especially when combined with inflammation of the ureter. Benign and malignant growths in a kidney may show bleeding at the corresponding orifice, but no enlargement or other change of the orifice itself. The segregator, with the clinical history, is usually sufficient to establish the presence of tumors of the kidney.

The cystoscope, segregator, or ureteral catheter, or all of them, may be needed to differentiate right kidney disease from gall-stones, appendicitis, or ovarian pain. In rare instances these means have to be employed to distinguish left kidney disease from lesions of the spleen. When, on account of thickening, misplacement, or new growths in the vicinity, the orifice cannot be found, coloring the urine with methylene blue will generally discover its position. Absence of blue may signify a total occlusion of the ureter, a destroyed kidney, or a more or less permanent loss of function, due to nervous interruption. The amount and character of the flow of urine will also afford some information, as determined by the cystoscope. A weak trickling fluid indicates an enfeebled kidney function, or a partial obstruction of the ureter. A strong spurting flow, an over-active kidney, and increased peristalsis of the ureter. A bloody flux shows chronic interstitial nephritis, stone, tuberculosis, or new growths; the slight tinging favors nephritis, quiet stone, or early tuberculosis. Clear blood, with clotting, is quite significant of malignant disease. A purulent flow, without blood (microscopically determined) indicates a pyelitis or pyonephrosis, and practically excludes stone, malignant disease and tuberculosis.

The Segregator.-The principle involved in this instrument is the division of the bladder by a lever into lateral pockets from which the urine is drained as it comes from each ureter. There are two ways for accomplishing this: one by an internal lever which depresses the lower bladder wall-the Luys segregator represents this type; in the other form, the Harris, the bladder is divided by an external lever which elevates the middle line of the bladder, and so forms the pockets into which the perforated ends of the two catheters dip. This is the Harris intrument. I have never used the Luys separator, but should say that on all theoretical grounds, the Harris instrument is incomparably better, and that cer

tainly it works well practically. The segregator, however, cannot be used when internal or external tumors, a very large prostate, or inflammatory contractions distort the bladder. Its use is unsatisfactory when an easily bleeding ulcer or growth occupies the site of a ureteral orifice. In women a retroflexed uterus will generally so lower the posterior part of the bladder that the urine will collect behind the pockets instead of draining through the catheters.

The urine drawn by the segregator occasionally contains albumin, but no red-blood cells, while that obtained just before by the catheter from the bladder is entirely free. For a long time I was unable to account for this, but am now convinced that it is due to the presence of blood serum exuded on account of the slight traumatism of the bladder by the segregator. This I demonstrated in the following way in a patient whose bladder urine by the catheter contained no albumin, but did contain albumin by segregator: I obtained the urine by the cystoscope direct, and this was free of albumin. I have repeated the experiment with like results. Rough manipulation of the kidney between the catheterization of the bladder and use of the segregator will sometimes bring about the same confusing condition. The presence of albumin in urine obtained by the segregator from both kidneys may be disregarded if the urine obtained just previously by catheter contains none.

If the urine from the bladder contains albu

min, and the segregator shows albumin from one side only, that side will show twice as much albumin as the bladder urine. If, however, the bladder urine contains albumin, and both sides show albumin by the segregator, but one much more than the other, it is quite possible that the side containing the larger amount is the only diseased side. In this case the cystoscope should be used as a segregator, if possible, to confirm the finding, as the urine obtained by the cystoscope does not provoke the exudation of albumin like the segregator.

The segregator, under proper conditions, has the advantage over the cystoscope, used as a segregator, of being less painful and much less tiresome to the patient.

The ureteral catheter is a dangerous instrument. The necessity for its use is much more

the

limited than has been considered essential, and should, for diagnostic purposes, be used only to prove ureteral stricture, to separate the urine, and to demonstrate stone when other means have failed. It often happens that it cannot be used when most needed. In separating the urine the catheter is needed only under conditions which usually prohibit the use of the segregator or the cystoscope used as a segregator, i. e., when there is great distortion of the bladder, a condition which renders the finding of the ureteral orifices difficult or impossible-the very condition, also, under which the catheter cannot be used. I would admit one exception to this rule: when a tubercular ulcer surrounds orifice whose corresponding kidney is under investigation, and the other proved to be diseased. In this case we may have to resort to the catheter, but it need not, and should not, be introduced more than three-fourths of an inch. The wax-tipped catheter or bougie of Kelly, while extremely ingenious, is very rarely a necessity for the location of stone, the history and physical signs, with the segregator, and perhaps the x-ray, usually sufficing. The best ureteral catheter will injure the ureter, and urine taken with it always contains blood. Its use is permissible when it is necessary to locate an obstruction in the ureter, and in the male when the orifice can be found, but the bladder is too distorted to use the segregator. It can be used in differentiating a kidney cyst from hydronephrosis, but this is possible only when a catheter can be made to pass the obstruction, and is usually unnecessary. Of course, if the surgeon does not have a cystoscope that can be used as a segregator, or if for any reason the patient cannot assume the kneechest position, he may be compelled to use the ureteral catheter when he would not under more favorable conditions.

The records of a few cases briefly stated will ilustrate the application of these helps to diagnosis and also show some of the difficulties and disappointments attending their use.

Segregator: Right kidney, pus present, blood few cells; left kidney normal.

Cystoscopy: Bladder surface normal except trigone reddened. kight orifice congested and pouting; left orifice normal.

Ureteral catheter: Result same as segregator, except blood from both.

right kidney,

Diagnosis: Left kidney normal; large immovable stone, with pyelitis. Confirmed by operation: Large stone weighing two ounces and branched into calices.

In these cases the ureteral catheter afforded no additial information, and should not have been used.

CASE 3. Miss F. Painful and frequent urination for three years. Urine never bloody.

Palpatation: Left kidney large and tender.
Urinalysis: Albumin present; urine acid.
Microscopy: Blood and pus; no T. B.
Guinea pig: Negative.

Segregater: Right kidney normal; left kidney, pus present; some blood.

Ureteral catheter: Same result.

Cystoscopy: Punctate ulcers about both orifices, and large ulcer near right orifice. A year later cystoscope showed large ulcer healed, but a smaller one surrounded the left.

Nephrotomy with fistula resulting. Later nephrectomy-microscopic section showing positive old tubercular process. Some thirty examinations were made in the case for T. B., and also one guinea-pig inoculation, but T. B. were never found. This case shows the difficulty of finding T. B. in some cases and also that tubercular ulcers near the orifice of a uterer may heal during a tubercular process in the corresponding kidney, and that a tubercular ulcer around an ureteral orifice does not necessarily indicate a tubercular disease of that kidney.

This also is one of the cases in which it is proper to use the catheter, because the segregator is very likely to give false evidence in this case, as there was, at one time, an ulcer surrounding the healthy orifice. In such a case the segregator should be very likely to show blood, T. B., and perhaps pus, even if the corresponding kidney was healthy.

CASE 4. Miss H. Frequent urination; blood and pus in urine; T. B. numerous; duration of symptoms only five weeks.

Cystoscony: Slight redness about orifices; more marked in right. Flow apparently normal.

Segregator: Both kidneys blood; the right T. B.; left negative.

Being still in doubt I introduced the catheter in left orifice. Result negative as to T. B. This catheterization brought on a pyelitis, and suggested to the use of the cystoscope as a segregator.

me

Diagnosis: Right tubercular kidney; probably healthy left kidney.

Operation: Right nephrectomy. Broken down tubercular focus in right kidney: advanced tubercular disease of right ureter.

Subsequent history: General health good; urine normal as to T. B.

The use of the cystoscope in this case, instead of the catheter or segregator, would have given me surer evidence, and I should not have endangered the life of my patient by bringing on a pyelitis with the cathe

ter.

This case also illustrates the fact that extensive tubercular disease of the kidney and ureter may exist without any widening or thickening of the corresponding ureteral orifice.

CASE 5. Mrs. C. Crisis of loin pain every month or two. No other symptoms.

Palpation: Right kidney slightly tender. Urinalysis: Sp. gr. 1,000 to 1,004; blood, few cells; pus 3 to 4 field, albumin present.

Cystoscopy: No enlargement or pouting of either orifice; both orifices appeared to be alike and normal.

Segregator: Right, 2 cc; left, 6 cc. Albumin twice that of bladder urine. Pus, 3 to 4 field. Blood, very few cells.

Skiagraph by Dr. C. D. Harrington gave a very good shadow in right kidney pelvis.

Diagnosis: Immovable stone in right kidney pelvis confirmed by operation.

CASE 6. Mrs. P. Frequent swelling and pain in left lumbar region, frequent urination, no bladder pain. Generally followed by large flow of urine. Attacks always immediately subsided with subsidence of swelling on administration of morphine or chloroform.

Palpation during attack: large tense tumor in left loin, dull, fluctuation not evident. During interval both kidneys movable; neither enlarged.

Cystoscopy: Bladder and orifices normal. Segregator: During attack, right, 20cc. in twenty minutes; left, none.

Ureteral catheter: During attack right passes three inches deeper than left. Urine passes freely from

right; none from left.

Diagnosis: Hydronephrosis from kink in left ureter. Confirmed by operation. Nephrotomy and dividing the adhesions kinking the ureter. No recurrence after five years.

This is a case in which close diagnosis could not be made without the ureteral catheter.

Incidentally, I may mention that the catheter was of great assistance in locating the exact point of bending in the ureter at the time of operation.

CASE 7. Mrs. T., Aged 45. Indefinite history of bladder trouble for three years. Frequent urination. Pain in left pelvis and loin constant, with exacerbations. Palpation: Right kidney normal. Left kidney normal in size, and slightly tender.

Urinalysis: Albumin and a few pus cells; no T. B. Cystoscopy: Right orifice small and puckered. Diagnosis: Obsolete pyelitis and ureteritis, with stricture of ureter 4 inch above orifice. Operation, gradual dilatation of stricture with complete relief.

This case illustrates one of the proper uses of the ureteral catheter, as also the following one.

CASE 8. Mrs. D. Weak, nervous; has lost flesh; no particular pain. Both kidneys normal in size; not tender; very movable.

Urinalysis: Urine normal, only 14 ounces daily; sp.

Result, as shown by the segregator three weeks after operation about 14 cc. in 20 minutes from each kidney.

CASE 9. Miss F. General health considered fair; no symptoms until three days before operation; then pain and swelling in left groin with temperature 103° F.

Palpation: Tumor 6x4 inches deep in left pelvis. Right kidney very movable; left could not be found. Urine: Normal.

Cystoscope: Could not be used on account of the distortion of the bladder by tumor; hence, also, neither catheter nor segregator could be used.

Diagnosis: Probable suppurating intraligamentous ovarian cyst.

Segregator: Right, 30 cc. urine in 20 minutes, no albumin or pus; left, 5 cc. urine in 20 minutes, albumin and a few pus cells.

Ureteral catheter: Right passed to kidney easily; left tightly gripped by ureter 34 inch above the orifice.

Operation revealed suppurating congenitally misplaced kidney, with recent obliteration of ureter.

This case is one of those in which neither the cystoscope, catheter nor segregator can be used on account of the distortion of the bladder by a tumor.

CASE 10. A case illustrating the source of error in the use of the segregator in retroflexion of the

uterus.

Mrs. C. Uterus retroflexed. Segregation attempted. Flow delayed; then came in streams, sometimes from one and then from both sides of segregator. Uterus replaced, and Albert Smith pessary inserted. Segregation again attempted, and again a failure, because sides of pessary held up the bladder wall so that the segregator could not form the pockets.

Separation finally accomplished by removing sary and using the cystoscope as a separator.

pes

CASE II. Mrs. R. Six years "drawing" pain in right loin, absent for a year at a time at first, lately more frequent, and now pretty constant. Frequent urination.

Urine: No albumin; no blood; pus averaged 17 cells to 4 inch field, unsedimented.

Cystoscopy: Orifices rather large, bladder normal. Segregator: Right kidney, no urine; left, 7 cc. in 15 minutes; no albumin; very few pus cells, and granular casts.

Ureteral catheter passed only 4 inch in right

ureter.

Diagnosis: Right, pyelitis and partial occlusion of ureter; left, normal, but not very active.

Operation: Nephrectomy, showing extensive perinephritis of right kidney, pyelitis and thickening of ureter with stricture. Microscopic section showed chronic interstitial nephritis.

This case, also, I believe to be a proper one for the use of the ureteral catheter. The greater amount of pus in the general urine, and the smaller amount obtained by segregator, was probably due to sudden emptying of a saccule of the ureter just above the

stricture.

DISCUSSION

DR. M. C. MILLET (Rochester): I have but little to add to Dr. Abbott's excellent paper. One point I wish to make, and that is the ease of examining the female bladder and the male with the same instrument.

For instance, if you use water dilatation to examine the male bladder and use the Kelly method to examine the female bladder, you have two pictures to keep in mind, while it is perfectly easy to examine, with the same instrument, the female and the male bladder with either the open instrument or the water dilation. The Kelly method is objectionable to me because of the pain. Every bladder is subjected to the pressure of the atmosphere, so it is hard to produce pressure without producing a corresponding amount of pain. For that reason I do not employ that method.

I am glad to hear Dr. Abbott recommend the

segregator. It has been a very useful instrument, and will continue to be in spite of the other instru

ment.

In regard to the use of catheterization, there are cases of hematuria accompanied by bladder trouble and those in which there is no bladder trouble, in which catherization is perfectly legitimate, provided you cannot secure results with the segregator. In cases of infection where it would be dangerous to use an instrument, one can certainly do no harm by catheterizing the one side, and it will prevent the infected urine from entering the bladder, and will get the urine from the other kidney.

The subject of urticaria is always an interesting one to the general practitioner, it being a troublesome skin disease to combat.

The smallest things in our work sometimes offer the greatest obstacles. Who is there among us who has not had this common question asked him? "Doctor, can you do anything for hives?" Urticaria is defined as an eruption consisting of rapidly formed evanescent wheals accompanied by burning and tingling. It is derived from the word urtica, meaning a nettle. It is a common disease, attacking forty-four per one thousand. There are four principal varieties, viz., u. acuta, u. chronica, u. papulosa, and u. pigmentosa; and there are several sub-varieties, the most important of which are u. tuberosa, u. bullosa, u. hemorrhagica, u. factitia, and circumscribed edema.

The mere nomenclature of these several varieties is a sufficient description in itself, so I shall not attempt further elaboration. The varieties and sub-varieties depend on the size, contents, and duration of the wheals.

SYMPTOMS. In an ordinary case the eruption comes out suddenly, either without any warning or preceded by burning and tingling in the skin. and sometimes by febrile symptoms. The lesion consists of firm, circumscribed, flatly convex elevations of the skin, from a quarter to an inch in diameter, the majority being about the size of the finger-nail. They are at first red, and as they develop they become white in the center,

"Read before the Upper Mississippi Medical Society, September, 7, 1905.

leaving a red border, or they may stop at the red stage.. Their formation and presence are attended with burning, tingling, and itching, sometimes slight, but usually so severe as to cause vigorous scratching. The temporary relief so afforded is liable to cause the formation of fresh wheals, which develop in a few minutes and last from an hour to a day or even several days, and then disappear without desquamation or other sign of their presence. The itching is usually more troublesome at night, for then the patient is not hindered by clothing, and can more easily reach the parts, with a consequent development of fresh wheals. In children this causes many a restless night, not only for themselves, but for the mother as well.

The eruption is never symmetrical, the wheals having no definite arrangement, and they vary in number from one or two, to sufficient to cover more or less completely the entire body including the mucous membranes of the mouth, tongue, pharynx, air passages, and stomach. Dyspnea and vomiting have sometimes been associated with the skin eruption. Temporary albuminuria has been noted, and occasionally cerebral symptoms.

In u. factitia, owing to the excessive irritability of the cutaneous nerves, wheals can be excited by local irritation. Letters can be written on the patient with the finger-nail or with a pointed instrument, and in a minute or two the white letters, with pink borders, stand out on the skin. This is called dermographism or autographism.

ETIOLOGY. Neither age nor sex brings immunity, but it is more common in the female and in infants and children than in adults, and more common in the summer months. Under the direct or local irritants come the stinging nettle, insect bites, such as fleas, bugs, mosquitoes, bees or wasps, etc., and violent scratching from any cause, electrical currents to the skin, poultices, and sudden changes of temperature. Indirect irritation acts chiefly through the alimentary canal, which may be healthy or unhealthy at the time. Other causes are as follows:

I.

Certain articles of food may excite it, such as shell fish, crabs, oysters, mussels, etc. Certain kinds of meat, especially pork and sausages. Fruit, such as strawberries and bananas; and nuts, such as almonds, etc. Mushrooms and branny food, such as porridge and oatmeal may excite it.

2. Medicines of many many kinds, especially cubebs, copaiba, quinine, mercury, morphia, turpentine, salicylic acid, valerian, chloral, etc. The hypodermic injection of diphtheritic antitoxin is sometimes followed by a violent urticaria, and certain odors may also excite it.

3. Worms are a common cause in children, but the main cause in them is chronic intestinal catarrh, commencing often in early infancy and persisting for years from want of treatment. The absorption of hydatid fluid may cause it. It has followed the tapping of a pleuritic effusion. In most of these causes there is a predisposing idiosyncrasy on the part of the patient. Gouty diathesis is a predisposing cause, probably from its association with acid dyspepsia; in fact dyspepsia, however induced, is one of the commonest factors. Disorders of the uterus and ovaries may cause it. Some women have urticaria just before each menstrual period, others have it at each pregnancy, and others have it during lactation. It is associated with many cases of asthma and gall-stone colic. It is also seen in certain diseases of the nervous system, such as neuralgia, locomotor ataxia, and emotional conditions.

PATHOLOGY.-Everything in urticaria points to its being primarily a vasomotor disturbance, direct or reflex, central or peripheral. The accepted theory is this: A spasmodic contraction is followed by a paralytic dilatation of the vessels, and stasis or retardation of the circula

tion in the papillary layer. Serous exudation then ensues, producing acute edema, which lifts up the epidermis into a wheal. This is pink at first, but as the fluid increases, the blood is pressed out at the center, which becomes white while the periphery is all the more hyperemic.

DIAGNOSIS. The sudden evolution and transatory duration of white or pink itching or tingling elevations, or wheals, are quite characteristic, and even when there is no eruption. when the patient is seen, an eruption which comes and goes at short intervals can scarcely be anything but urticaria.

PROGNOSIS.-Acute urticaria usually gets well in a few days, but some cases go on into the chronic form, if untreated. The prognosis of the chronic form depends largely on the possibility of removing or avoiding the cause.

TREATMENT.-An acute attack due to irritat

ing ingesta, if seen sufficiently early, is best treated by an emetic, and followed at a later period by saline aperients. These measures are usually sufficient, but where any gastric irritation remains, care must be taken lest it fall into the chronic form. Bland and unirritating articles of diet and an effervescing soda mixture would be the line of treatment to follow.

In the treatment of chronic urticaria the study of the etiology is of the greatest importance. This not only means the original cause, but also the exciting causes of fresh outbreaks. Careful inquiry should be made into the habits of the patient, and the conditions under which the eruption comes out. eruption comes out. The urine should be examined, and a routine examination of every organ and its functions may be required. In the larger percentage of cases it is the alimentary canal with which we have most to do. The diet should be carefully regulated. Fermentable articles, such as pastry, highly seasoned or sugared foods, and starchy foods should be restricted. Beer, etc., should be avoided, and alcohol should be very sparingly taken, if at all. All fruits, especially strawberries, should be avoided, except perhaps baked apples. Restrict nuts, fish, etc. A fair amount of meat may be allowed to those over two years of age. It is well to write out a diet list for the patient so as to insure the careful following out of your orders. The bowels must be carefully regulated,