globin. If bloody urine stands for some time, the four bands. of methemoglobin are discovered (v. Jaksch).

Heller's Test.-Add potassium hydrate to the urine, and boil a red precipitate of earthy phosphates and hematin forms. Throw the precipitate upon a filter and treat with acetic acid: a red solution is produced, which soon fades.

Rosenthal's Test.-Take the precipitate from caustic potash, dry it, and test it for hematin; put some of the dry sediment on a slide, add a crystal of common salt, apply a cover-glass, and cause a few drops of glacial acetic acid to flow under the glass; warm, but do not boil. Teichmann's crystals will appear on cooling.

Struve's Test.-Test the urine with hydrate of potassium, and add acetic acid in excess: a dark precipitate forms, which will yield crystals of hematin when treated with sal ammoniac and glacial acetic acid.

Almen's Test.-Take 10 c.c. of urine, and pour upon its surface a mixture of equal parts of tincture of guaiac and old oil of turpentine: at the point of junction of this fluid with the urine there forms a white ring which turns blue.

Microscope Test.-The microscope shows numerous corpuscles except in a very alkaline urine, when but few corpuscles may be found.

In hemoglobinuria-a condition sometimes occurring in burns, acute maladies, and metallic poisoning-there is present blood-coloring matter, which is shown by Heller's test and by Almen's test. The spectroscope shows methemoglobin. The microscope shows no corpuscles or only a few, but discloses masses of pigment.

Bleeding from the Kidney-substance.-Bleeding from the pelvis of the kidney and from the ureter may be due to inflammation, congestion, contusion, stone, vicarious menstruation, hemorrhagic diathesis, powerful diuretics, fevers, purpura, tumors, catheterization of the bladder, etc. Blood is thoroughly mixed with the urine, and no sediment forms (smoky urine). The corpuscles are profoundly altered, are devoid of coloring-matter, and show pale-yellow rings. The severity of the hemorrhage is measured by the number of the corpuscles. Von Jaksch states that the diagnosis between renal and ureteral hemorrhage rests on the nature of the casts and the epithelium present. From the pelvis of the kidney and from the ureter come small epithelium, the cells from the superficial layers being polygonal or elliptical, those from the deeper layers being oval or irregular. In hemorrhage from the ureter the cells are few; in

hemorrhage from the pelvis they are plentiful and rest upon one another like "tiles on a roof" (v. Jaksch). Cells from the tubules of the kidney are small, granular, and polyhedral, have large nuclei, and are often so arranged as to form cylinders (epithelial casts). The urine of renal hemorrhage is apt to be acid unless alkalies have been administered, unless the bleeding has been severe, or unless pus is present in the urine. A very large renal hemorrhage may cause the passage of almost pure blood. In renal hematuria there are aching in the loin, numbness of the corresponding leg, and often renal colic. The use of the cystoscope enables the surgeon to determine if the hemorrhage is vesical or renal, and if it comes from one or both kidneys. If the bladderfluid is kept clear, the blood can be seen flowing out of the ureter of the damaged organ.

Catheterization of the ureters may give valuable information. Kelly performs this operation in women with the

greatest ease. Aseptic precautions are observed. A speculum is inserted, the orifice of the ureter is cleansed with a bit of cotton, and the catheter is inserted, and the urine is collected in a sterile test-tube. Kelly's catheter is of flexible silk, 30 cm. in length, 2 mm. in diameter, with a blunt coni

cal end and an oval eye. The catheter is pushed into the ureter 12 or 15 mm. The rate of flow in a given time proves the competence of the kidney. The male ureter can be catheterized by means of the instrument of Nitze (Fig. 283).

Kelly has recently catheterized the ureter in a man by inserting a straight speculum, placing the patient in the kneechest position to inflate the bladder with air, and introducing a metallic catheter.

Vesical hemorrhage, including hemorrhage from the prostate, may follow the relief of retention of urine, may be due to stone, inflammation, tumor, etc., or may arise from traumatisms, instrumental or otherwise. The color of the urine is usually bright red, but if long retained in the bladder it becomes black and often tarry. The reaction is alkaline. The clots, when floated out, are large and without definite shape. In micturition the urine is clear or only a little colored at the beginning, but becomes darker and darker as micturition ends, at which time the flow may consist of almost pure blood. In very small vesical hemorrhages the urine may be smoky. Crystals of triple phosphate indicate bladder disorder. The microscope shows colorless and swollen corpuscles and many polygonal cells. Symptoms of bladder mischief usually exist, but cystoscopic examinations or exploratory suprapubic cystotomy may be demanded for the diagnosis.

Urethral Hemorrhage.-In urethral bleeding blood comes independently of micturition, or blood comes out first and is followed by clear urine. Urethral hemorrhage arises from an acute urethritis, from an inflamed stricture, from the passage of an instrument, or from some other traumatism. The source of urethral hemorrhage can be ascertained by the use of the endoscope.

Pain in Genito-urinary Diseases.-Pain as a symptom of genito-urinary disease may be found at some point distant from the seat of lesion. A stone in the bladder causes pain in the head of the penis just back of the meatus; stone in the kidney induces pain in the loin, the groin, the thigh, and the testicle; inflammation of the testicle causes pain in the line of the cord in the groin. In other cases of genito-urinary disease pain is felt at the seat of lesion, as in urethritis and prostatitis. Pain felt before micturition, and being relieved by the act, is found in cystitis and in retention of urine. Pain is felt during micturition in inflammation of the bladder, prostate, and urethra, and in the passage of

gravel or stone. Pain which is acute at the end of micturition is noted in stone in the bladder, in inflammation of the neck of the bladder, and in inflammation of the prostate gland. The pain of stone in the bladder, it may be observed, is ameliorated by rest and is aggravated by exercise. The pain of acute prostatitis is intensified by defecation. Frequency of Micturition. - Frequent micturition arises from irritation of the sensory nerves, from phimosis, contracted meatus, inflammations, very acid urine, calculi, urethral stricture, and hyperesthesia of the urethra. Frequency of micturition may be due to spinal irritability from concussion or from sexual excess, from contraction of the bladder rendering the viscus unable to hold much, from worry, anxiety, fear, or from excessive urinary secretion, as in diabetes or in the first stage of contracted kidney. Frequent micturition exists in obstruction by enlarged prostate and in atony of the bladder-walls. Hypersecretion of urine plus bladder intolerance is known as "nervousness," and is found in hysteria. Frequency of micturition increased by movement is observed in stone and tumor of the bladder; increased by rest, is found in enlarged prostate and atony of the muscular walls of the viscus. Frequency of micturition with diminution of stream-caliber suggests a constriction of the urethral diameter; frequency of micturition with diminished force suggests a posterior stricture, enlarged prostate, or bladder atony. Slowness of micturition hints at enlarged prostate, atony, or urethral stricture.

Thompson's diagnostic questions are as follows:

"1. Have you any, and, if so, what, frequency in passing water? Is frequency more manifest during the night or the day? Is frequency more manifest during motion or rest? Does any other circumstance affect it?

"2. Is there pain on passing urine, and, if so, is it before, during, or after the act? What is its character-acute, smarting, dull, transitory, or continuous? What is its seat? Is it felt at other times, and is it produced or intensified by sudden movements?

"3. What is the character of the stream? Is it small or large; twisted or irregular; strong or weak; continuous, remitting, or intermitting? Does it come by the meatus, or partly or entirely through fistula?

"4. Is the character of the urine altered? What is its appearance, color, odor, reaction, and specific gravity? Is it clear or turbid, and, if turbid, is it so at the time of passing? Does it vary in quantity? Are the normal constitu

ents increased or diminished? Does it contain abnormal elements, as albumin or sugar? What inorganic deposits are found? What organic materials are met with?

"5. Has the urine ever contained blood? If so, was the color brown or bright red; were the blood and urine thoroughly mixed; was the blood passed at the end or at the beginning of micturition, or did it come only with the last drops of urine; or was it passed independently of micturition?

"6. Inquire as to pain in the back, loins, and hips, permanent or transitory, and for the occurrence of severe paroxysms of pain in these regions."

DISEASES AND INJURIES OF THE KIDNEY AND URETER.

Tumors of the Kidney.-Tumors, innocent or malignant, may arise in the kidney. Among the innocent tumors are fibroma, lipoma, angeioma, and adenoma. A malignant tumor may be either sarcoma or carcinoma. Sarcoma is most common in the young, and may reach an enormous size. A malignant tumor of the kidney produces hematuria, the urine often containing blood-casts of the ureter, kidney, and pelvis (Osler), and sometimes, though rarely, characteristic cells. Pain is often present in the loin and thigh, and there may be colic-like attacks when clots are passing through the ureter. Emaciation is rapid and pronounced. A tumor can usually be detected. The only possible treatment is early nephrectomy. In some few cases an innocent tumor can be removed by a partial nephrectomy. A malignant tumor requires a complete nephrectomy. In making a diagnosis of renal tumor use the cystoscope. If blood is coming from a ureter, note if it is from only one or from both. Blood from both would contraindicate nephrectomy. Before removing a kidney it is well to be sure that the patient is possessed of two kidneys. Note if urine flows from each ureter, or, if uncertain, catheterize the ureters or have a specialist do it.

Mobile Kidney.-There are two forms of this condition: (1) movable kidney, which is an organ freely moving back of the peritoneum, either within the cavity of its fibrofatty capsule or entirely without its capsule (this condition is acquired); and (2) floating or wandering kidney, an organ having a mesonephron and lying within the peritoneal cavity (this rare condition is always congenital). Keen states that there may be drawn a clear theoretical distinction