from the formation of excess, or from interference with the neutralization of as large a proportion of that which is produced as ought to be thus taken from the whole amount of acid formed. In rheumatism an unusual formation of acid takes place. Acetic, butyric, formic and valerianic are among the acids produced. The same acids are often set free by chemical decompositions occurring in the contents of the stomach.

If bicarbonate of potash be taken before meals, the intensity of the acid reaction of the urine is diminished for some hours, but on the following day "the acidity was considerably higher than it was the day before the salt was taken. But when it was administered during the process of digestion, the acidity of the urine entirely disappeared" (Dr. Ralfe, "Morbid Conditions of the Urine, pp. 54 and 143). If, then, we desire to increase the acid reaction of the urine, we must give the bicarbonate of potash when the stomach is empty, while, if we wish to diminish its acidity, the bicarbonate should be given after food. Whenever alkalies are prescribed, the patient should be instructed to continue them for a definite time only, otherwise harm, instead of good, may result. Advantage is often obtained by a course of acids before meals, and a course of alkalies after meals alternately, and I have often found hydrochloric, nitric or phosphoric acid before two meals in the day, and bicarbonate of potash or soda an hour or two hours after the same two meals, of great use. Such treatment may be continued for a fortnight, or longer, at a time.

From numerous experiments, varied in many ways, Dr. Bence Jones came to the conclusion that ammonia in the organism was partly converted into nitric acid. Urea and caffein, and other substances containing nitrogen, give rise to the formation of a small quantity of nitric acid. Although Lehmann has failed to confirm these results, he has not, I think, succeeded in shaking the evidence adduced in favor of the conclusions. Lehmann attributed the action upon the iodide of potassium to the presence of sulphurous acid. Jaffé performed some experiments in Lehmann's laboratory, and obtained sulphurous acid, but no nitrous acid from healthy urine and from urine passed after

taking ammoniacal salts. Dr. Bence Jones subsequently repeated his experiments, and found that Jaffé's experiments did not invalidate Price's test for nitrous acid, as Lehmann supposed (Proceedings of the Royal Society, Vol. VII, p. 94). Dr. Bence Jones brings forward several cases of healthy persons whose urine did not yield a trace of nitric acid; but, three or four hours after they had taken carbonate of ammonia, evidence of the presence of the acid was afforded by the starch and also by the indigo test. After twelve hours, only a trace could be detected; and in twenty-four, even this ceased to be perceptible. The urine was examined in precisely the same manner in every case. We must, therefore, conclude that a small amount of ammonia in the organism is converted into nitric acid; and it is not improbable that, under certain circumstances, the quantity of nitric acid formed in this manner may be very much increased.

Irritable Bladder.-In some cases, the deposition of uric acid and the secretion of a highly acid and perhaps concentrated urine, persist for many years, and the derangements arising from this state, both as regards the urinary organs and the system, are often difficult to cure. Among the most common ailments which are due to a highly acid state of urine, is "irritable bladder." Without there being any actual disease of the coats of the bladder, the surface of the mucous membrane often becomes unduly sensitive, so that the mere contact of highly acid or concentrated urine excites an unpleasant feeling, and sometimes actual distress, which soon assumes the form of an uncontrollable desire to immediately empty the bladder, and although the organ may be nearly empty, this occurs again and again, causing much suffering and inconvenience. In some cases the patient cannot retain his urine for more than an hour; and the pain is so great that the case is sometimes mistaken for inflammation of the bladder. The acid urine sometimes occasions the deposit of urates and uric acid in the bladder, and may thus give rise to stone. In some of these cases there is severe intermittent pain at the neck of the bladder and along the urethra, with frequent micturition and an almost constant feeling of a desire to make water. So severe are these symp

toms, that the patient is prevented from discharging his ordinary duties, and is almost afraid to leave his own private room. He is ready to do anything or suffer anything in the hope of getting relief. Remedy after remedy is tried in vain, and he may fall into injudicious hands. Nitrate of silver or some other strong caustic may be applied to his urethra, not only without permanent relief, but his present suffering may be increased by this and other expedients most confidently recommended as being certain to effect his cure. Instead of this, changes, perhaps, take place in his urethra which may, at a future time, result in stricture, and necessitate constant surgical attention.

The pathology of many cases of irritable bladder is obscure. In some there is undoubtedly catarrhal inflammation of the mucous membrane, but not unfrequently the condition seems to be due to, or is complicated with, an irritable state of the sensitive nerves of the mucous membrane and disturbances of the nerve centres most difficult to relieve. The practitioner will, however, often find that in many a case of what to the patient seems to be most terrible irritability, accompanied by even severe pain, a mercurial purge, repeated at intervals of a few days, will be of great service, although all the ordinary remedies which have been tried for his relief have failed. Sometimes the symptoms are actually caused, or greatly increased, by a concentrated state of the urine, with excess of urea, and an unduly acid condition of the urine invariably causes increased suffering. Very free dilution of the urinary secretion is indicated. Two pints or more of linseed tea flavored with lemon juice, distributed over the twenty-four hours, should be ordered, and be kept up for a week or ten days. If the patient gets tired of linseed tea, barley water may be taken, or mucilage of gum, or infusion of triticum repens, or even pure water, or water flavored with orange or lemon juice.

In many cases, the salts of the vegetable acids (citrates, acetates, tartrates) will be found more efficient in counteracting this acid state of the urine than alkalies or their carbonates, and are less likely to interfere with the digestive process. There are, however, low conditions of the system in which the acid state of

the urine, and a tendency to the deposition of uric acid in large quantity, are not relieved by this method; on the contrary, such cases are often much benefited by an opposite plan of treatment -tonics and the mineral acids before meals, a nourishing diet, with a moderate supply of simple stimulants with a little alkali, or with alkaline waters. Many of these cases seem to be intimately connected with impaired digestive power, and I have frequently found pepsine a valuable remedy ("Slight Ailments," 2d edition, p. 89).

Some of the most obstinate forms of the malady under consideration occur in women. I have seen cases under the age of thirty, in which all sorts of devices had been employed without avail, yield at once to moderate purgation, alkalies, and plenty of linseed tea or barley water. In the treatment of such maladies, and in the management of the sufferers, we must be careful not to be influenced by the increasing tendency to prescribe remedy after remedy, to introduce various instruments, and to prosecute different methods of examination with the idea of immediately curing what is really a chronic malady. Sometimes, however, a careful consideration of the facts leads the practitioner to suggest a simple and efficient plan of treatment which may prove successful within a few days of its adoption, although all sorts of extraordinary and out-of-the-way expedients have been resorted to without relief having been obtained.

Of all the remedies employed for relieving a highly irritable bladder depending upon very acid urine, with or without presence of excess of urea, or of a deposit of uric acid, liquor potassa is the most efficacious, but it must be given with due care, and not continued for too long a time without intermission.

Alkaline Urine.-An alkaline condition of the urine may be due to several circumstances, and requires, therefore, to be treated on different plans. The connection between an alkaline state of the urine depending upon fixed alkali, and the secretion of a highly acid gastric juice, has already been referred to. In such cases, attention must be paid to the state of the digestive process; and when this is set right, the urine will usually regain its normal characters. Dr. Bence Jones alludes to three cases

of dyspepsia with vomiting of a very acid fluid (two of them rejecting sarcina), in which the urine became alkaline from the presence of fixed alkali when the quantity of acid set free at the stomach was very great; but when this was small the reaction of urine was acid. It must, however, be borne in mind that the very acid nature of the materials rejected in many cases of vomiting, and especially in cases of sarcina ventriculi, arises, not from the secretion of an acid fluid by the glands of the stomach, but from the decomposition or fermentation of the food, when acids are developed, among which may be mentioned acetic, lactic, and butyric acids. At the same time, there can be no doubt that, in some cases of dyspepsia, the feebly acid or alkaline condition of the urine arises from the secretion of an abnormal amount of acid by the stomach. The degree of the acidity of the urine, says Dr. G. O. Rees, may, to a certain extent, be regarded as a measure of the acidity of the stomach.

Dr. Rees long ago drew attention to a large class of cases in which he thought the alkaline condition of the urine was to be explained as follows: Urine which is highly acid at the time of its secretion, irritates the mucous membrane of the bladder, and causes it to secrete a large quantity of alkaline fluid. This mucous membrane in health secretes an alkaline fluid, to protect its surface, just as occurs in the case of some other mucous membranes. Under irritation, more alkaline fluid than is sufficient to neutralize the acid of the urine is poured out; and hence the urine, when examined, is found in some cases to have a very alkaline reaction. In such cases, this highly alkaline condition is removed by giving liquor potassæ or some other alkali, or a salt of a vegetable acid, which becomes converted into an alkali in the system. The urine is not secreted so acid, and, therefore, according to Dr. Rees, does not stimulate the mucous membrane to pour out as much alkaline fluid. I know no observations to disprove this explanation of the fact, that in some cases alkalies cause the urine to become less alkaline, or even restore its acid reaction; yet one would hardly expect, if this be the true explanation in cases generally, that the natural reaction of urine would be acid. If there was danger of the healthy mucous