We may expect more or less complications and involvement of the stomach, bowels, rectum, liver and spleen during the months of July, August and September, much depending upon the section in which one resides and his general environment. Changes in the weather, cool nights and hot days may all be contributing factors and thus prevent the body from the attainment of the equilibrium not too warm nor too much chilled.

Various bacteria causing states of fermentation, different kinds of food, indigestible substances, very cold drinks all may in a way be the cause of much mischief; and added to these we are liable to congestion of several organs. We still believe in the old manner of procedure in cleaning out the alimentary tract and although the modern "so-called" physician may think there is no virtue in medicine or therapeutic agents and smile when one speaks of hepatic congestion or disordered liver, let me say we pity the patient who lives in a malarial climate who calls in a modern therapeutic nihilist especially if the patient is afflicted with pernicious malarial fever of the congestive type. By all means clear out the intestinal tract first and use some hepatic stimulant, but if the case is urgent administer quinine either by mouth, hypodermically or by veins. Without going into detail in regard to the various symptoms which characterize such ailments as diarrhea and dysentery we will give a few prescriptions as suggestions in regard to the treatment of these symptoms. Do not neglect external applications such as; turpentine stupes, hot water bottles, blisters, poultices, steaming. Cold water applications and dry cupping, etc., all depending upon the case in question.

In all cases use calomel in small or large doses followed by the best antiseptic of all, castor oil. Now having cleared our decks for action we can use appropriate remedies to meet the requirements.

DIARRHEA.-The symptoms of this complaint may be a watery discharge, but the true cause may be due to a variety of elements, such as bacterial fermentation, undigested food, relaxed condition of the musculature mucous membranes, etc., hyperacidity or undue alkalinity and congestions of liver and spleen with catarrhal jaundice.

It therefore becomes essential to understand the condition with which we have to deal. In some cases we may have to use the alkalies such as sodium bicarb., magnesia, bismuth or the reverse such as nitro-muriatic acid, or some sedative as opium or hyoscyamus or an intestinal stimulant like strychnine. In many cases we need an intestinal antiseptic and where malaria is a factor quinine and hepatic stimulants or some drug to expel or kill intestinal worms. We see, therefore, that we cannot blindly prescribe a drug until we at least approximate the underlying element as one of the causative agents.

Having now taken a survey as to the right course to pursue we may thus proceed to administer any one of the following prescriptions for either diarrhea or dysentery.

Before proceeding further with the prescription formulæ let us add a word as to rectal injections as it will save time by having the methods before one's eyes in a general way. In nearly all cases of diarrhea and dysentery do not neglect rectal injections.

A good formula in diarrhea is the following:

Besides these prescriptions we have the sulpho-carbolates of zinc, etc., salol, the magnesias, bismuths, gallic and tannic acid, emetine and many valuable drugs each of which can be used in its appropriate place, for the alleviation of many conditions affecting the abdominal viscera, not forgetting many necessary remedies for disturbances of digestion, pepsin, etc., and the diet. Beware also of sudden chilling of surfaces. In fact in many cases we must forbid the use of water by stomach for hours or a day or so when there is nausea. Of course it must be understood that these prescriptions are for the most part for grown persons and not children.

1669 Columbia Road, N. W., Washington, D.C.

Podophyllin.

Sulphur (flowers).

Carbolic acid..

Gum acacia, q. s.

M. Make into 12 pills or capsules.

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RECTAL DISEASES AS A CAUSE OF NERVOUSNESS

Dr. L. Eliot (Va. Med. Semi-Monthly, Feb. 11, 1916) remarks that neuralgia, pruritus, sciatica, insomnia, hysteria and even insanity may be due to some rectal affection. It only too frequently happens that we question a nervous patient regarding all the diseases his far-away ancestors have suffered and neglect to inquire as to the rectum.

Always have a rubber catheter at hand. You never know when you will need one urgently.

Sig. Teaspoonful every three hours.

Insufficient sleep endangers health.

HEMATURIA

BY CHARLES J. Drueck, M.D.

Hematuria, (the presence of blood corpuscles in the urine) is always pathological and appears in a number of different conditions. The blood may come from any part of the urinary tract and, while the determination of its source is sometimes easy, at other times it is difficult if not impossible. Frequently the physician is pinned down by the patient or his friends for a definite diagnosis and where this differs from what has been previously offered by some other medical man it disturbs the confidence of the patient. An example of this I shall cite later of a child who had hematuria for about a year and which had been said to be due to kidney disease. When I diagnosed cancer of the kidney the family were very skeptical and it was only after the mother felt the tumor that she believed in my judgment.

The character of the blood in the urine and its time of appearance, whether clotted or diffused, profuse or scant and its relation to the act of urination differs and indicates somewhat the part of the urinary tract involved. The chemical reaction of the urine also affects the color (acid urine is dark red while alkaline urine containing the same amount of blood will be bright in color). Of course if the amount of blood is small it may not materially influence the color of the urine. The albumen test will, however, show even very small traces of blood.

Guyon (White and Martin) divides the causes of hematuria into trauma, congestion, inflammation, organic disease and foreign bodies. Sometimes the pathology seems hardly sufficient to create the disturbance in the case at hand. The amount of blood in the urine is variable. If slight it may not show. microscopically but if profuse the urine appears bloody. The microscope is always necessary to verify the clinical picture. If the urine contains pus as well as blood the blood will be found in the sediment leaving the liquid part of the urine uncolored.

The more dilute the urine is the less rapidly will the blood clot, but the more rapidly will it diffuse and dissolve. Blood clots in the urine have little diagnostic significance except the long, thin, cylindrical. These resemble earth worms in appearance and are formed in the

It has been said that renal hemorrhage is more protracted than the bleeding of the bladder or urethra, but that is uncertain. In all diseases of the urinary tract the periods of bleeding are more frequent and intense as the disease advances.

(a) Chronic diffuse inflammation of the kidney has no hemorrhage.

(b) In the following conditions the hemorrhage is slight and subsides as the other symptoms are relieved; acute parenchymatous nephritis (this is frequently the result or accompaniment of variola or scarlet fever); amyloid degeneration, abscess embolism, hydatids and purpura hemorrhagica and phlebitis (uterine or crural).

(c) In this group the hemorrhage is profuse and obstinate; cystic disease of the kidney, chronic interstitial nephritis (here the hemorrhage frequently alternates with hemorrhage from mucous membranes); malignant disease (hemorrhage here is brought on by slight or undiscernable cause; it is made worse by exercise but is not much relieved by rest). Guyon says that the hemorrhage of kidney tumor is intermittent. It will stop and then suddenly reappear, the variations occurring frequently. Sometimes the ureter is blocked with a clot and the urine is clear for a few hours, then the clot is suddenly released and the hematuria appears. The presence of renal casts shows positively that the blood is from the kidney. Tuberculosis of the kidney shows an intermittent hematuria which is brought on by exertion but the urine contains pus and debris which remain in solution and do not tend to settle out. Pain is also present but is variable, sometimes however amounting to a true renal colic. The hematuria of renal calculus is excited by the slightest muscular strain or violence, such as under normal conditions would not cause any disturbance.

The bleeding is promptly relieved by rest in bed. There is always more or less pain and renal colic which is reflected from the lumbar region in various directions. The pain of renal colic is quickly relieved by rest in bed but not the pain of tuberculosis or tumor.

(d) Drugs may also cause hematuria, as turpentine, carbolic acid, cantharides and mercury. It must also be remembered that senna and rhubarb cause the same reddish-brown color of the urine simulating hemorrhage.

(e) Trauma: In severe injuries and malignant disease the blood may be bright red and the hematuria may appear to be terminal. In trauma the location and character of the injury will determine somewhat the source of the blood, i.e. a kick in the back followed by hematuria would suggest a contused or lacerated kidney, while a blow on the abdomen, and particularly in the hypogastric region, would indicate a ruptured bladder.

A heavy dragging sensation due to the renal congestion sometimes precedes hemorrhage from these parts or an attack of renal colic may appear. These pains do not occur with hemorrhage from the bladder or urethra.

BLADDER

Associated with bladder lesions that cause hemorrhage we usually find cystitis and alkaline urine, and if so the muco-pus and phosphates so cloud the urine as to alter its appearance and prevent the easy detection of blood. When the urine is ammoniacal the hemaglobin is frequently dissolved out of the corpuscles and the cells are then called blood shadows. These are sometimes confusing when found in the urine. They appear as small bodies or rings the size of red cells and have no nucleus. (a) The hematuria of vesical calculus is terminal and the blood is fresh. The hemor

rhage is moderate unless prostatic disease complicates. (b) Prostato-cystitis and (c) vesical tuberculosis also have slight nominal hematuria and in this symptom closely resemble stone. (d) Polypi of the bladder and (e) fibrous tumors usually show slight or moderate hemorrhage but (f) villous growths bleed profusely and the blood forms a reddishbrown sediment. A vesical tumor so long as it is not near the bladder neck may not show any other symptom except hemorrhage and is not palpable in its early stage and thus the hemorrhage is frequently considered renal.

Of course if the colic or some other localizing symptom appears that will determine the source of the bleeding. (g) Varicose veins of the neck of the bladder sometimes rupture and cause quite a sharp free hemorrhage.

A cystoscopic examination must be made in all doubtful cases of hematuria. When the hemorrhage comes from the bladder we have besides the visible blood, frequent micturition and pain in all inflammatory, obstructive or traumatic cases. A bimanual examination will frequently detect changes in the bladder wall or prostate or the presence of a tumor. Vesical tumors ultimately necessitate catheterization and then cystitis is soon added to the clinical picture. When the blood is diffused throughout the urine and the last urine contains a quantity of pure bright blood it is probably vesical or prostatic bleeding.

URETHRA

Hemorrhage from the urethra usually precedes the flow of urine and also recurs between the acts of urination, but if it does not it may be squeezed out by stroking the urethra.

(a) Acute gonorrhea, a mild hemorrhage may occur in any case.

(b) Acute posterior urethritis presents only terminal hematuria.

(c) Chancre within the urethra sometimes causes hemorrhage that may be obstinate and

recurrent.

(d) Neoplasms and injuries to the urethra sometimes cause a hemorrhage that may be alarming.

In any case of hematuria the signs and symptoms other than those of the urine itself must be considered, because the trouble may be outside of the urinary system. Blood appearing at the beginning of urination (initial hematuria) the later urine being clear must come from the urethra. If the bleeding is from the prostatic urethra, it may flow into the bladder and in this condition the last urine is often almost pure blood (terminal hematuria).

TREATMENT

The great variety of causes of hematuria divide themselves into those that must be treated therapeutically and those that can be arrested mechanically. During the bleeding, rest in bed, liquid diet of buttermilk and

diluted drinks to lessen the tendency to coagulation and a soft free stool. Drugs by mouth are of doubtful value. Guyon gives turpentine three drops every four hours for 6 or 8 doses. Ergot in full doses is also recommended; oil of erigeron and gallic acid have also been used. Any of these may be of value in moderate and persistent hemorrhage. In sudden profuse bleeding that threatens to exsanguinate the patient a full dose of morphine to quiet the restlessness and anxiety. Next empty the bladder with a catheter or suction pump as needed and then irrigate with hot antiseptic solution of silver nitrate 1:2000 or hydrastis one ounce to the pint. After this the catheter should be held in the bladder until the bleeding ceases.

If this does not control the bleeding a perineal cystotomy should be performed. All clots removed and a drainage tube inserted. This must be done under the most rigid asepsis because the bladder is very liable to infection after the hemorrhage and particularly so in cases of tuberculosis or neoplasms. Prostatic hemorrhage is often relieved by opium suppositories in the rectum and by suprapubic compresses.

I wish to cite a couple of cases that may be of interest at this time.

CASE 1.-C. H. a boy 12 years old. Four years previously he was vaccinated and from that his parents date his trouble. About two years afterward he suffered a hematuria of slight amounts every couple of days for about a month. During this time, the parents say he appeared otherwise healthy. For the next year he had occasional hematuria but most of the time the urine was normal. There is no record of the urine at this time except the parents' statement. For about a year now blood has appeared constantly in the urine and has increased in amount until recently it was nearly always present and in large amounts. The urine at best is heavy and smoky brown in color (at times it seems to be largely blood). As his mother says "It is pure blood that runs from him." During the first year of this boy's illness no positive diagnosis could be made. About six months ago a tumor of the right kidney became palpable and continued to enlarge until it nearly filled the right side of the abdomen. The boy suffered very little pain, only a dragging sensation in the region of the kidney but grew waxy and anemic. The features were dis

torted by the anasarca. The boy cut his hand while playing with a knife and although the cut was one and one-half inches long and one-half inch deep it bled no more than a scratch. After his death we did a partial post and found the right kidney about the size of a cocoanut and somewhat the same shape. It was soft and boggy, quite friable and easily crumbled under the fingers. The pelvis of the kidney was filled with a granulating mass but there was no blood or blood clots. I was surprised at not finding clots or free blood in the pelvis of the kidney and very little on section of the growth. The liver was small and did not present any apparent secondary growths. All of the abdominal organs were very pale. Death was really due to exsanguination. No post was made of the chest as the parents objected. I was not permitted to take out the tumor but section of a small piece showed it to be a sarcoma.

During the time this boy was under my care I went through the whole list of drugs supposed to be good for hematuria but none had any effect on him.

CASE 2. Mrs. A had been a nurse. Following the birth of a baby she was troubled with paresis of the neck of the bladder which persisted after she was up and about. She insisted on catheterising herself. Later she developed a sharp cystitis with stone formation. Every couple of days she voided bits of calcium phosphate and as these pieces broke away there was considerable free hemorrhage. Sometimes this hematuria would accompany only one urination and again be quite free. In this way it was intermittent but persistent and blood corpuscles could be found in the urine at all times. Of course it had a gradually exsanguinating effect.

I made a vesico-vaginal opening and found the mucous membrane sheeted over with this stone deposit beneath which the surface was ulcerated and granulating. Under local treatment and drainage she soon recovered.

CASE 3.-About three years previously I had operated upon this man 37 years old for hemorrhoids. They were internal and so extensive that I removed considerable mucous membrane. The result was very satisfactory as far as the operation was concerned and the man has had no other rectal inconvenience since. When the bowels moved first after the operation (on the fourth day) he had quite a terminal hematuria and ever since then when