excited by trivial mechanical or psychical causes, and are associated with imperfect erection and diminished sensation; and, thirdly, spermorrhagia, or spermatorrhoea, in the strict acceptation of that term, which is characterized by a constant escape of a slight amount of seminal fluid, without the orgasm, pleasurable sensation, or impure thoughts, or during micturition and defecation.

1. Nocturnal Pollutions.—By far the most common of the varieties of seminal incontinence is the first, or that in which the emissions occur during sleep under the influence of an erotic dream, and which may, therefore, be regarded as an exaggeration of the normal or physiological condition. In health, provided the subject leads a continent life, the number of emissions varies greatly, and as they are merely reflex signs of distension of the seminal passages, they are not pathological nor are they attended with ill effects. The knowledge of this fact is of great practical importance, as it frequently enables the physician to assure his patient that the emissions are not abnormal, thereby relieving his mind of a great weight. It is, of course, to be remembered that the frequency of nocturnal pollutions depends upon age, climate, habits, temperament, constitution, diet, and predisposition, and that young men who suffered during childhood from nocturnal incontinence of urine are particularly obnoxious to them. Their frequency also varies greatly in the same person, and it is scarcely possible to determine what constitutes the standard of health merely by the intervals of their repetition, since a number which would be normal in one person would be abnormal in another. In men, however, who possess sound nervous systems and who do not trouble themselves with sexual matters an emission every fortnight is a sign of excellent health; and even if they should occur at intervals of several days, they are not inconsistent with temporary good health. The latter statement is well exemplified by a case which came under my observation in 1882. A druggist, twenty-seven years of age, had had for six years from three to live emissions a week, and occasionally two during a single night, attended with erections and voluptuous dreams, without the slightest evidence of impairment of his health. In all such cases, however, as well as in those in which the emissions have occurred at longer intervals for a number of years, it only requires a little longer time for general symptoms to manifest themselves.

Nocturnal pollutions are to be regarded as pathological when they occur in married or single men who indulge in regular intercourse; when they are followed by backache, headache, enfeeblement of the functional powers of the brain, mental depression, and bodily or mental lassitude; when they take place without erections or dreams; when they accompany or follow acute or chronic diseases; when they coexist with diurnal pollutions or spermorrhagia; and, finally, when they are complicated by one of the varieties of impotence, which may be the only indication that the emissions are abnormal or one of the effects of impairment of the functions of the genital nervous centres. The associated symptoms of myelasthenia and cerebrasthenia vary very much in degree in men of apparently the same amount of vigor and tolerance, and in whom the pollutions occur with equal frequency, or they may even be absent altogether.

2. Diurnal Pollutions.—Ejaculation of semen during the day is fortunately of comparatively infrequent occurrence, since it indicates a more serious condition than do losses of seminal fluid occurring when the patient is asleep, the genital organs and the centres which preside over them being highly impressible or in a state of irritable weakness. In what may be regarded as the lesser form of the affection the ejaculation is due to slight peripheral irritation, induced, for example, by friction of the clothing, crossing of the legs repeated several times, horseback exercise, driving over rough streets, riding in railway-cars, or even shaving, combing the hair, or shampooing the head; while in the more aggravated variety an emission is induced by psychical irritation, such as reading libidinous books, the sight of indecent pictures, dwelling upon sexual ideas, or the mere sight of a female. In the former of these varieties there is a fair erection, but the sensibility is blunted; in the latter the erection is flabby or the penis is flaccid and there is little if any pleasure.

3. Spermorrhagia.—In the third phase of the affection, which is still more uncommon than the second variety, there is a continuous passive loss of semen, without erection or sensation—a condition which depends upon paralysis and dilatation of the orifices of the ejaculatory ducts, and which is most conspicuous during the acts of micturition and defecation. The existence of spermatorrhoea, in the restricted sense of the term, is denied by some authors, but I have myself met with it in five instances, and typical cases have been recorded by other modern writers.

CLINICAL HISTORY.—Seminal incontinence usually supervenes upon the interruption of sexual intercourse, especially when the subject has been accustomed to excessive venereal indulgence, or, as more frequently happens, upon the abandonment of the habit of masturbation. Any one of these varieties may exist separately, but they gradually pass into each other, and are variously intermixed in the advanced grade of the affection. In the mild type there is increased frequency in the occurrence of nocturnal pollutions, ejaculation taking place at intervals of several days or for two or three nights in succession, when there is a respite for a week or ten days. The emissions are associated with disturbances of the nervous system, referable to the brain or spinal cord or to the cerebro-spinal axis, of which mental lassitude and muscular debility are the most common signs. When, as the result of the increase in the irritability of the ejaculatory centre and of the progressive weakness or exhaustion of the entire nervous system, the case goes on from bad to worse, it usually pursues the following course: Abnormal frequency of the nocturnal pollutions is associated with pain in the back, headache, muscular fatigue, and incapacity for sustained mental effort. With the increase in the number of the emissions erection becomes imperfect, ejaculation on coition is frequently precipitate, and the patient complains of dulness of perception, impairment of memory, mental dejection, a dull pain in the occipital region, weakness of vision, vertigo, palpitation of the heart, trembling and numbness of the limbs, shortness of the breath, flatulence, constipation, and other signs of gastric derangement. Diurnal pollutions are now superadded, and intercourse is impracticable, either from failure of erection or from premature ejaculation. The general symptoms, too, are more serious. The patient constantly broods over his condition, assumes that he has permanently lost his virility, and the mental anxiety and dejection verge upon or merge into a condition of sexual hypochondrism. The gait is unsteady; the hands and feet are habitually cold; he is subject to wandering neuralgic and rheumatoid pains; passes restless nights; loses flesh and color; shuns society; imagines that every one recognizes his condition, and fears to look one in the face; and is utterly incapacitated for mental or physical exertion. With the still further increase of the irritable weakness of the genitalia and nervous centres the semen flows continuously out of the urethra, and its discharge is augmented during defecation and micturition. Finally, the man becomes a confirmed hypochondriac, and should he have inherited a tendency to insanity, epilepsy, ataxia, or other nervous disorders, he may lapse into one of these conditions.