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 Pharmacopoeial dose is 1 Gm. (15 grains), in order to alkalize the urine 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

such condition that the diagnosis be made, and that surgical treatment be not too long delayed.

All inflammations of the pelvis of the kidney, of the bladder, and of the urethra are surgical conditions and require local treatment.

Hexamethylenamine.— Hexamethylenamine (urotropin), a condensation product of ammonia and formaldehyde, occurs in colorless crystals or as a white powder, and is very soluble in water. The Pharmacopoeial dose is 0.25 Gm. (4 grains); an effective dose as a urinary antiseptic is two or three times this amount. It is best given as a tablet or powder, dissolved in half a glass or more of water. It has been lauded for antiseptic and germicidal action in various parts of the body, but it has been shown that it cannot act as an antiseptic except in acid media (i.e., it cannot give up its formaldehyde except in the presence of acid), therefore it cannot act internally as an antiseptic except in the urinary tract when the urine is acid. A 0.25-gram dose may be administered several times a day, double that amount three or four times a day, or a gram (15 grains) may be administered twice a day. In acute or chronic nephritis urotropin should not be administered, and in some individuals with normal kidneys it causes irritation, and in large doses may cause hematuria. Hexamethylenamina is sold under many proprietary names, and sometimes is combined with other drugs, but none apparently has any advantage over the official hexamethylenamina. This drug should not be given in any form for any great length of time, at least not without intermission.

Methylthionine Chloride.-Methylene blue occurs as a dark green crystalline powder, is soluble in water and alcohol, and the dose is 0.10 Gm. (11⁄2 grains), in capsules, taken with plenty of water. It has been used as a genitourinary antiseptic in gonorrhea, in infections of the bladder and of the pelvis of the kidney. The drug may be administered every six hours, and, as just stated, should be always taken with plenty of water. Under its action the urine becomes blue or blue-green. It has been used with some success in malarial fever when quinine cannot be given.

This drug may cause nausea and vomiting, unless each dose is taken well diluted. If large doses have been given, it may cause backache, kidney and bladder irritation, and may even cause strangury and general depression.

DRUGS USED TO STIMULATE THE MUCOUS MEMBRANES

In chronic inflammation of the pelvis of the kidney, of the bladder and of the urethra, no one drug is more successful, in proper cases, than is santal oil. The more disagreeable copaiba, cubebs, corn silk, pichi, and numerous other lauded stimulant diuretics are no more efficient and generally not as favorable in their action as is the oil santal.

Most of the drugs called stimulant diuretics stimulate the membrane of the genitourinary tract. All aromatic oils act in this manner, and these, as well as the drugs above mentioned modify the character of the urine and prevent the growth of germs, but they more or less disturb the digestion.

Oil of Santal.-Oil of sandalwood is a volatile oil distilled from sandalwood, and occurs as a pale yellow, somewhat thick liquid having a strong odor and taste of sandalwood. It is best administered in flexible capsules containing 0.30 to 0.60 mils (5 to 10 minims), given three or four times a day, best after meals; or, if taken on an empty stomach, plenty of water should be drunk at the same time.

Santal oil gives its odor to the urine and to the breath. Large doses, and even small doses sometimes, cause backache in the lumbar region and pain down the ureters sometimes into the testicles. It not only acts as an antseptic in the urinary passages, but many times seems to stimulate a chronic inflammation to more rapid healing. It should not be used in acute inflammatory conditions.

Santal oil has also been used as an expectorant to promote more active secretion in bronchitis, when the exudate is thick and tenacious.

EMMENAGOGUES

Before giving so-called emmenagogues, the cause of the amenorrhea must be sought and pregnancy must be excluded. If the cause of the amenorrhea is systemic, the underlying con