I belong to the great church that holds the world within its starlit aisles; that claims the great and good of every race and clime; that finds with joy the grain of gold in every creed, and floods with light and love the germs of good in every soul. - R. Ingersoll.

The rising of a great hope is like the rising of the sun. - Charles Kingsley.
 

    The physiology or function of the tractus urinarius is: (1) peristalsis; (2) secretion- (3) absorption, (4) sensation.  Pathologic physiology is a deviation from the usual physiology without, however, invading the field of pathologic anatomy.  The tractus urinarius is a fertile field to study pathologic physiology, as it presents a wide zone of varying degrees, especially since recent investigations have enriched our knowledge of renal function.  What older physicians considered pathologic anatomy in renal function is now believed to be largely pathologic physiology.  The zone of kidney function is a continually increasing one.  In the study of pathologic physiology of the tractus urinarius rational and comprehensive views of the renal viscus will be entertained.  The study comprises: (a) the condition or state of the kidney; (b) the constituents of the blood; (c) the volume of blood that streams through the organ.  The discussion of (a), (b), and (c) in regard to the kidney lends a comprehensive view to the student in making a diagnosis of the living.
    We will here consider the pathologic physiology of the urinary tract or some of the common deviations from the usual physiology.

(1)  PERISTALSIS (EXCESSIVE, DEFICIENT, DISPROPORTIONATE).

    (a)  Excessive peristalsis may occur in the tractus urinarius from numerous causes.  The segment of the urinary tract subject to peristalsis is the ureter and bladder.  The ureter is an independent organ resembling the heart, uterus, stomach.  It possesses automatic ureteral ganglia as it performs peristalsis and functionates regardless of attitude or force of gravity.  Excessive peristalsis is most liable to arise from excessive drinking of fluids, from diabetes or polyuria where excessive volumes of fluid passed through the urinary tract in limited time.  The most marked example of pathologic physiology or excessive peristalsis in the urinary tract arises from the presence of an ureteral calculus.  The ureter experiences brusk, vigorous, violent, wild and disordered movements
 

INTIMATE RELATION OF THE TRACTUS GENITALIS AND TRACTUS URINARIUS       Fig. 128.  This illustration demonstrates how solidly and compactly the tractus urinarius and tractus genitalis are anastomosed, connected.  At the proximal arterio-ureteral crossing (11, 11) the ureter and ovarian artery are solidly and firmly anastomosed by the nervus vasomotorius (sympathetic).  Again at the distal arterio-ureteral crossing (2, 2) a similar but more extensive anastomosis occurs - hence the balanced relationship between the tractus urinaritis and tractus genitalis.  Every practitioner realizes the intimate relation of the bladder and the uterus, e. g., in gestation, through the nervus vasomotorius.  This intimately solid anastomosis between the two visceral tracts by means of abundant nerve strands aids to explain the vast and interdependent pathologic physiology observed in practice.

accompanied by excruciating pain.  A marked example of excessive ureteral peristalsis, based, however, on pathologic anatomy, is ureteritis which may be accompanied by excruciating pain.  From experimentation on dogs one observes that the peristalsis of the ureter is brisk, vigorous, resembling that of the heart, uterus.
    (b)  Deficient peristalsis of the urinary tract arises in connection with limited drinking of fluids, limited quantity of urine (the pressure of urine stimulates the ureteral peristalsis); a limited quantity of urine accompanied by a limited peristalsis is liable to be followed by precipitation of crystals and urinary calculus.  However, a compensatory action arises from the fact that limited urine is generally concentrated and hence is apt to irritate the ureter, inducing peristalsis.  It is probable that the automatic ureteral ganglia, similar to the automatic intestinal ganglia (in constipation) may become sluggish, inducing deficient ureteral peristalsis.
    (c)  Disproportionate peristalsis is irregular, unequal peristalsis in different segments of the tractus urinarius, as bladder or ureter.

(2)  SECRETION (EXCFSSIVE, DEFICIENT, DISPROPORTIONATE).

    (d)  Excessive secretion from the urinary tract is observed most typically in diabetes mellitus, insipidis or polyuria, frequently fields of simple pathologic physiology where no pathologic anatomy can be detected.
    Excessive renal secretion may be marked in change of temperature from warm to cold weathers difference of a quart of urine may be noted enduring for six or ten days - simple variation of renal function.  The function of the perspiratory apparatus has experienced a deficient secretion relatively equal to the pathologic physiology of the excessive renal action.  Cold, contracting the cutaneous vessels, forcing the blood into the central large vessels, and increasing heart action, will markedly increase renal secretion.  Pathologic physiology, compensatory, no pathologic anatomy; it is a form of vicarious physiology.  Sugar may appear in the urine for some time (pathologic physiology) without demonstrable pathologic anatomy - later, however, indigested fats may be found in the stools, which would call attention to the pancreas.  However, the pancreas may be suffering from pathologic physiology of secretion only (excessive, deficient, or disproportionate).  Pancreatic secretion may be insufficient to dissolve the fats.  So that even at the stage of diabetes, pathologic anatomy may not yet be afoot.  Paresis (sluggishness) of the renal plexus (ganglia) may allow polyuria.  Constipation may impose increased vicarious duties on the kidneys, compelling them to eliminate products usually eliminated by the tractus intestinalis.  We know kidney action may be excessive, that is, comprise pathologic physiology only, for we not infrequently observe one kidney successfully accomplishing duplicate work.  We can produce excessive secretion of urine artificially by administering NaCl in ample fluids.  Certain foods, as water-melon, produce temporary excessive renal function, with certain subjects, apparently excessive renal secretion (pathologic physiology) exists for years.  In excessive renal secretion the urinary salts may be excessive or deficient or vice versa.
 

ILLUSTRATION OF THE FEMALE URINARY TRACT       Fig. 129.  This specimen was drawn from nature from my own dissection by the aid of distending the ureter's veins and arteries with hardening material.  The ureter (calyces, pelvis and ureter proper) is ensheathed with a nodular fenestrated web, an anastomosing network of sympathetic nerves especially at the 3 ureteral isthmuses (of Byron Robinson) 3, ,5 and the entrance in the bladder.  Z, Y, 3, uretero-venous triangle (of author).  The nervus vasomotorius richly supplies the tractus urinarius and manifests itself violently during the presence of a moving calculus or periodic hydro-ureter, or ureteritis.

    (e)  Deficient renal secretion may be noted in limited drinking of fluids, in restricted diet in diarrhoea (vicarious), in cold weather, in debilitated heart, in fevers, in concentrated foods (flesh-eaters), in sedentary habits and in numerous nameless conditions.  Deficient renal secretion is, from my experience, a rather common condition.  Deficient renal secretion may present excessive or deficient urinary salts or vice versa.
    In certain subjects apparently deficient renal secretions exist for years.  In general, deficient renal secretions are saturated with concentrated urinal E:alts which may irritate the mucosa of the tractus urinarius sufficiently to, produce pathologic physiology.  Deficient renal secretion may lead to uremia.
    (f)  Disproportionate renal secretion is irregular in different segments of the kidney.  The urine may be excessive and the salt deficient or vice versa.  The renal glomeruli may secrete deficient or excessive fluids.  The uriniferous tubules may secrete deficient or excessive salts.
What influence has the disturbed renal secretion - the pathologic physiology - on the general organism?  Manifold injuries may occur.  The continual loss in albuminuria is exhausting.  The insufficient secretion of urinal, constituents from the blood leads finally to bodily disturbance.  In other words, pathologic physiology in renal secretion may be the incipient stage of disease - pathologic anatomy.  Disturbed renal secretion may be accompanied by disease in different organs - uremia, which represents the accumulated disturbances on various organs.

(3)  ABSORPTION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE).

    (g)  Excessive absorption of the tractus renalis would constitute extracting unusual material from the blood.  In a certain sense, excessive renal absorption might induce excessive secretion: e. g., on urinalysis albumen may be found which would suggest an inquiry as to the quantity of egg albumen the: subject is consuming.  Considerable ingesta of albumen may lead to rich albuminuria.  Hence, the state or composition of the blood should be investigated to decide the amount of albuminuria.  If there be excessive sugar in the blood and sugar being absorbed by the renal apparatus will present excessive secretion of sugar.  This suggests inquiry into the quantity of sugar ingested.
    (h)  Deficient absorption would indicate that the renal apparatus does not extract from the blood the proper amount nor the proper material.  The pathologic physiology has a wide range in deficient absorption, for some times we may observe an adult person eliminating 8 or 10 ounces of urine daily.
    (i)  Disproportionate absorption constitutes irregular disordered absorption of the different segments of the renal apparatus, as the glomeruli and the uriniferous tubules.
 

AN ILLUSTRATION OF THE ABDOMINAL SYMPATHETIC NERVE OF THE MALE, ESPECIALLY PRESENTING THE NERVES OF THE TRACTUS URINARIUS (4)  SENSATION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE).      Fig. 130.  An illustration of the nervus vasomotorius (sympathetic) drawn from a specimen which I secured at ail autopsy through the courtesy of Professor W. A. Evans.  The relation of the nervtis vasomotoritis to the tractus urinaritis is evidently intimate and abundant.  The network of nerves on the arteria renalis and ureter are apparent.  The enormous supply of nerves to the adrenal is remarkable - 7 in number.  The solid anastomosis of the plexus ovaricus with the plexus ureteris is noticeable, where the vasa ovarica (spermatica) pass ventral to the ureter.  The arteria renalis is enslieathed in a rich, plexiform, gangliated nerve plexus.  I dissected this specimen under alcohol, and the nerve relations are practically correct.  The artist, Mr. Zan D. Klopper, followed the fresh dissection as a model.  The ureter (calyces, pelvis and ureter proper) is dilated bilaterally.  Even the 3 ureteral isthmuses (of author) are dilated.

    It is evident on watching an exposed ureter of a sleeping dog that the sensation of the mucosa in the urinary apparatus is of vital importance, for each and every time that a certain quantity of urine collects in the dog's ureteral pelvis, the ureter proper executes its brusque, vigorous peristalsis with remarkable rapidity.  The automatic ureteral ganglia rule the ureteral peristalsis.  We do not realize the exquisitively poised sensory apparatus of the tractus urinarius until some catastrophy occurs, as ureteral calculus, to apprise us of the wild, disordered peristalsis and excruciating pain.  Pathologic physiology of sensation in the tractus urinari us may well comprise excessive, deficient or disproportionate states for sensation much depends on the composition of the urine and the state of the urinary visera.  Inordinate meat eaters produce concentrated, irritating urine, exciting excessive ureteral peristalsis with consequent pain - diluting the urine relieves the patient.
    In excessive sensation of the tractus urinarius we will include the so-called "Irritated bladder," because, though cystoscopy has lessened the actual number of irritable bladders by eliminating pathologic anatomy, it can not exclude the subject - pathologic physiology.  Irritable bladder exists without demonstrable pathologic anatomy.  The subjective symptoms of an irritable or excessively sensitive bladder are frequent evacuations (peristalsis).  The bladder may require evacuations several times an hour.  There is an increase in frequency and intensity in the desire to urinate - excessive visceral peristalsis.  Irritable bladder may persist day and night.  The desire to urinate may be so intense that insufficient time is allowed to prepare the dress and hence "wetting of the clothing" occurs.  Excessive vesical peristalsis, irritable bladder may be sufficient to cause vesical colic, which may radiate, reflexly to the tractus intestinalis or genitalis, disordering the function of peristalsis, absorption or secretion.  E. g., the patient may evacuate feces and urine simultaneously - so-called nervous diarrhea.
    The irritable bladder may produce cold perspiration, emesis, chills, and produce mental depression, hypochondria.  The main objective symptom of irritable bladder - pathologic physiology of vesical sensation and peristalsis - is hyperesthesia which manifests itself chiefly in the trigone where nerves congregate.   The neck and fundus may present irritability.  The hyperesthesia may occur as an increase in normal sensibility to tensions or as abnormal sensibility to pressure.  The abnormal sensibility may be manifest on the presence of solid feces in the rectum, digital examination or on cytoscopy.  The urine may present nothing abnormal in quantity, in reaction, chemical or physical characteristics; no hyperacidity, no excess of salts, concentration of urine, or glycosuria. What causes the hyperesthesia of the vesical wall - pathologic physiology, no demonstrable pathologic anatomy - is unknown.
 

Fig 131.  The nerve supply to the tractus urinarius is best remembered, perhaps by recalling its arterial blood supply; for the nervus vasomotorius accompanies the arteries.  The arteries to the tractus urinarius are: (a) arteria adrenalis; (b) arteria renalis; (c) arteria ovarica (spermatica); (x) arteria media ureteris; (y) arteria ureteris, distal (from iliac); (z) arteria uterina; (w) the three vesical arteries, each of which is accompanied by it own nerve plexus.  The upper part of illustration is from corrosion anatomy.

NERVES OF THE TRACTUS URINARIUS - CORROSION ANATOMY       Fig. 132.  This specimen presents quite faithfully the circulation, the kidney, calyces and pelvis.  The two renal vascular blades I present opened like a book.  The corrosion was on the left kidney and the larger vascular blade is the ventral one.  The vasomotor nerves accompanying the urinary tract may be estimated by the fact that a rich plexiform network of nerves ensheath the arteries, the calyces, pelvis and ureter proper.  When the renal vascular blades are shut like a book their thin edges come in contact, but do not anastomose.  The edges of the vascular blades are what I term the exsanguinated renal zone of Hyrtl, who discovered it in 1868, and we, at present, employ it for incising the kidney to gain entrance to the enterior of the calyces and pelvis with minimum hemorrhage.  This specimen presents excellently the capsular artery - Cap. A. Think of the vast amount of pathologic physiology which could be created by disturbing the rich sympathetic nerve supply to the kidney.

    Cystoscopic examinations and autopsies and examinations demonstrate that in irritable bladder no pathologic anatomy may exist or that a condition of hyperemia may exist in the bladder wall.  The subjects of irritable bladder in which no demonstrable pathologic anatomy  exists  are  simply  nervous  in  character, typical pathologic physiology.  The subjects possessing merely hyperemia of the vesical wall are of non-inflammatory type or non-detectable inflammation.  The irritable bladder is influenced especially by two factors, viz.: (a) psychic or mental disturbances; (b) tendency of blood to the pelvic organs (bladder).  The prognosis of irritable bladder, especially of the severe type. is unfavorable - almost every case I have observed was or has been practically life long.  The treatment is hygienic, dietetic - visceral drainage, preserving maximum state and contents of visceral tracts.  For more extensive views of the subject of irritable bladder see the excellent article by Hirsch, Centralbllatt f. die Grenzgebete Medizin u. Chirurgie, Vol. VIII, Nos. 13 and 14.
 

NERVUS VASOMOTORIUS OF THE TRACTUS URINARIUS       Fig. 133. I dissected this specimen under alcohol.  It presents excellently the solid and compact anastomosis of urinary nerves to all other abdominal vasomotor nerves.  Observe the solid anastomosis at M and N. The reflexes observed in practice may well be interpreted by this illustration.  Note the multiple, giant, ganglia accompanying the arteria renalis.  The nerves of the tractus urinarius presents a rich field in pathologic physiology.

    There are still apparently unsolved problems in the physiology of the tractus urinarius and hence multiple unsolved problems in the pathologic physiology of this important visceral tract.  For example, the urine (an acid fluid) is derived from the blood (an alkaline fluid) by a filtration process.  What changes the urine into an acid fluid from the blood, an alkaline fluid?  The explanation must be that the blood is practically and chemically an acid due to the presence of bicarbonates which are acid salts.
    The degree of the acidity of the urine is a measure of the degree of the acidity of the blood.  The acidity of both urine and blood is due to acid phosphates or salts of phosphoric acid (H3PO4), i. e., salts resembling acid sodium phosphate (NaH2PO4), acid calcium phosphate (CaHP04), and acid magnesium phosphate (MgHPO4,), which may assume more atoms in the bone.
 

CORROSION ANATOMY (HYRTL'S EXSANGUINATED RENAL ZONE)       Fig. 134.  In this specimen of corrosion anatomy the renal vascular blades (ventral and dorsal) are closed like a book.  It presents (left kidney) on the margin of the dorsal lateral surface the exsanguinated zone of Hyrtl - the line of minimal hemorrhage for corticle renal incision.  A rational method to estimate the quantity of nerves of the tractus urinarius is to expose the number and dimension of the arteries and other tubular ducts which are ensheathed in a plexiform networks fenestrated, nodular, neural vagina of nerves.  The nervus vasomotorius rules the physiology of the renal apparatus.  Modern investigation demonstrates an extensive zone of pathologic physiology in the domain of the kidney.

    "It is, therefore, obvious that the real urinary acidity is phosphoric acidity." (Editorial, New York Medical Journal, May 26, 1906.)
 

Fig. 135.  This specimen I dissected with extreme care under alcohol, and the artist, Mr. Zan D. Klopper, followed the dissection as a model.  It well illustrates the nervus vasomotorius in relation with the tractus urinarius.

TREATMENT OF PATHOLOGIC PHYSIOLOGY OF THE TRACTUS URINARIUS.

    Since pathologic physiology is the zone between physiology and pathologic anatomy it should be practically amenable to treatment.  First and foremost the diagnosis should be made, and the cause removed, as ureteral calculus, anal fissure, hepatic calculus or any point of general visceral irritation.  The most general essential feature of a subject suffering from pathologic physiology of the tractus urinarius is deficient visceral drainage.  The blood is excessively waste laden from elimination.  The secretions are scanty.  The urine is concentrated, its crystallized salts are evident to the eye.  The skin is dry from insufficient perspiration, sleep is defective from bathing of the innumerable ganglia with waste laden blood.  Constipation, deficient urine, limited perspiration, capricious appetite, insomnia and headache characterize subjects with pathologic physiology of the tractus urinarius.
    For many years I have applied a treatment to such subjects which I term visceral drainage.  Visceral drainage signifies that visceral tracts are placed at maximum elimination.  The waste product of food and tissue are vigorously sewered before new ones are imposed.  The most important principle in internal medication is ample visceral drainage for every visceral tract.  The residual products of food and tissue should have a maximum drainage in health.  I suggest that ample visceral drainage may be executed by means of:  (A) fluids; (B) food.

(A).  VISCERAL DRAINAGE BY FLUIDS.

    The most effective diuretic is water.  One of the best laxatives is water.  One of the best stimulants of renal epithelium is sodium chloride (1-2 to 1-4 physiologic salt solution).  Hence I administer eight ounces of half normal salt solution to a patient six times a day, two hours apart. (Note - NaCl is contraindicated in parenchymatous nephritis.) 48 ounces of 1-2 normal salt solution daily efficiently increases the drain of the kidney.  It maintains in mechanical suspension the insoluble uric acid, it also stimulates other matters.  It aids the sodium, potassium or ammonium salts to form combination with the uric acid producing soluble urates.
    The half normal salt solution effectively stimulates the epithelium of the tractus intestinalis, inducing secretions which liquefy feces, preventing constipation.

(B).  VISCERAL DRAINAGE BY FOODS.

    The great functions of the tractus urinarius - peristalsis, absorption, secretion, sensation - are produced and maintained by fluids and food.  To drain the tractus urinarius the adjacent visceral tracts should be excited to peristalsis, hence foods which leave an indigestible residue only are appropriate, all other visceral tracts must be stimulated to maximum peristalsis, secretion, absorption in order to aid that of the tractus urinarius.  Rational foods must contain appropriate salts whose bases may form combinations which are soluble, as sodium, potassium, and ammonium combined with uric acid and urates to form soluble urates.  The proper foods are cereals, vegetables, albuminates (milk, eggs), mixed foods.  Meats should be limited as they enhance excessive uric acid formation.
    In order to stimulate the epithelium (sensation) of the digestive and urinary tract with consequent increase of peristalsis, absorption and secretion in both, I use a part or multiple of an alkaline tablet of the following composition: Cascara Sagrada (1-40 grain), Aloes (1-3 grain), NaHCO3 (1 grain), KHCO3 (1-3 grain), MgSO4 (2 grains).
 

NERVUS VASOMOTORIUS OF THE TRACTUS URINARIUS  (CONGENITALLY DISLOCATED)      Fig. 136.  This illustration is drawn from a specimen I secured at an autopsy.  The right kidney was dislocated, resting on the right common iliac artery, with its pelvis (P) and hillum facing ventralward.  The adrenal (Ad.) remained in situ, It was a congenital renal dislocation, and was accompanied with congenital malformations in the sympathetic nerve, or nervus vasomotorius. 1 and 2 is the abdominal brain.  It sends five branches to the adrenal from the right half (2).  Though the sympathetic system is malformed, yet the principal rules as regards the sympathetic ganglia still prevail, viz., ganglia exist at the origin of abdominal visceral vessels, e. g., 3, at the origin of the inferior mesenteric artery; at the root of the renal vessels, HP is no doubt the ganglion originally at the root of the common iliacs (coalesced).  In this specimen the right ureter was 5 inches in length, while the left was 11 1/2.  This specimen demonstrates that the abdominal brain is located at the origin of the renal, celiac, and superior mesenteric vessels - i. e., it is a vascular brain (cerebru vasomotorius).  The solid and compact anastomosis of the nervus vasomotoritis of the tractus urinarius with nerve plexuses of all other abdominal visceral tracts is evident.

    Tablet is used as follows: 1-6 to 1 tablet (or more, as required to move the bowels freely, once daily) is placed on the tongue. before meals and followed by 8 ounces of water (better hot).  Also at 10 A. M., 3 P. M., and at bedtime 1-6 to 1 tablet is placed on the tongue and followed by a glassful of any fluid.  In the combined treatment, 1-3 of the (NACl) sodium chloride tablet (containing 11 grains) and (1-6 to 3) alkaline tablets are placed on the tongue together every two hours and followed by a glass of fluid.  The six glasses of fluid may be milk, buttermilk, cream, eggnog - nourishment.  This method of treatment furnishes alkaline bases (sodium, potassium, and ammonium) to combine with the free uric acid in the urine, producing perfectly soluble alkaline urates and materially diminishing the insoluble free uric acid in the urine.  Besides, the alkaline laxative tablet increases the peristalsis, absorption and secretion of the intestinal tract, stimulating the sensation of  the mucosa - aiding evacuation.
 

Fig. 137.  Illustrates the relation of the spinal nerves to the tractus urinarius, especially to the Plexus lumbalis.  The ureter is intimately connected with the genito-crural nerve (A); hence the pain reflected in the thigh and scrotum in ureteral colic and other ureteral diseases.  (2)  Ileo-inguinal nerve.

    I have termed the sodium chloride and alkaline laxative method the visceral drainage treatment.  The alkaline and sodium chloride tablets take the place of so-called mineral waters.  I continue this dietetic treatment of fluids and food for weeks, months, and the results are remarkably successful, especially in pathologic physiology of visceral tracts.  The urine becomes clarified like spring water and increased in quantity.  The tractus intestinalis becomes freely evacuated, regularly, daily.  The blood is relieved of waste laden and irritating material.  The tractus cutis eliminates freely and the skin becomes normal.  The appetite increases.  The sleep improves.  The patient becomes hopeful, natural energy returns.  The sewers of the body are drained and flushed to a maximum.
    Had space permitted it might have enhanced the clearness of the above subject to first discuss the pathologic physiology of the tractus urinarius, and, second, to discuss the pathologic physiology of the contents of the tractus urinarius.