a large amount of skin has been destroyed by burns, and the secretion and excretion of the skin is seriously interfered with, the kidneys are likely to become irritated, and the urine to become albuminous. Any serious skin disease that attacks a large portion of the surface of the body, preventing its normal activity, may also cause kidney disturbance. The obverse of this is also true, namely, in chronic nephritis the skin is called upon to do extra work, and it, sooner or later, becomes dry, irritated, and perhaps eczematous. When this condition of the skin develops the prognosis of the kidney disturbance is grave. Acute inflammations that attack large surfaces of the body, as scarlet fever, erysipelas and small-pox, also tend to cause kidney irritation, congestion, and perhaps inflammation.

In any of these conditions named treatment aimed at a modification of the urinary secretion is advisable. If the urine is concentrated and diminished in amount, plenty of water should be ingested, with perhaps some non-irritating drug that would increase the output of the urine. Often, however, the kidneys should be relieved by causing the skin to become more active, by hot baths and hot drinks, or by other methods that cause perspiration.

If albumin is found in the urine, the diet should be non-irritating and bland; often meat, tea, coffee, spices and condiments should be withheld, and no drugs should be allowed that could irritate the kidneys. If congestion of the kidneys has occurred, the treatment should be such as would prevent acute nephritis, if possible, and it may be inadvisable to push the ingestion of water. This, however, is determined by the cause of the kidney irritation. In general infection it may be well to give extra amounts of water, even at times by high enemas.

Local congestion of the kidneys may be relieved by heat, applied as in body baking or by electric light baths, or by moist hot applications to the lumbar region. This is not with the object of causing elimination of toxins in uremic conditions, but with the object of relieving the congestion in the kidneys by dilating the systemic blood-vessels, especially the surface vessels. It should be emphasized that if there are edemas, either from kidney insufficiency or from cardiac insufficiency,

the ingestion of water should not be pushed, in fact it may be well to diminish the intake of water.

There is probably no such thing as a "sedative" diuretic; hence if the kidneys are inflamed, everything should be taken out of the diet and every drug omitted that carries or produces salts difficult for inflamed kidneys to excrete. In other words, so-called diuretic drugs should never be administered in acute and rarely in chronic nephritis.

The amount of urine is increased by buchu, which is a mild stimulant to the kidney epithelium; by caffeine, which raises the blood-pressure, stimulates the heart, and is also a mild stimulant to the kidney epithelium; by digitalis, which strengthens the heart and raises the blood-pressure; by scoparius, which stimulates the epithelium of the kidneys; by squill, which may raise the blood-pressure, and stimulates the kidney epithelium; by theobromine sodio-salicylate (diuretin) which slightly raises the blood-pressure and is a stimulant to the kidney epithelium.

DRUGS USED TO RENDER THE URINE ALKALINE

If the urine is very acid and irritates the bladder and urethra, as evidenced by an increased desire to urinate, with more or less pain, all food that increases the acidity of the urine should be withheld, a diet of milk and cereals given, plenty of water should be drunk, and no mineral acids should be taken. With this increased acidity of the urine there may be lumbar backache joint pains, and other signs of disturbances from uric acid.

In this condition potassium or sodium citrate, given in doses of 2 grams, three times a day, directly after meals, combined with a modified diet, is effective treatment. The old "A. B. C." mixture, i.e., potassium acetate, potassium bicarbonate and potassium citrate, is a heritage used in the treatment of gonorrhea that may be buried without causing privation. The acetate and the bicarbonate are more disagreeable and no more efficient than the more pleasant citrate of potassium.

If there is acute bladder or urethral inflammation, the potassium or sodium citrate should be pushed to the point of rendering the urine alkaline, ever though it is necessary to give a 2-gram dose four or five times a day to accomplish this purpose.

The urine, however, should not be allowed to be too long alkaline, as an alkaline urine tends, sooner or later, to irritate the mucous membrane of the bladder and cause more secretion of mucus,with a tendency to alkaline deposits, and later, perhaps, ammoniacal fermentation and actual infection. Alkalies too long continued also debilitate the system rather than strengthen it, as they promote destructive metabolism. Consequently, alkalies are not tonics to weak, convalescent and neurasthenic patients. On the other hand, nervous patients are many times quieted with calcium salts, which, however, would rarely alkalize the urine.

Urine that is too acid or too long alkaline may allow deposits of salts and the formation of calculi; hence in either case the diet should be modified according to the condition.

Potassium Citrate.-Potassium citrate occurs as transparent crystals or as a white powder, is very soluble in water,has rather of an unpleasant taste, and is well administered in peppermint, wintergreen, or cinnamon water. Although the Pharmacopœial dose is 1 Gm. (15 grains), in order to alkalize the urine I generally 2 Gm. (30 grains) must be given three or four times a day. The dose of 2 grams may be dissolved in 10 mils of a flavored water, and should be taken well diluted, best after meals, and on going to bed, if it is decided to give the drug four times a day. The official effervescing citrate of potassium is a pleasant method of administering this drug. The dose of this preparation is 4 Gm. (1 drachm). An alkali given directly after meals more readily alkalizes the urine than when given at other times.

Potassium citrate is not an antacid as far as the stomach is concerned. It is rapidly absorbed, tends to increase the alkalinity of the blood like all alkalies, somewhat lowers blood-pressure, and increases nitrogenous metabolism.

As the potassium element is slightly depressant to the muscular system, the sodium salts are sometimes preferable. Some indigestion may be caused by potassium citrate, but poisoning will not occur.

Sodium Citrate.-Sodium citrate occurs in crystals or as a granular powder, has a saline taste, and is very soluble in water. The dose is the same, and the method of administration is the

same, and it is used for the same purposes as potassium citrate. The only advantage of the sodium salt is because sodium causes less muscle depression than potassium.

DRUGS USED TO RENDER THE URINE ACID

When the urine is too acid, meat, coffee and tea should be withheld, and the diet should be limited to carbohydrates and to vegetable proteins. On the other hand, when the urine is alkaline, meat should be allowed and dilute hydrochloric acid may be administered. In either condition more water should be taken to dilute the urine and therefore prevent deposits.

An alkalinity of the urine may be temporary, due to drinking alkaline waters, or to a vegetable diet; or it may be due to some nervous disturbance, as shock or anxiety, or to actual disease of the brain. An alkaline urine deposits the alkaline phosphates, and if this deposition long continues, phosphatic calculi may occur, and later fermentation. Except sometimes soon after meals the urine should not be alkaline, but should be acid.

The diet should be modified to, if possible, render the urine acid. Nerve tire should be prevented, and, if necessary, a rest cure should be ordered. Although drugs cannot be guaranteed to render the urine acid, the most successful are dilute hydrochloric acid and acid sodium phosphate. Salol, and all forms of salicylic acid, by causing salicyluric acid to appear in the urine, will more or less prevent fermentation in the bladder and may render the urine acid. Hexamethylenamina (urotropin), especially if given in conjunction with acid sodium phosphate, will generally succeed in rendering an alkaline urine acid.

Sodium Biphosphate.-Acid sodium phosphate occurs as colorless crystals or white crystalline powder, has an acid taste, and is very soluble in water. The dose is 1 to 1.5 Gm. (15 to 22 grains), given well diluted. It is well administered in syrup of citric acid and water.

It is often advised that this drug be given in conjunction with hexamethylenamina when the urine is alkaline and an antisep

tic is desired, as hexamethylenamina will not act in alkaline media; but these two drugs, namely, acid sodium phosphate and hexamethylenamina, should not be combined in the same prescription, and should be administered at different times so that one drug is out of the stomach before the other enters it on account of chemical changes that may occur.

This salt does not change in the stomach, but is converted in the intestine into disodium hydrogen phosphate. The acid phosphate in the intestine is neutralized by alkali drawn from the blood, and to offset this reduction of the alkalinity of the blood more acid is excreted in the urine. In large doses it has a laxative effect.

DRUGS USED TO PREVENT THE GROWTH OF BACTERIA IN THE KIDNEYS AND BLADDER

To meet this indication, namely, to destroy bacteria growing in some focus in the kidney, in the pelvis of the kidney, or in the bladder, no drug exeeds in value hexamethylenamina. This drug may not be tolerated in doses that are efficient, and salol or methylene blue may be substituted. Both are valuable. The oil of santal may also meet this indication, as, like many resins and aromatic oils and the turpentines, it is not only a stimulant to the genitourinary mucous membrane, but it is more or less of an antiseptic during its excretion, and germs do not well grow in urine carrying a considerable amount of santal.

Alkaline urines tend to allow bacteria to grow, especially staphylococci; consequently, all alkaline urines must be made acid if possible, although colon bacilli will grow in both acid and alkaline urine. A bacilluria necessitates careful investigation as to its cause; also as to where the trouble lies, in the pelvis of the kidney, in the bladder, or in the urethra. Whatever treatment is needed, surgical or other, one of the urinary antiseptics is advisable. In acute conditions, with bacilluria, salol or hexamethylenamina are the best drugs, provided there is no inflammation of the kidneys. Methylene blue may also be used, and is not irritant. In chronic bacilluria santal oil is also of benefit. But, as just intimated, it is essential in every

13