out of forty cases examined by Busk;1 in fourteen out of sixtyseven, by Begbie; in four out of twenty, by Frua; and in some of Dundas Thomson's cases. Becquerel states that it is generally absent, but this is an entire mistake. In none of my cases (about twelve, in which the first urine was examined) has it ever been absent; but I have twice seen it in small amount. The presence of albumen has been suggested, by Buhl, as a diagnostic mark between true cholera and severe diarrhoea occurring in cholera epidemics. As remarked, however, by this writer, albumen may occur in the urine of simple diarrhea; so that this distinction will not always hold good. The amount of albumen has a general, though not very close, relation to the severity of the algide stage. I have, however, seen it large in slight cases, and the reverse.

Sugar is occasionally present, sometimes in large quantities, in the first and second day's urine.

Pigment. A substance which gives a beautiful violet-purple, and sometimes transient reaction with acids, is present with the first urine in all cases. It has never yet been noted as absent in any instance in which it has been looked for. It is soluble in alcohol. The reaction with acids is much the same as that given by Heller's uroxanthin; whether it is this substance, or some modification of bile-pigment, is not yet known.7 If albumen be present, and be thrown down by nitric acid, it is coloured violet, purple, or dark brown, by this substance. It soon disappears, even before the albumen. It is, in my opinion, the best diagnostic mark of cases in which the symptoms are so slight as to make us uncertain whether we have to deal with cholera or not.

Sometimes this pigment takes on a blue colour, when a drop or two of nitric acid is added in the cold, and the mixture allowed to stand. Black-coloured urine has also been noted, but it may have been owing merely to dissolved hæmatin.

A

Dissolved blood colouring-matter is not unfrequently seen; the exact frequency of its occurrence is uncertain. sulphureted compound (probably sulphuret of ammonium)

1 Quoted by Gull, in Report on Cholera, College of Phys., 1854, p. 136.

2 Monthly Journal, Oct., 1849.

3 Canstatt's Jahresb. for 1856; Eisenmann's Report, Band iv, p. 163.

• Finger found it in 8 of 65 cases of customary diarrhœa.

Heintz, Samoje, Buhl, loc. cit., p. 25.

See Begbie's interesting paper, in the Edin. Med. Journal, 1849, and paper by Author in the same journal.

7 A precisely similar reaction can be sometimes obtained from the thin fluid of the cholera dejections. The substance certainly resembles that described in the section on "Blue Pigment." Zimmermann has found a substance assuming a blue colour in the blood of cholera, and believes it to be a modification of hæmatin.

is sometimes present. It is not common: I have found it in two or three cases, in perhaps twenty.

Morphological elements are seen in every case of cholera urine; viz., casts of tubes, often beautifully perfect and transparent, renal epithelium, and, to an immense extent, bladderepithelium. Renal and bladder catarrh are invariable sequences of cholera; and, in twenty-four to thirty-six hours after the first urine is passed, perfect pus-cells and ill-formed epithelium are also found in great numbers. Blood-corpuscles are often present at first, and crystals of uric acid. At a later date, urates and oxalateof-lime octahedra generally make their appearance.

The casts and blood-corpuscles disappear long before the albumen; according to Frerichs, the abundance of casts is favorable, as showing that the conduits of the kidneys are being freed from the exudation which had occurred in them in the cold stage.

At present, the researches on the urine in cholera do not throw any light on the remarkable alterations in circulation and diffusion which occur in that disease. There is, evidently, at first, retention of all urinary products; and then, when the circulation is restored, and the kidney-tubes are cleared of their albuminous plugs, there is compensatory elimination. But is there any lessened, heightened, or perverted metamorphose during the algide stage, or afterwards? Only one case is known to me in which the examination of the urine was carried on for a long enough time to give any kind of answer to this question. It is the first case recorded by Buhl.1 A man, aged thirty-three, began to pass urine on the fourth day. From this time to the end of the twelfth day, he passed 404-434 grammes of urea, 25.609 grammes of phosphoric acid, and 30-255 grammes of chloride of sodium. His excretion during these nine days was, therefore, as far as the urea is concerned, over the average; a little below the average for the phosphoric acid, and much below it for the chloride of sodium. If, however, we take the whole twelve days of the disease (during the first three days of which no urine was passed), and assume that urine was passed as usual on each day, we have a daily excretion of

That is to say, if the kidneys had acted daily he would have

1 Three other cases recorded by Buhl cannot be used; for in two a day is missed out, so that the excretion is not known for those days; and in the third some urine was lost on one day.

passed about a normal amount of urea on each day, and the excess in the latter period may have been owing simply to the non-excretion of the first three days; there is, therefore, so far, no evidence of either augmented or depressed metamorphosis, but merely of retention and subsequent elimination. The phosphoric acid was below the mean, and perhaps there may have been loss of this acid in the stools. The chloride of sodium was greatly less than normal, owing, no doubt, to the previous loss with the stools; so that almost all that was taken as food, during convalescence, was held back by the body, which had been drained of its salt.

It will, however, be imprudent to draw general conclusions from a single case.

That there is perverted metamorphosis in cholera is shown, at present, merely by the peculiar pigment; for the albuminous and the exudation casts, &c., are merely evidences of great kidney congestion and exudation. The import of the pigment is not known; but it is not peculiar to cholera.

CHAPTER IV.

CHRONIC DISEASES (NOT RENAL).

CHRONIC diseases may be separated into two great classes, those which are, and are not, febrile. In some cases, however, the line of demarcation between the two series is not marked, or one class may temporarily pass into the other.

The chronic febrile diseases are often later stages of the acute; and the urine, as far as it has been examined, resembles that of the disease they follow. As the observations of the urine in this class are, however, fragmentary and imperfect, it is inadvisable to occupy space by a detail of the appearances in chronic febrile bronchitis, pneumonia, peritonitis, or rheumatism, or gout.

The chronic a-febrile diseases constitute a vast class of maladies, which are notoriously intractable and persistent. The condition of the urine in them is much more variable than in acute cases; for the agencies are more complex. In acute diseases, one important factor-the heart's action-is tolerably stable; for, as a rule, during the height of the disease the blood flows more rapidly, and with greater pressure. But in chronic cases the rapidity and force of the circulation are very variable; and, apart from any direct changes in metamorphosis, secretion everywhere must be constantly affected, in different degrees, from this cause alone. Primary digestion also is more variably affected in chronic diseases, and in the same case the amount of food entering the system changes greatly from day to day; whereas in acute cases there is almost uniformly a lessened ingress of nutritive substances. Assimilation also, if less violently disturbed in chronic than in acute cases, is really little less profoundly implicated; and the action of certain organs is sometimes much perverted, or perhaps is even for a time suspended.

Unfortunately, the vast field of chronic diseases has not yet been sufficiently examined. Since the discovery of the easy modes of examining the urine, attention has been directed chiefly to the acute diseases, the great perturbation in which interest the observer at first more than the less obvious, though not less important, mutations of non-febrile affections. But, as far as investigations have yet gone, it would appear that the general condition of chronic disease is a diminished urinary excretion,'

1 Professor Vogel has some good remarks on this point. Archiv für wiss. Heilk., Band i, p. 130.

indicating a lessened metamorphosis from enfeebled circulation, depressed innervation, or deficient ingress of food. This diminution affects both solid and fluid parts of the urine, but especially the former; and of these particularly the urea, the pigment, and the sulphuric acid. The chloride of sodium is generally also lessened, as less enters the system; the uric acid and the earthy phosphates are, on the other hand, less diminished, and may be even normal or increased (Mosler). The frequency of oxalate-of-lime crystals is increased, owing, if a favorite hypothesis be correct, to lessened oxidation. The diminished urinary elimination is sometimes attended by compensatory discharges from the bowels, or less frequently from the skin, or by unnatural discharges from, or diseases of, the stomach, uterus, lungs, or skin, which complicate and to a certain extent alter the course of the primary disease, whatever that may be. In many cases, especially in chronic pulmonary phthisis, these discharges themselves may perhaps react on the urine, and produce still further alterations in it.

I have provisionally divided chronic diseases into two classes: 1. Diseases of organs or tissues.

2. Diseases the origin of which is uncertain, but which are distinguished by prominent urinary symptoms.

DIVISION I.

CHRONIC DISEASES OF ORGANS.

SECTION I.

CHRONIC DISEASES OF THE NERVOUS SYSTEM.

Epilepsy.

In the intervals of the epileptic attacks, no observations have yet been made which show any constant change in the urine. Immediately after an epileptic fit, a large quantity of urine is often passed, which is pale, only feebly acid, and has been said to contain sugar.'

1 Michea; Reynoso, Comptes Rendus, tomes xxxiii, xxxiv; Goolden; Gibb, Lancet, March, 1855.