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by nitric acid or by heat, and, consequently, does not claim discussion in this paper; but there is a form of incompletely digested albumen, called hemi-peptone, which is precipitated by cold nitric acid, and, therefore, must be mentioned here. It was first described by Bence Jones, and from this is commonly called "Bence-Jones albumen." He found it in the urine of a case of osteomalacia. It is not precipitated by boiling; and it gives a precipitate like ordinary albumen with cold nitric acid, but this is redissolved on the application of heat. In this way it may be easily distinguished from ordinary albumen, and here lies its sole importance. It possesses no established clinical significance.
Resinous Drugs, like Copaiba.-Nitric acid often causes a precipitate in the urine of those who are taking copaiba, turpentine, or other resinous drugs. The odor of the urine, with the history of the patient, is generally sufficient to prevent error; but, in case of doubt, the addition of alcohol will dissolve the resinous precipitate and thus distinguish it from albumen.
When the urine contains blood, pus, prostatic fluid, or spermatic fluid, albumen will be present, which must be distinguished from albumen coming from the kidneys.
Blood.-Urine containing a small quantity of blood has a smoky appearance; and when a large quantity of blood is present, the urine is reddened and may contain clots. Even a very slight admixture of blood renders the urine highly albuminous. It is inferred that the albuminuria is dependent entirely upon the blood mixed with the urine, when the daily quantity and specific gravity of the urine remain normal and no symptoms of renal disease are present. The presence of blood is usually determined by the microscope. In some cases, however, the corpuscles are dissolved in the urine, leaving only albumen and coloring matter to prove the hæmorrhage. In such a case, having found albumen, and suspecting, from its smoky appearance, that the urine contains blood, test for hæmoglobin as follows: Wet a piece of white blotting-paper in the urine and dry it slowly over a spirit-lamp. When it is dry, drop upon it two drops of tincture of guaiacum, and a moment later, one drop of
ozonic ether. If the urine contain hæmoglobin, a blue color will develop in a few minutes as the spirit evaporates and leaves the paper dry. This test can not be relied upon if the patient be taking iodine in any form.
It should be remembered, in this connection, that the urine often contains albumen in the course of jaundice. A urine containing bile coloring matter and albumen is to be distinguished from bloody urine in which the corpuscles have disappeared by solution. The distinction is made by testing for hæmoglobin as described above, and then for bile-pigment with the familiar nitrous acid, or Gmelin's test.
Pus. Urine containing pus in any quantity is always albuminous, the albumen coming from the pus-serum. The only problem which is of interest to us in this connection is the discrimination between albuminuria from renal disease and albuminuria from bladder-catarrh. If a specimen of urine, otherwise normal, contain a trace of albumen and a few pus-cells, can we say that the presence of pus-cells shows that the albuminuria is due to catarrh of the urinary passages? The books tell us that, if more albumen be present than would correspond with the quantity of pus-cells in the urine, this excess must be referred to the kidney and be taken as evidence of renal disease. This statement is based upon the assumption that the relation between pus-cells and pus-serum is a constant one, and that so much pus-serum is always exuded with so many pus-cells. This is a mistake; there is thick pus, and thin, watery pus. Thin, watery pus contains more albumen in proportion to its cells than does thick pus. This may easily be proved by adding them to two specimens of normal urine until there is an equal deposit of cells at the bottom of each. The specimen to which thin pus has been added will then be found to contain much more albumen. This is further shown, also, by the clinical fact that while on one day a specimen may be seen containing a little albumen and a few cells, on the next day one may be met with which contains as many pus-cells with no albumen. The albumen contained in the former specimen can not with certainty, therefore, be attributed to the pus present. Except in extreme cases, it is
not possible to be sure that in pus-containing urine more albumen is present than the pus can account for. In such cases, the co-existence of renal disease can only be inferred from the presence of casts and from morbid variations in the daily quantity and specific gravity, with corresponding associated symp
Prostatic or Spermatic Fluid.—If a specimen of urine contain prostatic or spermatic fluid, it will be slightly albuminous. In the "Lancet" for May 13, 1882, Dr. Bradbury describes some cases of slight and intermittent albuminuria, in which he believes that spermatic and prostatic fluids were squeezed into the urethra during efforts at defecation and so imparted an albuminous reaction to the urine. Senator also speaks of this in his work on albuminuria and recommends that the urine first passed be thrown away and a specimen taken from the later flow. In this way, only the urine which was passed after the urethra had been washed out would be examined, and all such sources of error would be removed.
In conclusion, it may be said, by way of moral, that attention paid to the details of ordinary urinary analysis is time well spent; for there are few greater mortifications in the experience of a physician than to see albuminuria demonstrated where he has positively denied its presence, or to see its absence proved in a case in which he has confidently affirmed its exist
THE EARLY USE OF THE KNIFE IN ANGIOMATOUS NEVI AS COMPARED WITH OTHER METHODS OF TREATMENT.
By SAMUEL W. SMITH, M. D., of New York County.
MR. PRESIDENT AND FELLOWS OF THE ASSOCIATION: In presenting this paper for your consideration, I shall, at the outset, express my decided preference for the more general and the early use of the knife in dealing with those troublesome and unsightly vascular growths which appear on the face of infants and so rapidly increase in size. I am aware that this will seem to you a bold position to take, antagonistic as it is to many eminent and trustworthy authorities; nevertheless, we are here for an interchange of views derived from actual experience, regardless of their conflicting relations to the theory and practice of others. Facts are stubborn things; and we can not afford to ignore them, however unwelcome they may be. It is not necessary that I should consume your time with a review of the various plans of procedure recommended by others, such as the application of caustics, the use of coagulating injections, the ligature, electrolysis, acupressure, hot needles, etc. I concede that all these have their advantages and disadvantages; but none, I firmly believe, is so immediate in good results as the use of the knife, while in my opinion they are all more fraught with danger from the absorption of putrescent matters. I use the term angiomatous nævi, without particularizing the exact pathological character of these
growths, as to whether the venous or arterial elements predominate; for it not infrequently happens that the two exist in equal proportions. The rapidly increasing size of these tumors with the growth of the child makes their treatment, at an early stage of development, a matter of considerable importance, whatever may be the course adopted for their removal. I have seldom met with a case in which I should have hesitated to use the knife, from a lack of confidence in the results.
The following two cases are selected from those of a number of patients, treated by me at the Demilt Dispensary, suffering from these vascular growths. I have selected them for my paper because, at an early date in their history, I saw them and proposed an operation with the knife, when the tumors were comparatively small. I think the history of these cases will speak more forcibly and conclusively than I can write, in vindication of the early use of the knife in angiomatous nævi, as compared with other modes of operation for their removal.
CASE I.-Angiomatous Nævus of the Face successfully removed with the Knife, after some other Method had been tried endangering the Life of the Patient.-Mamie T., aged eight months, born of healthy parents, in October, 1883, was brought by her mother to the Demilt Dispensary, when four months old, for advice with regard to a birth-mark and a small tumor on the side of the face. The mother informed me that she first noticed the swelling underneath the birth-mark some two months previously, and that it seemed to be getting larger. Examination showed the following conditions: The wine-mark was of about the size of a twenty-five-cent piece, and was situated just below the zygoma and in front of the tragus. The tumefaction, of about the size of a hickory-nut, was not adherent to the skin, was soft and inelastic to the touch, compressible, and it increased in size whenever the child cried. I advised the immediate removal of the tumor with the knife; but the mother refused to have it done at that time, and left the dispensary. One month later, the mother returned with her child, the tumor having perceptibly increased in size, and said she would have me remove the tumor if I would use bot needles. Hot needles were not used, and she left the dispen