Case in Practice.

CASE III.-In March, 1866, Mrs. K—, aged about 55, consulted me with regard to a varicose ulcer of about seven years' standing, situated a little above the right ankle. The veins were in a varicose condition up to the knee joint, and on several occasions alarming hæmorrhage took place. She had been treated by the principal physicians in the neighborhood for several years. The operation of ligating the veins had not been tried on account of the great number of ligatures which would be required, and the danger of inflammation which would likely follow. The treatment pursued before I saw the case consisted of local applications, such as black wash, solution of tannin, sulphate of zinc, &c., together with a bandage from the toes to the knee. As the case appeared a rebellious one, I did not think that any treatment of mine would prove successful; however, as she desired me to take charge of the case, I adopted the following course, which is somewhat different from that prescribed in the books. After relieving the constipation under which the patient was laboring, I prescribed Quinia (sulphate) and aromatic sulphuric acid, and, for a local application, ordered a weak solution of tincture of the sesquichloride of iron. The limb was firmly bandaged from the toes to the knee, and kept in an elevated position. This was continued for about two months, the tonic having been alternated with sulphate of quinia and hydrastis. The result was most satisfactory; the ulcer healed, and the varicose condition of the veins totally disappeared. Although the local application of a weak solution of the tincture of sesquichloride of iron acted like a charm in this case, yet I believe no local application would have proved successful without sound constitutional treatment. I may also mention that I have found this preparation of iron a very valuable local application to all ulcers, and especially those of an indolent character. I do not consider it a specific for ulcers, but it is certainly far superior to such preparations as black wash, solution of sul

phate of zinc or copper, and the greasy applications recommended by some of the books.

In ulceration of the mouth, throat and tonsils, I have found the tincture of iron to act admirably as a local application. I have cured several cases of ulcers in the throat by a topical application of this remedy, and a gargle of capsicum and chloride of sodium. I. M.

PERISCOPE.

On Diseases of the Urinary Organs.

FROM Sir Henry Thompson's admirable lectures recently published in the Lancet, we extract the following:

HEMATURIA. The sources of hæmaturia may be determined as follows: 1. The kidneys, where it may be from diseased action, more or less temporary, as inflammation; or from disease more or less persisting, as degeneration of structure; or from mechanical injury, as from calculus there, or by a strain, or a blow on the back. If the hæmaturia is the result of inflammation, there will be general fever denoting its presence; if produced by slow organic change, there will be the history of failing health, and probably urine changed in quality otherwise than by the mere admixture of blood. Where blood is in very small quantity, as it will naturally be at times, note the character of the urine proper -whether of low specific gravity, pale, with albumen in greater proportion than blood or pus will account for; perhaps renal casts may be found; and look out for dropsies in any degree. In both the preceding forms, if blood is present it will give the smoke tint to the secretion. Perhaps it may be affirmed that such urine, associated with very little if any local pain, is more likely to come from the kidney than elsewhere. In malignant renal tumor, blood may be large in quantity at times: the rapidity of growth, and the size attained, are the marked characteristics of the disease. If mechanical injury be the origin of hæmaturia, there will be the history of a blow or strain; or there may be the signs and symptoms of renal calculus, of which more detail presently.

2. Then, putting aside the ureters, you will remember the bladder as the second source of hæmorrhage; and here

it may be due to some acute cystitis, stone, or tumor. The former is obvious enough from muco-pus in the urine, and through other signs; while the second may well be suspected by the symptoms, and its presence realized by the sound. Here the hæmorrhage is usually florid, and in proportion to the patient's movements. But the third condition—namely that the hemorrhage arises from tumor-is not always to be so affirmed. As a rule, however, blood from such a source is larger in quantity than from stone, and may be associated with less of muco-pus. If the tumor is malignant, it may be felt, and the pain is often severe; if villous, it gives an even pale-red tint for days together to the urine; and in both cases the blood is florid, unless it is long retained in the bladder, when dark sanies, like coffee-grounds, results.

3. In hæmorrhage from the prostate, the third principal locality or source, the same thing occurs, if the organ is hypertrophied and the blood is retained; but the age of the patient, and the ascertained condition of the organ from the bowel, aid the diagnosis. A slight appearance of blood mixed with the last few drops of urine is a not rare occurrence in chronic prostatitis.

4. When bleeding arises from stricture of the urethra, the patient's history and the cause of the bleeding, almost always instrumental, leave no room for doubt. From the use of instruments also in the bladder, hæmorrhage sometimes arises. Then it is not to be forgotten that occasionally blood is found in the urine as the result of violent diuretics, from purpura, in fevers, and in a hæmorrhagic diathesis.

Now for the treatment of hæmorrhage. When you have determined that its source is above the bladder-that is, in the kidney or in its pelvis, probably the first and most influential remedial agent is rest in the recumbent position. Whether from a lesion affecting the intimate structure, or from the mechanical irritation of a calculus in any part of the organ, rest is the first and the essential condition. The patient is, moreover, to be maintained in as cool and tranquil a state as possible.

It is in renal more than in any other form of hæmaturia, perhaps, that direct or internal astringents or styptics are useful. I shall do no more than name those which are most commonly used--namely, gallic and tannic acids; lead and turpentine; equal to them is, I think, the infusion of matico, say in doses of two ounces every two or three hours. The tincture of iron and also sulphuric acid may sometimes be taken with advantage.

It is, however, in cases of severe hæmorrhage from the

bladder, or more commonly from an enlarged prostate, that active and judicious treatment is necessary. You will be called sometimes to a patient whose bladder is distended with coagulated blood, or who is passing frequently a quantity of fluid in which blood is the predominating element. Usually this has arisen from some injury inflicted by the instrument, although it may also be from tumour of the vesical walls. Here you will keep the patient on his back, and forbid the upright position, or any straining, so far as you can prevent it, in passing water. To this end give opium. liberally, to subdue the painful and continued action of the bladder. Apply cold by means of bags of ice to the perineum and above the pubes. Better still, introduce small pieces of ice into the rectum. Do not use an instrument if it is possible to do without it. There is a great dread in some people's minds about the existence of a large coagulum in the bladder. I have even known a bladder to be opened above the pubes by the surgeon for the mere purpose of evacuating a mass of clotted blood. Leave it alone: it will gradually be dissolved and got rid of by the continued action of the urine; while if you are in haste to interfere, and are very successful in removing it, you will succeed also most probably in setting up fresh hæmorrhage. The bleeding vessels have a far better chance of closing effectually if they are not subjected to mechanical interference. Meanwhile support the patient's powers by good broths, &c.

But it sometimes happens that hæmorrhage occurs in a patient who has long lost all power of passing urine except by the catheter. This is a very different position. Here the coagulated mass which fills the bladder must sometimes be removed, or no urine can be brought away. Thus you introduce a catheter and none appears, for the end of the instrument passes into a mass of coagulum, and nothing can issue. Sometimes sufficient may be removed by attaching to a large silver catheter a six-ounce syringe or a stomachpump. Clover's lithotrity apparatus has answered remarkably well with me in two or three instances. Let me caution you never to inject styptics into the bladder; the irritation does more harm than good.

What is the seat of the lesion in his case? Perhaps the bladder: we found it tender to the sound, and it acts with undue frequency. Yet remember this is by no means evidence of any primary morbid change there, such conditions constantly accompanying diseases affecting primarily the kidneys or the upper part of the ureter. Much more probably the kidney. The manifest local tenderness, the

repeated attacks, the impaired health, the history, the absence of all the more common causes of cystitis in any form, point to the left kidney as the seat of mischief. The absence of albumen and of renal casts a fact of not much weight, although their presence is of the utmost importance-lead us to believe him free from organic changes affecting the renal organs. I conclude that his left kidney is the seat of calcu lus, although he has never passed one, and has at present no crystalline deposit in his urine-a fact by no means essential to the diagnosis; and that this calculus is the source of the blood and pus found in his urine.

It is sometimes not easy to say what kind of calculus exists in these cases, of which this is a fair type. When any calculous matters have been passed which can be examined, or when the crystalline deposit in the urine is constant, the inference is pretty clear. Add to this that the probability in any case is strong in favor of uric acid, from its known frequency of occurrence-taking large numbers, say at least fifteen to one, as compared with oxalate of lime.

A NEW MODE OF EXAMINING THE URINE.-I shall here, by way of episode, refer to a mode of determining the true character of a patient's urine, which is of extreme value in some doubtful cases-a mode which has never to my knowledge been recommended or practised, and which I have systematized for myself. I have already told you how essential it is to avoid admixture of urethral products with urine, if you desire to have a pure specimen. It is sometimes quite as essential to avoid its admixture with products of the bladder. And I defy you to achieve an absolute diagnosis -by which I mean a demonstration, and never be satisfied with less if it be practicable,-in some few cases, without following the method in question. When therefore it is essential to my purpose to obtain an absolutely pure specimen of the renal secretion, I pass a soft gum catheter of medium size into the bladder, the patient standing, draw off all the urine, carefully wash out the viscus by repeated small injections of warm water (before shown to be rather soothing than irritating in their influence), and then permit the urine to pass, as it will do, guttatim, into a test tube or other small glass vessel for purposes of examination. The bladder ceases for a time to be a reservoir; it does not expand, but is contracted round the catheter, and the urine percolates from the ureters direct. You have, indeed, virtually just lengthened the ureters as far as to your glass. And now you have a specimen which, for appreciating albumen, for determining reaction, and for freedom from vesical pus and even blood,