Billeder på siden

four blankets over them, they would freeze to death. He said there was never a place between White River and the Wabash where there was so much fever. I am not opposed to the doctrine of bacteria producing disease—that is, I believe that germs have been found-but I am not convinced that they are not the result rather than the cause. I do not want my friends to say when my patients die, as they do once in a while, as I suppose yours do, that they died because I neglected to take advantage of this theory, so I take what I regard as innocent measures in order to protect my patients if this doctrine should be true. That is one of the best evidences that I am not wholly denying the proposition. Now, in regard to typhoid and typho-malarial fever: Every physician in every locality has had to deal with fevers that he could not say clearly were of an enteric form, and yet they seemed to run on and run on and have symptoms very much like that disease, and it was called typho-malarial fever. I think so far as the experience we have had in this city is concerned, as in the case Dr. Woolen has spoken of, it is sufficient to convince us that we are dealing with enteric fever and we would be safer to regard it as such. On the other hand, may we not have a so-called malarial fever in a more or less continued form? I think when a man has been so enervated by excessive heat in the day and the cold at night that his system would be so broken down that he might have a fever that is more or less continuous, and that that is the fever which would be called typhomalarial fever. It does seem to be a convenient term with which to express what we often have to deal with. As a term I think it

ought to be retained.


Suppose you had five cases in the same family, four of them being a mild form, no diarrhoea and no hemorrhage, and the fever lasts four weeks or five weeks, that the temperature went to 103 and 104 and they got well; that in one case in the same family there would be severe hemorrhage, diarrhoea and enteric trouble, would you call it all the same?

Dr. Fields-It is all typhus fever; different grades of the same disease.

Dr. Harvey-The safest way is to regard it as typhoid fever and treat it so.



Last year, it will be remembered, I read a paper before this Society on urea, and the subject was referred by vote of the Society to me to be investigated during this year, and report at the present meeting. In the paper read last year, I called attention to urea as a normal excretion of the body, and gave data showing the limits of variation in the twenty-four hours, as found by careful observation of others, as well as those made by myself. That this normal variation might be altered by change in diet, by the quantity of fluids taken in the body, or by increased muscular action; that these variations, being due to an increased or decreased quantity of tissue change which was thus eleminated from the body does not subject the individual to any ill effects.

Secondly. That urea retained in the blood in abnormal quantities has the tendency to produce discomfort in the individual, and generally does so do from dyspnoea, vertigo, blindness, nausea, general weakness or some of the many symptoms auxiliary to this condition, and that the severity of these symptoms bears a relation always to the quantity of retained urea.

Thirdly. That in the course of other diseases or abnormalities the variation is well marked, being in many cases one-half the normal excretion for that individual, and in others greatly increased quantities of urea are passed; but in these cases careful observation and examination will determine the primary cause of this variation, and no account should be made of the symptoms in this connection.

Fourthly. There exists, in my judgment, a disease or class of

[ocr errors]

diseases which can not be differentiated into other lesions or diseases and which are not known to be the result of any normal variations, but which have as a constant factor a decreased quantity of urea excreted in twenty-four hours; that there is a train of symptoms, many of which are almost constant for this class of patients, and that careful examination of this excreta will determine the extent of the disease and the distress of the patient; that the symptoms attending these patients are well marked, and resemble those found in known cases of Bright's disease, but may be accompanied with albumen and casts, or may exist without them; that the disease may occur many months previous to the occurrence of albumen and casts, and be followed afterwards by these conditions, or may continue for many months without any of these manifestations, and patients finally die and post-mortem disclose diseased kidneys, or patient may, after a time, entirely recover and pass the normal quantity of urea.

It will be the purpose of this paper, or report, therefore, to still further inquire into the causes of these symptoms, and see, if possible, what part retained urea plays in their production. For three years past I have been investigating the subject of urea as a normal excrementitious compound of the body, and as a prominent factor of disease when from pathological changes it is not eliminated in sufficient quantities from the blood. In order to make such an investigation it is necessary to procure or devise some kind of apparatus adapted to the purpose, and I speak of this here because the transactions last year made me say, in my talk at the close of the discussion, that such an apparatus could be had by writing to Charles Haven & Co., which is a mistake. I said at that time that there were many methods already in use among the members of the profession, but that most of them were impracticable owing to the time consumed in the test, or an inability to judge accurately of the steps in the examination because of care required in all the details. Compounds containing chlorine, such as the hypochlorite of soda or lime, when mixed with urea in solution, will unite with some of the elements of this compound, and drive off nitrogen gas. It is only necessary, therefore, to improvise a vessel that shall be marked at equal intervals within the maximum and minimum variations of this gas, as is shown by allowing the

gas to displace water in the vessel. This can be done at the office, if you care to spend the time in making sufficient tests to establish an accurate instrument, otherwise you can use an apparatus manufactured by Parke, Davis & Co., of Detroit, which is quite accurate, as you can prove by observation while using it. As the hypochlorite of soda loses its chlorine in a few days if not exceedingly careful, I have found it the best plan to obtain chlorinated lime in powder, and make a saturated solution of it in water every few days, thus making sure that enough chlorine was present to unite with and break up the elements of urea when put to the test.

A book should be improvised that may contain name of ient, time of examination, age of patient, sp. gr. of urine, reaction, quantity passed in twenty-four hours, whether urine contains albumen, casts or sugar, the per cent. of urea, and grammes of urea passed in twenty-four hours, so that an accurate record may be made of each examination, and a comparison will thus be always before you of the relative amounts of urea passed by each patient at each examination.

In turning to such a record I find the following cases, which I will give to better illustrate my meaning in regard to the examinations and the varied conditions before referred to that occur among this class of patients.

Case 1. On September 25, 1885, Henry M., German, age 56, came to the office complaining of the following symptoms: General weakness, headache, nausea, dizziness, shortness of breath, swelling of lower extremities, and slight disturbance of heart. Examination showed sp. gr. 1023; acid; one-half pint passed in twenty-four hours. No albumen or casts. Three per cent. of urea passed, or 7.2 grammes in twenty-four hours. No other objective evidences of disease could be found than those mentioned above. Gave this patient 10 drops of digitalis three times daily and advised free use of epsom salts to evacuate bowels. Patient showed a gradual improvement by passing a greater quantity of urine, as well as urea, for about three months. Urine was examined and examination recorded every week during this time, but at no time were casts or albumen found in urine. The last of November patient was exposed to cold and relapsed into first con

dition, except that urine showed slight traces of albumen. From this time all symptons were exaggerated and he finally died of uræmia. Post-mortem showed chronic interstitial-nephritis. This case certainly presents no perplexing symptoms, and is given as a means of comparison only.

Case 2. Mrs. H., aged thirty, native American, came to my office in April, 1885, with following symptoms: Headache, nausea, vomiting and general weakness which had continued for two or three years previous. No objective signs of disease could be found on careful examination. Examination of urine showed sp. gr. 1020; acid; passed 23 pints in 24 hours; slight trace of albumen ; no sugar and no casts. Per cent. of urea of 1 per cent. or 6.6 grammes in 24 hours. Examinations following for almost one year showed slight improvement with occasional relapses almost continuously until August 4, 1886, when from exposure, patient passed but 6.6 grammes of urea in 24 hours and had all her former distressing symptoms. Has since more rapidly improved, and although has passed through child-birth, has not had another relapse, and is now apparently well. Was this a case of Bright's disease or other disease of kidneys, or was it the result of some other general disturbance with these manifestations?

Case 3. John S., age 57, American, came to office October 7, 1886, with following symptoms: Vertigo; numbness in lower extremities; nausea; general weakness; pain in chest and in back of head; soreness in muscles; insomnia. Had been treated by other physicians for several months for same symptoms, but now more severe than before. Examination showed the urine to be acid; sp. gr. 1015. Passed two pints in 24 hours. No albumen, sugar or casts. Passed 1 per cent. of urea or 13.6 grammes in 24 hours. The use of diuretics and free evacuation of bowels seemed for a time to relieve all these symptoms, but patient gradually passed from a higher to a lower number of grammes of urea in 24 hours, and as gradually grew worse in all the former symptoms until he finally died with uræmia. In this case no albumen was found at any time in the urine, and no evidence, save these urea tests and subjective symptoms could be had of disease.

« ForrigeFortsæt »