else than a slight increase of the natural mucus of the bladder mixed with the urine. Here the inflamed mucous membrane, naturally more sensitive, becomes quickly intolerant of the presence of water and drives the bladder to expel it at frequent intervals. The tripod of Keyes, followed out to the letter during the acute exacerbations, supplemented by pichi and Silurian water, will fetch about in the large majority of cases quick and marked improvement, and in time permanent cure.

It is the second variety of chronic cystitis, called, as I think improperly, vesical catarrh, which is the most frequent of all the bladder troubles.

Sir Henry Thompson stated, now a long while. back, that cystitis has almost always some ascertainable cause, and that it very rarely in deed appears in what is called an idiopathic form. Keyes goes so far as to say that it never appears as an idiopathic affection, but is always a secondary result arising from other morbid conditions of the urinary passages. And he adds, that once started it does not tend to get well spontaneously, but to become steadily worse. Most of the several causes of this condition can be removed, and with them the chronic inflammation which they keep up. Nece-sarily some cases are incurable because of permanent structural changes in the bladder walls, or where the cause can not be reached. All, however, may be benefited by careful and judicious management.

In no disease is the command to remove the cause more imperative than in chronic cystitis. It goes without saying that in many cases this can not be done. Where it can be accomplished chronic cystitis is among the most curable di-ea-es at any period of life, unle-s it has continued for such a length of time as to produce structural and permanent change in the bladder walls (hypertrophy, sacculation, etc.). Palliative treatment is reserved for these latter cases; and it is in just these cases that our art is capable of doing so much to comfort and assuage, to make life bearable and to lengthen its span. And when results here are not all that may be desired we have left the operation for supra pubic fi-tula. This procedure is unfortunately often too long delayed. It were bet

ter, I hold, to do this early than late, and I venture to think that the improvement in the management of obstinate cases of vesical catarrh, which the near future will emphasize, lies in early cystotomy.

In vesical catarrh due to causes which can not be overcome, the first thing to do is to empty the bladder by a catheter once or more a day, with the gentlest possible hand. Where this can be thoroughly done the most important advance toward relief has been made. It unfortunately happens, however, that the contents of every bladder can not be completely removed with the catheter. For causes which I shall not stop to enumerate, a portion of the urine remains; this and the mucus undergo chemical change, decompose, become stale, acrid, irritating, and intensify by their presence the already existing evils.

In this condition of things it becomes necessary to supplement catheterism by washing out the bladder. How often should the patient be catheterized? The best answer, I think, is furnished by the bladder itself. Whenever this organ becomes sufficiently distended to produce pain, empty it. If the patient can do this unaided, so much the better; but be sure the evacuation is complete, otherwise employ the catheter yourself, for the urethra had better be subjected to the irritation of an instrument than the bladder subjected to the irritation of residual urine. Soft instruments are better than hard. Water containing a small quantity of salt or of chlorate of potash is a more agreeable injection to the patient than simple water. But equally agreeable, and of positive curative value, are injections containing boracic acid. Whatever be the injection, its temperature when it reaches the bladder should be not less than 100° F. Allowance should be made for the water to cool as it passes through the instruments, and it had better, therefore, be started from the vessel at a temperature of 105° to 110°. The ordinary Fountain syringe is as good an instrument as any for making injections. Few bladders will receive at first without pain more than an ounce or two of water. A sense of vesical uneasiness should be the guide as to the amount of water introduced. Positive

pain should not be inflicted. The water, after remaining in the bladder for a few moments, should be allowed to run out. It will bring with it at first whatever substance is mixed with the urine-always mucus-sometimes pus and mucus. The injection should be repeated until the water runs away clear. After a time there will either be an improvement in the bladder itself, or it will have grown accustomed to injections, when larger quantities of water, and often of much higher temperature, may be introduced. Injections of gradually increasing size are, I think, indispensable to the cure of these cases. Without being used in this way they can not do their full work. The fluid must be made to reach every nook and corner of the pouches which are so often present in cases of long standing, and without the thorough cleansing of which no progress can be made toward cure, and not much even in the way of comfort.

Injections are medicated with many different substances. When the urine is alkaline and depositing phosphates, half a grain to a grain of acetate of lead to the ounce of water is strikingly valuable. A very soothing injection will be found in the bi-borate of soda, 15 grains dissolved in half an ounce each of glycerine and water. A few drops of dilute nitric acid to the ounce of water I have used with benefit where the urine was heavily charged with the phosphates. Nitrate of silver in even so small quantities as a quarter of a grain to the ounce, which is often recommended, I have found at times to cause great suffering. And though as much as 40 grains to the ounce of water have been thrown into the bladder, notably by my friend and former classmate, Prof. Richardson, of New Orleans, I have never ventured upon the introduction of so strong a solution except in a single case. In this the suffering was so very intense I have trusted since to remedies which were less

severe.

As an all-round substance for injection I know none to compare to boric acid in every variety of cystitis in which injections are called for. It seems to me to fulfill every indication. It lessens the phosphates as well as lead or nitric acid. It changes the odor better

than carbolic acid, and when given in full doses internally at the same time it has appeared to me to accomplish all that can be done toward changing, correcting, and sweetening the urine. To get these results, however, the system must be saturated with it, and the bladder fully distended with it in saturated solution. Short of this it will be found necessary to supplement it by some one of its companions that I have named.

Among internal remedies the salicylates and the benzoates embrace perhaps the best. Tonics are useful, in all, and essential in many cases. Warmth, as obtained by climate, by clothing, and by other means, is scarcely second in importance to any thing I have named. Many a man with chronic cystitis has been able to secure comfort by spending his winters in the South, and many cases have escaped exacerbations at home by avoiding all exposure to cold.

Catheterization done properly and sufficiently often, irrigation done properly and sufficiently often, with a saturated solution of boric acid introduced as hot as it can be borne, and gradually carried to the point of full distension of the bladder, constitutes, I think, the best local treatment for all the ordinary forms of vesical catarrh.

Bibliography: Sir Henry Thompson, Keyes, Bumstead, Berkely Hill. LOUISVILLE.

LEPROSY.*

BY D. T. SMITH, M. D.

It may be safely said that no other disease that has fallen upon the human race has been attended with so much misery as leprosy. Consumption, smallpox, pneumonia, malaria and many other diseases that might be mentioned, have each slain thousands to its one, but such has been the dread of leprosy that those who suffered from it have been compelled to die a thousand deaths.

Syphilis is easily concealed, is communicated except in rare instances only to those who go half way to meet it. Smallpox spreads its contagion with such fated certainty that escape

*Read before the Louisville Medico-Chirugical Society, August, 1889.

from it was deemed hopeless during all the ages when it was most destructive; while the plague, that bid fair at one time to depopulate the earth, was so quick in its deadly work that the human race stood dazed as the deer in the tiger's teeth, or the bird in the jaws of the serpent, and men scarcely realized that it was on them till death relieved them.

Consumption alone of all the diseases that make up the sad heritage of man could be made. to yield so much of wretchedness and misery. If once the consumptive could be made the pariah that many who go wild on the question of microbes seem to desire; if forgetful of the fact that the bacillus tuberculosis is too widely and abundantly distributed for a suitable soil ever to remain unoccupied, even after all human efforts at disinfection have been exhausted, and forgetful that worse things than death can befall, then indeed might we see a worse state of things than Europe exhibited in time of the prevailence of leprosy during the middle ages.

During that period, when one was found to be afflicted with leprosy he was judged dead in the eyes of the law and putrid in the eyes of society, and even the church required the administration of extreme unction, while dirt was sprinkled over the head of the leper to typify the ceremony of burial.

To us the largest interest that attaches to leprosy concerns its diagnosis as a prerequisite to prophylaxis when once the disease threatens to invade the community. For, if it is contagious, as I have no doubt it is, then at some period when the medical constitution favors, it may spread rapidly and again become widely prevalent.

Leprosy has been well defined as an infectious parasitic disease of exceedingly chronic course, capable of involving all the organs and tissues of the body, characterized by cutaneous pigment alterations, di-ordered or abolished sensation, tubercles or other circumscribed or diffuse infiltrations, bullæ, ulcers, cicatrices, destruction of deep tissues, loss of appendages of the skin, and the ultimate production of a cachexia which usually terminates fatally. The definition fairly describes the disease. The history of a case of leprosy runs parallel with a

case of syphilis, only that an initial lesion is never known.

There is the same experience of malaise and fever with chilly sensations, but so slow is the development of the eruption, that in the large majority of cases these may be forgotten by the time the eruption becomes manifest; months and even years may elapse in some instances. The eruption may be of any shape and of any diameter, from that of a split pea to that of a walnut. The infiltration of the skin may go no further than a stain, such as might be made by the moderate bruising of the flesh, and will slowly go through such appearances as will such a bruise, the changes requiring months instead of days. This form is known as macular leprosy. Again, from these maculæ in a large majority of cases will arise, especially about the hands and face, tubercles corresponding in diameter and several lines in thickness. Sometimes they become bullæ, ultimately ulcers, though absorption may take place and the macular spot may remain as before. This form of leprosy is known as the tubercular. As in syphilis, there is constantly in these cases a new growth of irregularly shaped cells infiltrating the affected parts and producing the accompanying nodules. This new growth of cells commonly attacks the skin, in other cases, however, the nerves are the first to suffer. In cases where the granular infiltration first takes place in the nerves, there is, as might be expected, more decided anesthesia, and, what would not be expected, far less of drowsiness and hebetude. There is also in this form a greater amount of pain and a greater abundance of maculation than in the others.

The actual physical suffering in leprosy is not great, less even than in consumption, it being a mercy of the disease that all the sensibilities are lowered, and the ego contracted in all its relations. The diagnosis to the close and thoughtful observer ought not to be difficult. The pain, which has a distant resemblance to the lightning pains of locomotor ataxia, and the tingling and anesthesia when associated together are always suggestive. With the eruption added, no mistake should be made, especially when there occurs loss of color of the hairs in the affected spots.

Treatment is only palliative. It is now admitted on all hands that there is no specific, and that the most that can be done is to maintain the general health and sustain the powers of the system in their contest with the disease.

LOUISVILLE.

NOTE ON THE TRICHLORACETIC-ACID TEST FOR ALBUMEN IN URINE.

BY SIMON FLEXNER, PH. G., M. D. In the Johns Hopkins Hospital Bulletin for February, 1890, Dr. D. Meredith Reese asks attention anew to trichloracetic acid as a valuable test for albumen in urine. According to the above article, Boymond (Repertoire de Pharmacie for October, 1889) claims to have made first mention of the re-agent, and it has been adopted by Raahe. Dr. Reese quotes Boymond's original article, and says that "Marsalt and Languipin (Archives de Pharmacie, December, 1887) have described albuminous urine, in which urine the precipitate re-dissolved in acetic acid. Potein (Comptes Rendus Acad. Sci., et Report. de Pharm., September, 1889) attributes this fact to the presence of a special albumen differing from serum albumen and globulin."

To further quote Dr. Reese, Boymond has observed this phenomenon repeatedly, and considers that the condition is much less rare than supposed, and that the peculiarity has much import, for in a rapid examination of urine, when heat and acetic acid are used alone, we might perhaps conclude that albumen was absent when the urine might contain a considerable proportion of this special variety of albumen. He (Boymond) has been accustomed for some time to employ trichloracetic acid instead of acetic acid. Other agents which precipitate albumen also precipitate this variety, but trichloracetic acid presents some advantages, and particularly that of not changing the albumen. The re-agent precipitates albumen in cold solution, and is considered to rank among the most delicate tests. Raahe considers it extremely sensitive, superior to HNO, and to metaphosphoric acid. Raahe gives the

relative amount of albumen recognized by metaphosphoric acid, nitric acid, and trichloracetic acid as in the proportion 1: 3.7: 6.2. He (Raahe) also states that .0295 gram of albumen can be recognized in 250 c.c. of urine." According to this, trichloracetic acid has more than six times the delicacy of metaphosphoric acid and more than three and a half times that of nitric acid.

It is stated that it may be used in the crystalline form or in saturated solution. If used in the solid form, it is dropped into the specimen and a turbidity results if albumen is present. In the liquid form it is best used by superposition in the same way as Heller's nitric-acid test. The white ring which forms, in my experience at once, is characteristic and unobscured by the colored zone of oxidized pigments as in the nitricacid test. It may be used for detecting all varieties of albumen.

The report from the Clinical Laboratory of the Johns Hopkins Hospital is as follows:

"In all, eighty-seven different urines have been tested, the urine filtered, and that from women drawn by catheter. At first only those urines showing albumen by control tests, such as heat, HINO,, and picric acid, were used, and in all cases trichloracetic acid gives a distinct, clearly defined zone, produced immediately, with no discoloration whatever between the urine and acid. Generally the zone was produced more quickly than with nitric acid, and was of a greater thickness and intensity. On standing for some time, a slight pinkish discoloration may in some cases be obtained below the urine in the acid when trichloracetic acid is used."

"In forty-three cases, where the control tests gave albumen, a precipitate was obtained by trichloracetic acid, not dissolved but made more distinct by heat."

"In twenty-five cases no reaction whatever was obtained by any test. In fourteen cases, where there was no reaction by control tests, the trichloracetic acid gave a precipitate. In eleven of these cases granular, epithelial, and hyaline casts were found, and

in three of these eleven cases the post-mortem showed distinct changes in the kidneys."

"In three cases, where heat and acetic acid and nitric acid gave no precipitate of albumen, a precipitate was obtained by picrie and trichloracetic acids. In all three of these cases casts were found. In two cases where the precipitate on heating was redissolved by acetic acid, trichloracetic acid gave a good precipitate."

Since beginning the use of trichloracetic acid ten specimens of urine have been examined. Of these seven give reaction for albumen, six with the trichloracetic acid only,

and one with nitric acid and heat as well as trichloracetic acid. Of the six which gave the reaction with trichloracetic acid only, five contained pus in small amounts, and two of these five contained hyaline casts besides. One of these contained, besides. pus, oxalate of calcium, and in one of those containing pus and casts there was considerable uric acid and oxalate of calcium. The remaining specimen contained a large amount of oxalate of calcium, and is a case of oxaluria of long standing, in which albumen had previously not been found.

In conclusion, I can affirm that the test is sensitive and the reaction is distinct and conclusive.

LOUISVILLE.

CHEMICAL COMPOSITION OF SEVERAL SAMPLES OF MILK.

BY C. J. RADEMAKER, M. D.

Milk supplied to consumers living in towns is subject to adulteration. This is generally done by removing the cream and adding water, a fraud which is not easily detected. Milk is heavier than water, as it has a specific gravity of 1.032, consequently the fatty matter, which is lighter than water, can be removed and water added without altering the specific gravity. The simplest method of ascertaining the quality of milk consists in setting it aside for twenty-four hours in a lactometer, which is divided into 100 equal parts. The cream separates above and should range between 11 and 13 divisions. The cream may be rapidly

separated by means of a centrifugal separator, in which the tube containing the milk is placed in a case attached to a centrifugal apparatus, making 1,000 revolutions a minute. By this means all the cream can be separated in thirty minutes. But to estimate the solid constituents a chemical analysis must be resorted to. The following are the results of the analysis: Weight of milk taken 6.667 grms. This was evaporated in a weighed platinum dish, at a temperature of 212° to 220° F., until the weight remained constant. The total solids thus obtained were placed in a Soxhlet's displacement apparatus and the fat extracted with boiling ether, the ether allowed to evaporate at a low temperature, and the fat weighed. The residue from which the fat had been removed by ether was treated with boiling distilled water and set aside for the casein and insoluble salts to settle. The solution is then decanted from the precipitate. This solution is evaporated to dryness on a water bath to a constant weight, and then incinerated; the loss in weight being milk sugar and the ash soluble salts. The casein and insoluble salts were next dried and weighed. This was also incinerated the loss in weight being casein and the ash insoluble salts. The fat was also estimated in milk by adding a little caustic soda solution and then extracting with ether, but no weighable difference was obtained in the result.

Petroleum naptha may be substituted for the ether in extracting the fat from milk, with equally as good results. Besides the petroleum ether is much cheaper.