arteriosclerosis, may be traced. Diseases of the nervous system are increasing at an alarming rate, hence information concerning hereditary tendencies toward the acquirement of nerve derangements are particularly significant in this connection when we remember how close a relationship exists between the condition of the nervous system and that of the urinary tract. Diseases of the former may give rise to functional diseased conditions of the kidney, the urethra, the bladder, the prostate, and the sexual apparatus. Certainly so far as the kidneys are concerned, and probably also to some extent with the other organs mentioned, nerve derangement may even be the direct cause of organic changes in them. Questions regarding a tendency toward early arteriosclerosis are of equal significance, certain American families displaying an astonishing leaning in succeeding generations to suffer from progressive changes in the arteries, such as cause apoplexy and various forms of paralysis. This is particularly noticeable among the wealthy, and seems to indicate that luxurious habits tend to produce early changes in the arterial system, whereas excessive nerve strain may give rise to some renal condition, such as interstitial nephritis, and thereby shorten the life of the individual.

Personal questions can not be gone into too exhaustively, and it is well to have some definite plan that will insure against any important symptom being overlooked. The practitioner must be prepared here to meet a certain amount of obtuseness, for even individuals apparently well equipped mentally sometimes show an inability to answer intelligently the simplest questions concerning their past or present symptoms. In these cases, where the patient is suffering from some obscure conditions, long and patient questioning may be necessary.

Interrogate first regarding the presence of headache in its various forms-frontal headache, for instance, if not due to a diseased condition of the air-passages, is often associated with kidney lesions. Next inquire into the condition of the hair, and the acuteness of sight, hearing, taste, and smell. Ascertain also the condition of the throat, and inquire as to pain in the chest and shoulders, pain in the back, shortness of breath, and palpitation of the heart. Questions concerning the condition of the stomach and the digestion in general may elicit valuable information. Con

cerning pain in the abdomen or back, mere local pain, such as the well-known kidney colic, the pain extending along the course of the ureter, is generally due to calculus. In addition to this typical renal colic, it should be remembered that other diseased conditions of the kidney give rise to pain, which may start in the region of that organ and follow the course of the ureter. Diseased conditions of the kidney may give rise to pain in the lower extremities, and very frequently in the lumbar region. The most common type is the ordinary backache; this latter, however, is not necessarily diagnostic of diseased kidneys, and is very likely to be confused with some diseased condition occurring in the sacro-iliac synchondrosis. Zuckerkandl believes that a continuous pain in the kidney which is increased by pressure and is accompanied by endocarditis or myocarditis, associated with the passage of bloody urine, would warrant the diagnosis of kidney infarct. Pain in the kidney is generally believed to be relieved by rest in a horizontal position, whereas standing or moving about is said to increase it. This, however, is true not only of kidney disorders, but is equally true of pain emanating from the kidney region due to disturbance of other organs or to certain forms of myalgia. Pain in the kidney is at times an indication of tuberculosis of the kidney, and when associated with blood in the urine is quite suggestive of this affection.

The condition of the bowel should be definitely ascertained— whether there is constipation, whether defecation is accompanied by pain in the prostatic region, whether a discharge from the urethra occurs during defecation, and whether there is pain in the

rectum.

Ascertain whether or not any present or past acute urethral discharge has been observed; whether pus is discharging from the urethra during the intervals of urination; whether a slight discharge appears with the first urine passed; whether there is a discharge of a thin, milky character following urination or defecation. A considerable amount of pus discharging between intervals of urination is generally due to acute urethritis. come from an abscess of the prostate or from an abscess of the perineal tissues. The same is true of any considerable amount of pus discharged at the beginning of urination. Discharges from

It may

the urethra following urination or defecation may be due to increased secretion from the urethral glands or to spermatorrhea, phosphaturia, or prostatorrhea. Shreds in the urine may be due to a previous urethritis. Discharges from the urethra may also be due to tuberculosis, and very rarely to a syphilitic involvement of the urethra, such as chancre. During pneumonia, rheumatic attacks, typhoid fever, or other infectious diseases pus may be excreted from the urethra. As in the case of hematuria associated with malaria, we are inclined to believe that this will appear only in urethras that have been damaged, perhaps years before, by some acute inflammatory condition, such as gonorrhea. Regarding tuberculosis as a cause of purulent urethral discharge, we hold a similar view as that expressed concerning malaria. It seems to be well established that an antecedent gonorrhea predisposes to a subsequent tubercular infection.

Next, all possible information concerning micturition should be elicited. The force of the stream; whether or not pain is present during or after urination; whether the stream is interrupted or suddenly checked, should all be inquired into, the answers to these questions bearing upon a diseased prostatic condition or stone in the bladder. Increased frequency of urination is a symptom in a large variety of conditions; it may point to diabetes, to increased ingestion of fluid, to polyuria (due to interstitial nephritis), to various forms of gravel, to disease in the upper urinary passages, to the influences of heat and cold, and to reflex irritation (in both. men and women) from diseases of the neighboring organs. In young men it generally indicates some disease of the urethra; in the elderly, as is well known, it points to diseases of the bladder or prostate.

A diminished amount of urinary excretion or diminution in the frequency of its elimination may be due to an unusually small ingestion of fluid or to excessive perspiration. The smallest amounts that we have observed passed by healthy subjects have occurred in cooks, stokers, and others whose occupation subjected them to prolonged exposure to heat, and who did not counterbalance the excessive perspiration by the ingestion of a proper amount of fluid. Zuckerkandl considers stricture and enlarged prostate as occasional causes of this condition; we believe that whereas

they may occasionally be a cause of infrequent urination, the converse is more often true. Tabes and other disturbances of the spinal cord are also causes. The habit of many, particularly of women employed in manufacturing establishments, of refraining, for as long a time as possible, from answering nature's demand for the performance of this physiologic function is a common cause of this condition. It is unfortunately too true that proper accommodations are not always afforded to the employed, and that a sense of delicacy often acts as a factor. Continued overdistention of the bladder may later lead to the development of cystitis, and this may explain the reason why women are more often affected with cystitis than are men.

Whether there has been a change in the caliber of the stream should be ascertained, although a correct conclusion can rarely be reached in this way. Change in caliber from the normal is ordinarily due to diseases of the urethra, such as stricture, which may lead to the ejection of a crooked or a forked stream. Diseases of the prostate, nervous system, or bladder-walls may give rise to a mere dribbling of urine. Here it may be well to mention that the careful anatomic investigations carried on by Ciechanowski on the amount of muscular tissue in the bladder-walls in healthy individuals show that in the aged there is a lessening in the amount of normal bladder muscle tissue; that in old men, as shown by accurate measurements, only about two-thirds of the amount of muscular tissue present in healthy adults exists. In children a long tight foreskin causes greater diminution in the caliber of the stream; in adults, increase in size of the meatus affects the caliber of the urinary stream. The force is also dependent, to a great extent, upon the condition of the nerves and muscles of the bladder and urethra, and upon the presence or absence of urethral obstruction. When the stream is suddenly completely checked, only to start again at full caliber, stone in the bladder is generally indicated. If prostatic obstruction exists, the stoppage is more gradual, ending in a sort of dribbling. Other bladder lesions besides stone may probably give rise to sudden stoppage of the flow. It has been observed in old men the trabeculæ of whose bladders were thickened and in whom repeated examinations failed to elicit the presence of stone.

The question as to whether or not pain accompanies urination may not furnish much information, owing to the marked differences regarding sensitiveness to pain that exists between various individuals. Those suffering from neurasthenia or hyperesthesia of the deep urethra may complain of painful micturition; whereas those suffering from marked organic disturbance in the urethral canal may not. Some writers believe that pain occurring at the beginning of urination indicates disease of the urethra and prostate, and that pain at the end indicates disease of the bladder. Pain in the bladder between the acts of urination may indicate stone, tumors, or pus-formation in the prostate. Concentrated urine and the passage of gravel, as is well known, will give rise to pain and disease of the bladder. Pain is most prolonged and marked in the bladder region in acute cystitis, which may be associated with tuberculosis or tumors, more especially those of a malignant type. Tumors of the prostate, particularly cancer, exhibit pain in the prostate as one of their most characteristic symptoms, but this does not necessarily give rise to painful micturition unless the disease has advanced beyond the prostatic capsule. Pain in the glans penis is often caused by stone in the bladder, and is less often associated with cystitis or gravel, which gives rise to painful urination. Marked neurasthenics are occasionally subject to spasmodic attacks of tenesmus, which occur in the day-time, never at night, last for an hour or two, and pass away. These attacks resemble those occurring from gravel. As a general rule, gradual recovery follows. The origin of these attacks is, at the present time, unknown.

An inquiry into urinary retention, partial or complete, may elicit valuable information. Complete retention is in most instances due either to stricture, more apt to occur in early life, or to an enlarged prostate, the latter being usually the case in the aged. Rupture of the urethra, coagulated blood in the bladder, and various forms of apoplexy and paralysis may cause retention. It also frequently follows a surgical operation for hemorrhoids, gynecologic operations, or excessive tamponade. A condition of chronic retention may be caused by overdistention of the bladder and by hypertrophied prostate.

Incontinence may be due to acute urethritis and to prostatic