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Theoretically, at least, this treatment ought to appeal to all who give the matter serious thought..

Practically, the results are almost ideal.

It is useful in all forms of dysmenorrhea, and, although a very effective treatment, produces no objectional by or after effects.

It rests upon broad scientific principles, and, when generally understood, will not only find a permanent place in the therapeutics of dysmenorrhea, but will also displace other less active measures.

I do not wish to imply that with the re-introduction of this method the millenium in the treatment of dysmenorrhea has arrived, but when positive, permanent, and almost immediate results follow the use of a remedy one can become almost enthusiastic.

URINE UNFIT FOR EXAMINATION.

CLIFFORD MITCHELL, M. D., CHICAGO.

The writer believes that if it were possible, after the fashion of the Chicago Vice Committee, to visit all the hospitals, dispensaries, and doctors' offices with the one aim in view to scrutinize the samples of urine examined, it would be found that at least one-half of them were, for some cause or other, unfit for serious consideration.

The causes which militate against a proper and thorough examination of urine are the following: (1) Ignorance, indifference, and slothfulness on part of those collecting and preparing it; (2) failure to preserve the urine from decomposition; (3) tardiness in delivering it to the analyst; (4) failure to supply a sufficient volume for thorough analysis; (5) failure to supply a suitable specimen of urine; (6) failure to supply a suitable receptacle for it.

Patients have no idea, of course, how to collect, preserve or deliver urine for examination. The duty devolves upon nurses, internes, and physicians to instruct them in regard to this. Such instruction is seldom given.

Immense care is taken to make everything ready for a surgical operation of even the least importance, but the collection and preservation of a sample of urine is undertaken in a spirit of carelessness which in some cases may almost be criminal, depending upon the gravity, of course, of the case.

Nurses need to be taught several things about urine: First, that a surgical "urinalysis," so-called, is not an analysis of urine; that for

the latter purpose, i. e., for diagnosis and treatment of obscure cases, the entire 24 hours' urine must be collected, and what is more, in such a way that none of it will decompose. Hence, for such a purpose the average hospital urinal is worthless, and must not be used unless the nurse can find time to rid it of its sui generis odor-not the odor of urine, but the smell of stale urine. Moreover, the nurse needs badly to learn that for an analysis of urine a few ounces will not suffice. It is safer to use a well sterilized fruit jar for the purpose of collecting urine than the average hospital urinal. The nurse should be instructed to keep the day and the night urine in separate receptacles, and when the day urine is collected to bottle it in a tightly corked bottle, and to keep the latter on ice. The night urine will in this way be free from any possible contamination from bacteria in the day specimen. We do not favor two 12-hour specimens, but prefer even this to the whole in one bottle. Moreover, the nurse should be told not to throw any away. This is a favorite occupation of nurses. Time and again the writer has been called up over the phone and the statement made that urine for analysis was saved, "but the nurse threw it out." There are some nurses who like to learn how to do things better than they have been in the habit of doing. Then again there are those whose ignorance, indifference, and slothfulness makes the proper collection and examination of urine almost an impossibility. A strange commentary upon our human nature! The writer once even received a bottle of stomach contents from a nurse with a request for an "urinalysis."

Urine collected in unclean receptacles, like chamber vessels, hospital urinals, etc., develops bacteria in number very rapidly. Urine containing an appreciable number of bacteria is unfit for examination. Urine can be protected from bacteria by collection in sterile receptacles, bottling in clean bottles, which are to be provided with clean corks, and kept on ice during the period of collection. If urine be removed from the ice and allowed to stand a long time before it is delivered to the analyst, more or less decomposition will set in. This is especially true in warm weather. The urine of pregnant women is difficult to preserve. Women in general, and especially pregnant ones, should cleanse the parts thoroughly before voiding urine for examination.

What is the effect upon the urine if the nurse or doctor fail to have it collected properly, preserved properly, and delivered properly? In the first place, the analysis is likely to prove unsatisfactory to the physician, and in the second, the patient is likely in some way to get the worst of it, either directly or indirectly. Or the analyst may be blamed for what is not his fault at all. During the warm summer months a

great amount of urine received shows the effects of carelessness on part of those engaged in collecting it. The lack of knowledge possessed by the average patient regarding the care necessary for collecting urine is surprising.

When bacteria get into urine and multiply there, the following happens: First, tubecasts disappear as if by magic. The writer has repeatedly seen tubecasts disappear from urine over night. In their place are seen the dirty-brown colonies of various bacteria. Hence, the writer is reluctant to report "tubecasts absent" in any specimen of urine in which these bacteria clusters abound. (These same bacteria clusters betray the carelessness of many an attendant upon the sick.) Again, when they are present in number, the urine is likely to show a trace of albumin. Many a diagnosis of "interstitial" has been made. upon no greater proof than this! Third, alkaline decomposition soon. follows in the wake of bacterial multiplication, and then we "lose out " on the acidity determination and the ammonia analysis-two important things in diabetes and in pregnancy. Fourth, when alkaline decomposition causes the urine to be strongly ammoniacal, all quantitative determination of urinary normal solids is vitiated to a greater or less extent. The Folin process for uric acid, and the uranium determination of phosphates then become a farce. Urea is lessened, owing to partial conversion into ammonium carbonate. The test for diacetic acid becomes doubtful, owing to the red color which the strong alkali gives with the ferric chloride, simulating or masking the real reaction for diacetic acid. It is claimed that Fehling's test for sugar is less delicate in ammoniacal urine

Again, in ammoniacal urine the test for albumin may mislead the inexperienced in several ways. First, he may mistake phosphates for albumin; second, if phosphates are not thrown down on heating he may fail to add enough acid after heating to coagulate the albumin present. Albumin in urine is converted into alkalialbuminate by action of ammonia. Alkalialbuminate is not coagulated by boiling until after enough acid is added to neutralize the liquid. This fact may possibly be the reason why inexperienced hospital internes sometimes fail to find albumin in cases of nephritis.

When patients' lives are at the mercy of anesthetic, such errors are deplorable and disheartening. Another sad commentary on our human nature! Last, but by no means least, it is often impossible to find tubecasts in ammoniacal urine, since the latter dissolves them. Hence, a report should not read "tubecasts negative" without addition of a statement that the urine is ammoniacal.

In regard to tardiness in delivering urine to the analyst, it may be said that this also is a great evil. Especially annoying is the slowness and indifference of express companies in making deliveries. Packages arriving in Chicago after twelve noon are frequently not delivered until the next day. On one occasion the writer found that the sample had been a year in transit! When urine is sent by express it should be marked "Perishable - Rush," and "Glass, with care." Many samples in glass containers sent by express are lost because the bottles are broken in transit. This is often the fault of those sending them, in neglecting to pack the bottles well in sawdust, or other protecting substance. There are still many persons who send glass bottles of urine in paper boxes to avoid the expense of the weight of wood. There are also those who wedge bottles tightly into too small a box, without wrapping paper or packing to protect them.

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Failure to supply a sufficient volume of urine is one of the most annoying things the analyst has to contend with. The question here comes up, How much urine is needed for the thorough examination of urine?" This depends upon what is meant by the term "thorough analysis." The following shows how much is required for various tests: Folin process for uric acid (books demand 300cc.) can be done. with 150cc.; determination of phosphoric acid, 50cc.; ammonia and acidity, 25cc.; indican test, an unknown quantity, according to difficulties, say 50cc.; chloride determination, albumin test, diacetic acid test, and sundries, 50cc. This total of 325cc., or say 12 fluid ounces, is a minimum required for even a clinical analysis. In how many cases is such a large amount ever supplied the analyst?

OTITIS MEDIA IN CHILDREN.

C. E. WEST, M. D., LINCOLN, ILL.

The subject of acute otitis media in children is of special interest, because of its importance and because of its difficulty of diagnosis in early childhood.

Out of sixty-five cases examined at postmortem by Ponfick, fatal cases under one year of age-cases of diphtheria, scarlet fever, infection of the lungs, purulent meningitis, gastro-enteritis, furunculosis and erysipelas-all but seven of the sixty-five showed pathological conditions in the ears.

Because of certain well-recognized anatomical differences, such as

the shortness of the Eustachian tube, the opportunity for extension of infection to other organs and structures near the ear, thereby causing otitis media, is much greater in childhood than in adults, and the disease therefore becomes one of more serious consequence.

The prevalence of abnormally developed lymphoid tissue in the nasopharynx and throat, such as adenoids and tonsils, of the young children, makes them more susceptible than adults to aural infection. Ballenger contends that a very large per cent. of ear troubles are due to adenoids.

Dr. L. Fisher, of New York, believes that ear diseases and resulting gastro-intestinal symptoms are caused by development of micro organisms in the mouth and nasopharynx, and the usual bacteria responsible for these conditions in children are the pneumococci and the streptococci. The pathogenic bacteria enter with the air and nasal secretions through the nose into the Eustachian tube. The infection may take place from the pharynx or by infectious secretions from the bronchi.

During the act of vomiting, it is easy for pathogenic bacteria to gain entrance to the Eustachian tube and into the ear. Sneezing, yawning, coughing, and swallowing, and indeed any muscular action associated with regurgitation of food while the child is lying down, are conditions which should be remembered in seeking the source of infection.

Nurslings vomit easily, and food is frequently expelled through the mouth and nose; in case the nose is obstructed by secretions and there is a damming of the decomposed food in the pharynx, bacteria, if present, can be forced easily into the Eustachian tube and give an infected

ear.

Diarrhea may be nature's method of eliminating poisons from the body, hence if the child suddenly shows gastric disturbances, food suddenly disagreeing, the temperature should be taken, and the diagnosis should not be considered complete without thorough examination of the nose, throat and ears. Symptoms of auto-infection may so resemble an acute milk infection that only a careful examination of the ears can determine the correct diagnosis. When the intestinal digestion is impaired, in spite of eliminative treatment and careful dieting, it proves that the seat of the trouble is elsewhere.

An examination of the blood in a doubtful case of prolonged fever may at times reveal obscure suppuration, and if the polynuclear percentage is high it indicates the presence of pus.

Grunert recommends very strongly that every case of a nursling with intestinal disorders, or with catarrhal disease of the lungs, or with dis

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