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URINARY ANALYSIS AS A MEANS OF DIAGNOSIS. READ BEFORE THE ALLEGANY COUNTY MEDICAL SOCIETY AT ITS Annual Meeting in FROSTBURG, Md., June 6, 1895. By E. T. Duke, M. D.,
NOTHING original is offered as the excuse for speaking on the subject of urinary analysis, but merely a desire to awaken an interest in the importance of it as a means of diagnosis. We are too apt in the hurry and cares of professional work to be satisfied with hurried and incomplete diagnoses of our cases, and to treat them empirically. This ought not to be when we have at our command a means of finding out the true nature of the disease and applying suitable remedies. Chemical analysis and microscopic examination have thrown a brilliant flood of light on hitherto obscure diseases and have given to us a window, as it were, through which we can see the interior of the body, and determine accurately in many instances the seat of disease, its progress, and the exact condition of the diseased organ. The examination of the urine need not be confined to diseases of the kidneys and bladder, but may be found serviceable in many other affections.
The urine being one of the excretory products of the body may contain in solution substances which, when examined chemically or microscopically, will show organic changes in organs not directly connected with the urinary system, and thus afford an opportunity for a correct diagnosis of the case, and more rational treatment.
The methods of determining the specific gravity, the tests for albumen, sugar, etc., are of course familiar to all of you, and need not occupy more space. Formerly urine was allowed to stand in a vessel some time in order that the sediment might be obtained for examination. This was unsatisfactory, as changes would take place in the urine, and render its examination almost useless. To obviate this difficulty Dr. Charles Purdy of Chicago has devised
an electric centrifuge, which allows of the immediate sedimentation of the urine, and its examination before any chemical change has taken place. Conical tubes are used and after centrifugal action has been employed the amount of sediment can be determined by a graduated scale on the tube. Precipitation of the substances in solution in the urine may be accomplished by the use of chemical agents, and the amount of substance determined by measure. Examinations made during a course of treatment will aid materially in determining the progress of the disease.
The diazo test was suggested by Ehrlich in 1882 as a diagnostic measure in typhoid fever. The reaction depends upon the fact that if sulphanilic acid be acted upon by nitrous acid (HNO2), diazosulphobenzol is formed, which unites with aromatic substances frequently found in the urine to form aniline colors. In this case a carmine red color is formed. This reaction is usually found in typhoid fever from the fourth to seventh day and afterward. If entirely absent the diagnosis is doubtful. The reaction has been noted in pulmonary phthisis of a rapidly fatal type. It is always absent in chlorosis, hydremia, diabetes, diseases of the brain, spinal cord, kidneys and liver.
The urine in scarlet fever assumes the febrile condition more or less marked in proportion to the degree of fever. During the first week the amount is less, and urea and uric acid increased, the chlorides reduced. About the sixth to eighth day if the disease proceed toward a favorable termination the urine becomes abundant, pale in color and approaches the normal standard. It should be examined both chemically and microscopically to determine the progress of the fever. Recent observations show
that nephritis exists almost as constantly as the rash or angina. Albumen appears about the the fifth to eighth day, subsiding about the fifteenth if the disease proceed favorably. The amount varies very much, sometimes mere traces, in others the urine becomes almost a solid mass when heated. Casts are found if carefully looked for in most cases, the hyaline in favorable cases, epithelial, bloody and granular if nephritis becomes established.
During the algid stage of cholera the urine is more or less suppressed, due to collapse, and in part to exudation into the renal tubules, and thickened blood. After the cold stage the volume slowly increases or is entirely suppressed, death rapidly following. The specific gravity of the urine upon reappearing is below normal, 1006-1008, and gradually rises to normal during convalescence. Urea is much diminished, sometimes entirely absent during the first day. The prognosis may be considered favorable in proportion to the amount of urea excreted in cases which have passed the algid stage. The phosphates and chlorides are absent or in small amount at first. The normal urinary pigments are nearly entirely absent during first two days, returning later. Indican is present in marked quantities and prior to the discovery of the cholera bacillus was considered the most important diagnostic sign of cholera. The first urine in cholera almost always contains albumen, but as a rule the albuminuria is of short duration. It sometimes persists, however, and death may result from uremic coma. Renal casts and large deposits of epithelium are invariably found. Frequently blood corpuscles and uric acid crystals are also found.
In diphtheria the urine is much less in amount than normal, of high specific gravity, and acid in reaction. Uric acid is copious; amorphous urates, oxalates and sometimes phosphates are found in the deposit. Albumen is present in 50 per cent. of cases, sometimes in large amount. The kidneys become affected in some cases, but not so frequently as in scarlatina. The quantity of urea is nearly double the normal
amount. Renal casts are seen, and sometimes free from pyelitis associated with the disease.
The general pyrexial characters of the urine are well marked in pneumonia. The quantity is lessened one-half, but urea and uric acid are increased in amount, especialiy on the so-called critical days. ical days. The increase of pigment is often two or three times the normal range.
The chlorides are greatly diminished or entirely absent during the first stage of the disease. When absent later in the disease there is danger of a fatal termination.
Albumen is present in about 45 per cent. of all cases, and if in large quantity it may be looked upon as an unfavorable symptom. Nephritis may be latent in pneumonia, only to be discovered some weeks or months after convalescence.
In organic diseases of the stomach the urine contains a considerable quantity of peptone. This is especially true where there are ulcerative changes.
A mild form of albuminuria is frequently present in disorders of the stomach, and examinations in these cases will show no casts. Small quantities of sugar are found in a number of stomach affections. Amorphous phosphates and calcium oxylate crystals are most frequently found in the urinary sediments of dyspeptic subjects.
In yellow fever the urine is diminished, frequently suppressed, when the symptoms of uremia follow. The reaction is first acid, becoming alkaline during convalescence. Its color varies from a bright-yellow to greenish-brown or black, or it may be red from the presence of blood. It is almost always albuminous. Urea is lessened, sometimes entirely absent. This is also true of the uric acid.
The most noted change in the urine in typhoid fever is the diminished amounts of chlorides; in severe cases they are entirely absent, or not excreted. This is not due to lack of food, or diarrhea, but seems a constant feature of the disease, thus furnishing another diag nostic sign for this malady.
Cirrhosis of the liver is marked by a constantly lessened flow of urine; so marked is this fact, that a constant copious flow would be strong evidence of the absence of cirrhosis. The urine is darkred, brown or even blackish. The acidity is increased and it becomes still more acid on standing. So constant is the association of bile pigment in the urine in this. affection that it may serve to distinguish ascites of hepatic origin from that of peritoneal effusion.
Albuminuria is rare except when associated with valvular heart lesions. The urinary sediment does not contain renal casts.
As a rule, the volume of urine is somewhat lessened in jaundice, uric acid is increased and urea diminished. It is highly acid, becoming more so upon standing. The color, due to bile pigment, varies from a saffron-yellow to a greenish-brown. Where sugar is present the case is unfavorable for recovery. The value of urinary examination in this affection is to establish the diagnosis promptly, which may be readily done as the bile pigments are present in the urine early. The presence of bile pigments, or their absence in doubtful
cases, assists in determining whether the case is one of obstructive or non-obstructive jaundice.
CONTAGIOUS and infectious diseases produce a large proportion of the suffering and death to which the human race is subjected. Medical science has accomplished great results in mitigating those evils, and it may be confidently expected that the glorious work of immunization and antidotal treatment, which is fortunately exciting the interest and enthusiasm of medical scientists in the leading countries of the world, will produce additional advantages equal, if not superior, to those which have already been attained.
One hundred years ago smallpox was a scourge almost as horrible as war.
The urine contains both bile acids and bile pigments and is strongly acid. The amount is much diminished, though not suppressed, and the color is very dark brown. Urea is lessened, sometimes nearly absent, uric acid and phosphates are reduced in quantity. Casts, when present, often appear yellow from staining with bile pigment.
The most noticeable urinary change in gout is the deficiency of uric acid, and the presence of small, narrow hyaline casts and crystals of calcium oxalate. In acute rheumatism the increase of the sulphates in the urine is greater than in any of the acute fevers.
In closing, gentlemen, let me say that in my effort not to be tiresome I have avoided formulae and detailed methods of testing urine, as my purpose has been not to give information, but rather to awaken a greater interest in the subject of urinary analysis.
THE NECESSITY OF ISOLATION AND ADVERTISEMENT OF CERTAIN CONTAGIOUS AND INFECTIOUS DISEASES. READ BEFORE the State MEDICAL SOCIETY OF PENNSYLVANIA, June 9, 1895.
By F. Le Moyne, M. D.,
But by the general introduction of vaccination, its ravages have been so restricted that it is no longer a reasonable source of dread.
Those who have witnessed and experienced the desperate helplessness of the diphtheritic victim have the unspeakable gratification, in this, the infancy of the antitoxine method of treatment, of being able to reduce the mortality in desperate cases of diphtheria at least fifty per cent. of their former death rate, with a prospect of better results from the perfected methods which will surely follow more matured experience.
All contagious and infectious diseases should be treated as preventable by immunization and isolation.
Immunization is known to be effectual by natural methods in a considerable proportion of such affections, and enough has been accomplished in its scientific application to lead to the belief that it is practicable in all.
Perfect isolation is impossible, because the most susceptible subjects will be impressed by very remote influences. But that fact does not justify the exposure of the whole susceptible community by unisolated cases.
Every center of population should be provided with hospitals for contagious diseases, and laws should be enacted which would provide for the removal thereto of every case of dangerous contagious disease, for which reasonable isolation is impracticable in its existing location.
The members of the medical profession are the natural and acknowledged guardians of the health of the people, and it is incumbent upon them to lead the public mind safely in that direction. We should emphasize the fact that every case of scarlatina or diphtheria not care
PELVIC ABSCESS COMMUNICATING WITH INTESTINE. Marx (British Medical Journal) records an operation on a woman, aged 44, long subject to symptoms of pelvic inflammation. She had not been pregnant for eighteen years. On December 8, 1894, there was extensive parametric deposit, with indistinct. fluctuation in the left iliac fossa. By December 17 this fluctuation had become quite distinct; the pain was intolerable. On the next day vaginal hysterectomy was performed. Large abscesses were then laid open. The appendages could not be removed. One very large collection of pus was opened on Hilton's method. About a pint escaped. It was bluish, and smelt fecal, but no fecal matter was found in it. A T-shaped drainage tube was placed in its cavity. On the tenth day a quantity of feces was found in the vagina. For a fortnight motions passed both ways; when there were scybala in the rectum
fully isolated and plainly placarded is a shameful menace to the surrounding population.
Existing laws in this State commit the strange inconsistency of exacting precautions and restrictions in regard to smallpox, which is to a great extent under control by vaccination, and from which disability and mortality are comparatively inconsiderable, while scarlatina and diphtheria, to which a much larger proportion of the population is susceptible and in which the death rates are very high, have every opportunity for dissemination and are not subject to legal regulations.
Fortunately this subject is under wise consideration by the Legislature of Pennsylvania now in session. An act has been framed which although not all that we could desire, has much to recommend it, and I hope that it will meet with the approval and support of every member of this society. It has passed the House of Representatives and it is reported by good authority that it will be favorably considered by the Senate. I offer, herewith, a copy of the bill for the information of those who may not be familiar with it.
more feces escaped through the vagina. Much fluid had to be thrown up the rectum before any of it returned through the vagina, hence the communication must have been high up. It could not, however, be detected by the finger passed into the abscess cavity. By February 18, 1895, the patient was in good health. A little pus still escaped from the vagina, but all pain had disappeared.
VASCULAR SPASM WITH CARDIAC DILATATION.-J. Jacob (Medicine) says: "A sudden spasm of the peripheral vessels occurs with a chill and sometimes pain, precordial distress, dyspnea, cold skin, and very slow or very rapid pulse; at the same time there is acute dilatation of the heart, the area of dullness is increased, and the apex is displaced. This continues for several weeks, or indefinitely if the attacks are recurrent. The best treatment is hypodermic injections of full doses of morphia."
ALLEGANY COUNTY MEDICAL SOCIETY.
ANNUAL MEeting June 6, 1895.
This Society held its annual meeting in Frostburg, Md., Thursday, June 6, in the Council Chamber.
A large number of physicians were present. Promptly at 2 o'clock Dr. A. G. Smith called the meeting to order. About ten or twelve new members were elected. Dr. W. Q. Skilling read a paper ON THE IMPORTANCE OF EARLY INCISION IN TREATMENT OF OSTEO-MYELITIS. Drs. Carpenter, Cromwell, J. M. Price, Jacobs and others took part in the discussion.
Dr. E. T. Duke followed with a paper on URINARY ANALYSIS AS A MEANS OF DIAGNOSIS. (See page 291.) The following officers were elected for the ensuing year: Dr. A. G. Smith, President, Drs. Boucher, Spear and Jacobs, Vice-Presidents, Dr. F. W. Fochtman, Secretary, and Dr. W. J. Craigen, Treasurer. The afternoon session then closed and the Society proceeded to the St. Cloud Hotel, where they were handsomely entertained by the physicians of Frostburg.
At 8 P. M. the Society was again called and opened by Dr. C. C. Jacobs with an able paper on THE TREATMENT OF STRANGULATED HERNIA. Discussion followed, participated in by Drs. Spear, Cromwell, Boucher, Price, Smith and others.
Dr. Carpenter, on behalf of the physicians of Cumberland, gave a full statement of the differences which have existed between the physicians of this city and the Board of Managers of the Western Maryland Hospital. These difficulties have been adjusted and the physicians of the county and adjoining neighborhood are invited to send their patients to the Hospital. Cumberland was selected as the next meeting place, and Drs. Porter, White, Cromwell and J. M. Price were selected to read papers. The meeting closed with the President's address, PHYSICAL CULTURE. Everyone
present seemed to enjoy himself and to appreciate fully the kindness of the physicians of Frostburg.
E. T. DUKE, M. D., Secretary.
THE DOCTOR'S LIFE AND WORK.At St. Mungo's College, London, on Saturday, June 29, Dr. D. C. McVail delivered the closing address, as reported in the British Medical Journal, to the students in the rooms of the MedicoChirurgical Society. He said there was no enormous difference between men engaged in the ordinary work of life and a true and genuine member of the medical profession, except that his best work was done among those from whom he could expect no reward, and sometimes not even gratitude. In that respect the medical profession resembled the Church, but its work entailed far more labor and self-sacrifice. The true doctor was an unpaid medical missionary. The merchant, the manufacturer and the engineer were as well educated, though on different lines, as the medical man; but they differed in this, that the best of the medical work was given to the poor as though they were rich. Government payments to medical men were a mere fraction of the market price of the work that the profession had to do. Though the medical man seemed to live a public life, the nature of his duties made him probably the most solitary man in his village, carrying secrets of importance, and knowing oftentimes conditions of life and health which he must keep locked up against his most unguarded moments. His duty lay with his own conscience alone. His patients could not judge of his failures or of his triumphs. The public could not estimate his work as they could that of a clergyman or a lawyer. The doctor's work, so far as the patient was concerned, was written in water. Work of this solitary type was fraught with grave temptations and dangers to the medical man. Why should he continue to be the plodding, hard-working student, watching the ad