state of things can be restored. No wonder, then, that from the earliest days of medicine, the urinary secretion should have been studied with especial care, and that its consideration should constitute one of the most important departments of practical medicine. In these days, so extended is the range of our knowledge of urinary diseases, that the subject could not be treated of in a volume consisting of many more hundred pages than the present contains. I shall only attempt to direct the attention of practitioners to the management of those derangements and diseases of the urinary system which frequently fall to the province of the physician to treat. In many cases I can only give hints as to the general line of treatment to be pursued, but as regards some conditions, I hope to offer suggestions based on facts I have observed, or learned from others, in the course of more than thirty years' practice, which may be useful to the practitioner. I shall not attempt even to enumerate all the remedial measures which have been proposed or carried into effect, but endeavor rather to concentrate attention upon the principles which should guide us in the treatment of the various departures from the healthy state, of which indications are afforded by examining the urine, or by other methods of clinical observation.

Nor is it only in great alterations in the amount of its usual constituents that the urine of health may differ from that secreted in physiological derangements or in structural disease. There are several substances which may be present, of which not a trace can be detected in the secretion in health-biliary, albuminous and other matters from the blood, sugar-besides many things forming definite and perhaps bulky deposits, of which mere traces, or no indications whatever, exist in the urine in the healthy condition, may be present, and in varying quantity. Of these, some indicate a condition of things which may be expected to end fatally within a short period of time, while others are due only to a transitory disturbance, a temporary and unusual chemical change, or are accidentally present. The practitioner has to bear in mind the distinguishing general features and chemical microscopical characters by which sub

stances which are of great significance may be identified and distinguished from those which are of no clinical consequence.

VARIATION IN THE QUANTITY OF WATER-IMPORTANCE OF DILUTING THE FLUIDS OF THE BODY, AND OF WASHING OUT THE TISSUES.

All the liquid secretions of the body vary from time to time as regards the proportion of water by which the special constituents are held in solution, but in this respect the urine varies more than any other secretion. At one time the proportion of solid matter to water may be as 1 to 10, at another as 1 to 1000. Although the quantity of water in the urine is determined mainly by the amount taken, it does not wholly depend upon this circumstance, neither does it vary in direct ratio with the water imbibed, for in hot weather, though an excessive amount of water be taken, the urine will be found highly concentrated, the water removed from the cutaneous surface preponderating over the quantity passing through the renal emunctories.

The action of the kidneys as regards the removal of water from the blood varies from day to day and even from hour to hour. This constant variation is physiological, and is one of the many factors by which a uniform composition of the blood is maintained in spite of the tendency to change consequent upon various actions which determine chemical decomposition. An ever-varying body temperature would necessarily result, but for the compensating changes induced by the action of the skin and kidneys, whereby solid excrementitious matters and water are continually removed in ever-varying proportion, and some alteration in the composition of some of the solid constituents also occasioned.

One is often surprised at the very different amount of liquid persons in good health habitually consume. Some find that a quart, or even less, suffices for their daily requirements and for the satisfying their thirst, while others drink twice or three times. as much. One healthy man will walk from morning to night, and though sweating freely the whole time, will not feel any great desire for drink, while another, under precisely the same

conditions, will not be able to get on without consuming many pints of fluid. Some consider that water containing various nutritious matters and alcohol (beer!) is absolutely necessary if any unusual exercise be taken. In cases where the quantity of water removed by the kidneys is habitually considerable, we shall generally find on inquiry that the patient has gradually acquired the habit of drinking largely of water or other liquids, until at last he cannot get on without continually yielding to the desire to drink. The amount of food as well as liquid taken by an individual in good health is very much a question of habit.

From time to time the most extraordinarily rapid flow of water from the blood takes place. Through emotional influence more than a pint of water may be separated from the blood in ten minutes. In these cases the total amount of urine secreted in the twenty-four hours is not necessarily increased, but in response to rapid changes in the nerve centres, sudden relaxation of the vessels of the Malpighian body takes place, and the water transudes through the thin capillary walls with great rapidity. As is well known, the secretion of watery urine follows in the course of a few minutes the imbibition of considerable quantities of liquid. In a man in whom the anterior walls of the bladder were absent, and the orifices of the ureters fully exposed to view, I have seen limpid urine distilling drop by drop within five minutes after the man had swallowed a glass of champagne. Those who fancy that albumen of serum ordinarily escapes with the watery part of the blood from the vessels of the glomerulus, have not, I think, given sufficient weight to these facts, which, as it appears to me, tell against their hypothesis; for is it not difficult to accept the conclusion that in this very rapid operation time is allowed for the reabsorption of the effused albumen by the cells of the convoluted portion of the uriniferous tube? At the same time one cannot go so far as to hold that this would be impossible under the circumstances referred to.

The Importance of Water and of Dilution and Diluents. Some persons no doubt get into the habit of taking more water than is necessary for their system, or for many reasons desirable. I feel sure that more take too little in proportion to

the solid food they consume-in fact, eat too well and do not take fluid enough to ensure the proper assimilation of much of the solid matter, and effect the free solution and removal of the excrementitious substances formed during the physiological action of the tissues and organs. The consequence is, that as time goes on the deposition of various substances takes place, and contraction and condensation of the tissues proceed faster than they should do, old age being reached years before the natural period of its advent. Not only is free dilution advantageous in many ways, but in this way food is wonderfully economized. Some of those who while really eating sparingly nevertheless gain rapidly in weight, take considerable quantities of fluid with or after taking food. In endeavoring to reduce weight, this important point must not be lost sight of, and the imbibition of large quantities of water must not be permitted. One reason why milk is so fattening is that its constituents are dissolved and suspended in a large proportion of water, for, as is well known, the insoluble fatty matter is very minutely divided, and by a special arrangement evenly spread through the whole bulk of the milk. Many morbid conditions are relieved by the introduction of plenty of fluid at proper intervals. The public have discovered the benefit of considerable, if not excessive, water drinking for a period of one or two months out of the twelve, and the annual expedition to springs in every part of the Continent has become more than fashionable. The value of many of the mineral "waters" seems to be mainly due to the chief and universal constituent of all.

In many forms of illness, which, if they persist for any time, are certain to damage the whole body, and may be painful to endure during the entire period of their existence, all that is really required to restore the healthy condition is to wash out the tissues and organs, so that various noxious substances which have been accumulating, it may be for many years, may be dissolved by the water made to traverse the minute interstices of the textures, and thus removed in solution. To effect this purpose considerable time is often required. A course of one or two months, during which from two to six or more pints of water

are taken daily, is often requisite to produce much effect. Although there can be no doubt that alkalies and other saline constituents in natural waters exert a beneficial influence, in many cases an excellent result is obtained by the use of water alone, and especially distilled water, which may now be obtained pure, or impregnated with carbonic acid gas, of the "Salutaris Water Company," 286 Fulham Road. Many, therefore, who are unable to spend weeks in a German or even an English watering place, who cannot without losing their position, and perhaps their prospects of earning a livelihood, leave their work in town for a week or even a day, may subject themselves to remedial measures, from which they may derive great benefit, and in a comparatively short time. A fair allowance of fluid per diem not only economizes food, but by keeping the fluids in the interstices of the tissues in a dilute state, promotes free interchange, favors oxidation, and prevents the occurrence of many of the so-called degenerations. For these are mainly due to the state of things resulting from the accumulation of substances in an insoluble form in the tissues which should be rendered soluble by oxidation, and removed in solution and excreted as fast as they are produced in the course of chemical change.

66

Although not unfrequently we are constrained, from inexactness and insufficiency of our knowledge, to attribute certain symptoms to a "gouty tendency," "diathesis,' "habit of body,' disposition," "peculiarity," or "susceptibility," acquired, inherited, or evolved, which belong to a different category, being due to causes different in their nature from those upon which gout depends, it is certain that a state of system, a state of the blood and the tissues, which often eventuates in gout, is really very common. That this state may be produced in certain constitutions by persisting in a particular mode of life is true, but it is also true that some are so prone to the change referred to, so 66 susceptible" or "vulnerable" in this respect, that by no plan of diet can they, at least in this climate, wholly avoid it or protect themselves from it. In the great majority, however, the state in which one or more of the many symptoms