ORIGINAL COMMUNICATIONS

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Reminiscences of a Laboratory Specialist. I. LESSONS FROM 17,885 URINALYSES.

EDITOR MEDICAL WORLD:-Eight years ago I decided to enter general practise in a town of twelve thousand inhabitants. I entered the town, but did not enter very far into the general practise.

In the first place, I had just completed a year's service upon the laboratory staff of a clinical professor, and so was prepared for, as well as intensely interested in, the precise aids of diagnosis. Briefly, it may be stated that after a short time I had entirely deserted general practise and had specialized in diagnosis. The events which led me to this decision would make a story in themselves and might interest a few, but they cannot be given here. To the reader I will explain that this series of articles is based upon the records and recollections of several years spent in a district where my colleagues were country practicians, and during which I have worked overtime with. the microscope and test-tube. Indeed, so closely have I confined my work to diagnosis that no sick man in this region would think of calling upon me for plasters or pills.

A word parenthetically in regard to the country practician, for I am often questioned in regard to his interest in and willingness to avail himself of the precise diagnostic methods. I have met in consultations both the city practician and the man who works in the rural districts. The latter has seen both the city and the country; the former, alas, has often been circumscribed and squeezed by skyscrapers to such a degree that he has become narrow. The country practician is, as a rule, perfectly at ease in

the city. The city man knows but his narrow little sphere in which the broaderminded man has spent at least four years of his life before he entered the vicissitudes and problems of his real labors.

The country practician has become to-day the real leader in medicin. Let not the man in the great hospital centers deceive himself. He may not fill the medical journals with record of experiments of questionable medical value at the expense of some commonwealth or endowment. Nor may he paraphrase the practise of Osler or Flint and sign his name to it for a standard text. But I can truthfully say, having worked with both, that the country man is in more cases the true medical student. There is a lot of chaff in some medical centers to-day. I know this to be a fact, because keener and more experienced observers than myself have called my attention to it. The country practician is the live one of coming years, and no apology for the rural medical laboratory is necessary.

Before proceeding to a recitation of laboratory and clinical observations supplied by my work, I will say a few words about the character of my laboratory organization, not only for the reason that many men will become interested in laboratory specialization in the next few years, but because there is abundance of laboratory heresy designed to mislead the practician of medicin:

1. In all cases this work has been referred by physicians who had been compelled prior to this to let it go undone or send it to some distant medical center to be done by some unknown chemist or other layman, interested mainly in the fee that could be landed from the doctor. I can state very frankly that the only proper and ethical way the laboratory man can survive is thru referred work. My attention has been called to several who are advertising directly to the patient. For shame! What does a layman know of pathology; consequently what can a laboratory report mean to him? It is bad enough for a layman to diagnose for a doctor; it is worse for a layman to diagnose for a layman.

2. It has been my experience that about. one-fourth of all the work referred to me should be turned down; and I early adopted the motto that any analysis which was a waste of my time and of the patient's money, and which might mislead the physician, had best be left undone. The basis of success for some laboratories may be found in the

large number of examinations they do not attempt. Laboratory men should not, under any conditions, undertake the study of a decomposing urin, a poorly spread blood specimen, a quite necrotic tissue, any old stomach pumping, and so on.

3. Very early I decided to leave therapeutics strictly to the man in general practise, and I have been told that I am perhaps the only man outside the large city (even here may be found so-called laboratory specialists who use their specialty as a means of stealing patients from the practician) who has specialized so narrowly. I have gone a step further. I do not make up vaccines, and have refused to administer vaccines even under the direction of a physician.

4. I realized very early that pathology rather than technic is the foundation of laboratory work, just as pathology rather than technic is or should be the foundation of ophthalmology, surgery and the other medical specialties. Laymen, nurses, students, and so on, have been barred, and the laboratory made a strictly medical institution. I have been shocked when approached by some counter jumper boasting with considerable pride of his slick method of using a pipet or adjusting a microscope. Can it be that physicians are trusting their diagnoses with these fellows? And yet it would seem so, for they insist that they have worked in other laboratories. One lady told me that she had examined hundreds of sputums, ending with the significant observation, "Our director was a physician, and the doctors believed that he did the work."

These fellows never get any further than my front door. Since man has ministered to man for his bodily afflictions, just that long has almost every man ventured to try his hand in the diagnosis and treatment of disease. In the past the layman has been compelled to present his case to the patient. Now with plain nerve he demands a hearing from the physician.

These and many other articles in my policy early gained me the name of crank, but I have never been sorry that they were adopted.

According to the title of this paper I have done several urinalyses, and should by this time have learned and relearned many lessons. Likewise my recollection runs back to some lessons which have been unlearned, and I recall with some amusement the first urinalysis done in this laboratory. The case was one of "cystitis"; and I was advised by

the physician that the urin was clouded with urates, phosfates or "something." The last possibility proved to be the finding, for the specimen was opaque with pus. The report was made out and given to the physician with the simple statement at the bottom that pus was the important finding.

"Well, what about it?" asked the physician. I gasped with surprise. Here was a hard one and certainly a new one. For in the hospital the laboratory man is a mere technician, as a rule. In the hospital we did the mixing of chemicals, looking thru the microscope and other machine work and the surgeon did the thinking (if any was done). We never had the audacity to comment upon or interpret a laboratory report, all of this being done by the operating room technicians.

What about it, indeed? I had not yet begun to unlearn many of the laboratory fallacies taught me in medical school by men who were not even practising physicians. After some hesitation I concluded that pus was a very serious finding and told the physician as much, nothing more.

To-day I know that that analysis was valueless because it was aimed at the finding of results rather than cause. The analysis was incomplete, and both diagnostic and prognostic conclusions unjustified.

One lesson learned from my first urinalysis was the fact that practising physicians are not interested in "interesting" pathologic phenomena and finds quite so much as they are in precise information of diagnostic value. Conclusions should always be placed upon reports. It may be and usually is impossible to make a diagnosis from a urinalysis alone, but such important findings as are met should be commented upon and the possibilities run over, for one of these may prove the happy suggestion to the other

man.

This patient is still alive and in excellent health, notwithstanding my gloomy prognosis. The woman did not have a cystitis. I recall now that the urin was acid. Had I busied myself I would have found that the acidity was excessive, that tubercle bacilli were absent and that colon bacilli were present. The further history was that of typical colipyelitis with recovery. Of course, I was not entirely to blame, for our idea of colon bacillus infection at that time was vague indeed. I have unlearned many other college teachings, but the first year was especially trying.

Collecting Urinary Specimens.

There are two cautions that should be ob

served by physicians when sending speci

mens of urin to laboratories; first, ascertaining the amount of urin secreted by the kidneys each 24 hours; second, proper preservation of the specimen. The following note will show a somewhat different view that must be contended with:

Dear Dr. WILLIAMS:-In the past you appear to have been able to tell me much concerning the condition of my patient from the examination of the urin, and I am inclosing a specimen from a very puzzling case. I want to know what is the matter with this man. Do not write back to me that this urin is spoiled or that I have not given you the 24-hour amount, for I know that.

Yours truly, etc.

A sample from a mixed 24-hour specimen properly preserved should be examined. At certain periods of the day the urin may be alkalin; at others, acid. At certain hours diabetic patients may pass no glucose, icteric patients may pass no bilirubin, heart patients may pass no serum albumin, and liver patients may pass no urobilinogen. Lung patients may pass no urochromogen, bowel patients may pass no indican, and pancreatic patients may pass no acetone. Moreover, from a specimen taken at random the many valuable quantitative estimations are hopelessly impossible.

Unless urin is to be examined fresh or almost so, it should always be preserved. A single lump of thymol is best for this purpose. The entire chemical and microscopic makeup of the urin is altered by fermentation, and it is hopelessly impossible to arrive at safe conclusions by the investigation of the stinking sample.

Value of the Urinalysis.

The urinalysis properly completed should be as routine to the physician's examination as the taking of the pulse rate. Neither will give the diagnosis in every case. In five successive urinalyses no aid whatsoever may be given. But in the very next one an important therapeutic clew may be found, and this is indeed sufficient recompense for all six examinations. As early as 1857 Barclay made the following observation: "In many instances abnormal urinary states are dependent upon diseases of distant organs by which the function of the kidney is merely interfered with, while no actual change passes on to the structure of the organ.' Thus the proposition of the value of the

urinalysis in all patients is not a new one, and the wonderful progress in this work during the past half century has brought it to a point certainly never dreamed of by Barclay.

By the urinalysis we may make important conclusions concerning the functions of the heart and arteries.

By the urinalysis not only may we determine the nature of the several diseases of the kidney, but nowadays we can tell much concerning its functional possibilities. Moreover, the diagnoses of the surgical conditions of the urinary tract are almost impossible without the urinalysis.

By the urinalysis we can tell much concerning the functions of the liver, pancreas, and so on, as well as something of their diseases.

By the urinalysis we often keep lookout upon the sluggish colon.

By the urinalysis we can determine to some extent the prognosis of pulmonary tuberculosis.

By the urinalysis we often diagnose bone tumors, typhoid, diseases of metabolism in babies and many other important conditions.

Very

But none of these strikes its most important field. Did you know that the urinalysis is becoming to be more important to the therapeutist than to the diagnostician? Our pharmacologists are proving that by correcting the various abnormal urinary states we can do much for our patient. And so we cylindruria, acetonuria, and so on. are coming to treat albuminuria, oliguria, rational treatments of so-called phosfaturia have been proposed very recently. I would like to go into this subject and give some of my observations, but space forbids. Our research workers are five years ahead of the practician here, and the country practician is five years ahead of his city colleague. It is just as rational to meet therapeutic indications suggested by the urinalysis as it is to treat headache. It is more rational to treat hyperacid urin than to treat headache when the latter condition depends upon the former.

In the country I find that the physicians are discussing these things. In the larger teaching hospitals you will find a few dingy laboratories where the student is trained to take the specific gravity of the urin, make a dozen coarse tests for any old albumin, squint thru a microscope and fill out a blank somewhat larger than a postage stamp. The professor may accidentally read it, and

then it is filed forever as a hospital record. Some urinalyses are not as fascinating as the ripping open of a belly; but great is the victory where thru a proper urinalysis a hint supplied places the patient on a sure road to recovery. Yes, I believe in the routine urinalysis, but only when it is properly carried out. Do not forget the urinDo not forget the urinalysis when diagnosing: do not forget the urinalysis when treating.

General Properties of the Urin.

They tell me that a sect of physicians once existed whose members could diagnose disease by simple inspection of the urin, but I rarely see a urin where inspection alone will give any usable information. If blood is present in amounts sufficiently large to be recognized by the eye, the question arises at once, "Whence came this blood, and why?" Some of our clever observers may be able by holding a specimen of urin to the light to say: "This deposit is not phosfates, but true pus," and yet he has told us absolutely nothing concerning the nature of the disease which we wish to treat. The fact of the matter is, he might be compelled to plead with us rather strenuously not to use a microscope, to keep us from showing him up. I will say in general that the inspection of the urin may suggest possibilities or even probabilities but can never prove them. Proof rests upon the careful chemical and microscopic examinations. These guesses are interesting, but it is remarkable how frequently the experienced laboratory man guesses incorrectly. Pus may turn out to be blood or casts; phos fates may turn out to be macroscopic masses of bacteria or urates; pathologic pigments may turn out to be normal substances and vice versa. A urin which is pale does not mean polyuria; it may mean paucity of pigments; and so it goes.

oliguria may be explained by the fact that the patient is not taking enough liquids into his stomach, and this fact may be tested out. Pathologic oliguria occurs when the renal cells do not secrete enough water, even tho the patient drinks sufficient quantities. Such oligurias may be met not only in true nephritis, but where for any reason the blood pressure is lowered. Every oliguria should busy the physician with an attempt to make these discriminations. An oliguria of itself may not be so pernicious if the solids are reduced simultaneously. When aiming at a reduction of the total solids, do not overlook what may be accomplished in the matter of diet. Overeaters with oliguria are most certainly bound for the grave of the nephritic. No matter how specialized the renal cell, it is nevertheless a mass of living protoplasm and all living substances may be destroyed. It stands to reason that living cells work better and longer supplied with plenty of water for their work than when forced to deal with concentrated liquids.

A polyuria may be placed in one of two classes, viz., inability of the renal cell to hold back the water either because of disease (or nervous influences?) or because the blood contains true diuretics, as glucose, overplus urea, and so on. It will thus be seen that a polyuria as such is rarely treated, tho it may direct our attention to conditions which should be treated.

The Specific Gravity.

The advice given in connection with the meaning of the appearance of the specimen applies also to the specific gravity reading. By means of the specific gravity in connection with the total daily secretion of urin, we may gain an approximation of the total solids, but usable information comes only by computations of urea, chlorids, and so on. A low specific gravity does not always mean a low urea, for some other solid may be decreased much out of proportion. Specific gravity variations deal with possibilities and probabilities.

Reaction of the Urin.

The reaction of the single specimen means but little. The reaction normally varies. from hour to hour. The reaction of the mixed 24-hour sample should normally be slightly acid, due to acid phosfates. A tremendous acidity or an alkalinity continuing day after day is usually or always a pathologic phenomenon.

Excessive Acidity.

An excessive acidity is invariably due to the presence of poisonous organic acids. The following types have been recognized: First. The hyperacid urins of copremia, where the poisonous acids are absorbed from the colon.

Second. The hyperacid urins of retrograde changes in the tissues, where the acids are manufactured in an abscess or necrotic process. Third.

The true acidoses, where diacetic acid and related acids are formed. These include the cases of true diabetes, acidoses of childhood, acidoses following anesthesia, and so on.

Fourth. The hyperacid urins of local urinary infection, as colipyelitis, tuberculous kidney, and so on.

In all of these cases the hyperacidity is easily determined by titration, the discrimination being made with a clinical and laboratory study, and the remedy applied as indicated.

Excessive Alkalinity.

An excessive alkalinity may be due to one of two causes:

First.-A volatile alkalinity, where ammonia is the chief alkali, may be due to ammoniacal fermentation of the urin by virtue of bladder retention, or may exist because of a high urinary ammonia where the liver urea function is impaired.

Second.-A fixed alkalinity. These are usually the so-called "phosfaturias" associated with neurasthenia, and so on, and concerning which the pathology may be somewhat misty.

Incipient Bright's Disease.

Before proceeding to a consideration of the several urinary tests, I wish to explain that I am one of those men who believe that

if an examination is made early enough, most cases of Bright's disease may be diagnosed in their incipiency. Moreover, I am satisfied that the exact cause may be determined in the majority of cases, by the careful urinalysis, and that rational and successful treatment may be instituted.

I believe these things because I have seen nephritis cured (or at least seen remedied those conditions which lead to hopeless Bright's), and because the work of other men has given convincing proof. Many abnormal urinary states permitted to continue indefinitely are certain to result in fatal damage to the renal parenchyma. The organic

acids and indicans absorbed from a bowel, the bilirubin trace carried to the renal cell to secrete or the poisonous bodies absorbed from an infective focus even tho the latter be hidden and of a low grade, causes, first of all, a trace of albumin to appear in the urin. Next come hyalin casts and more than a trace of albumin, then granular casts, then renal cells and granular débris from necrotic protoplasm. I have gone into this subject more deeply elsewhere, and have detailed the lines of treatment which should be carried out, as suggested by such abnormal urinary finds as are met, and cannot take them up here. But if any one lesson has been impressed upon me, it is that the urinalysis furnishes the most valuable and probably the only therapeutic indications applicable in the matter of preventing hopeless Bright's.

The next of these articles will consider some lessons I have learned concerning the urinary chemical tests.

Paris, Ill. B. G. R. WILLIAMS, M.D.

Director Wabash Valley Medical Laboratory,
Author of "Laboratory Methods for the
Practitioner," etc.

[With this article Dr. Williams begins a series that will run thru the next ten issues of THE WORLD. The exact status of the best up-to-date clinical laboratory work in diagnosis will be shown. The series will be of great value to our readers.-ED.]

Mr. Kline Explains.

The following letter explains itself: Dr. C. F. Taylor, Editor-in-Chief, "The Medical World," 1520 Chestnut Street, Philadelphia, Pa. DEAR DR. TAYLOR:-In the April issue of THE MEDICAL WORLD it was stated that the "Smith, Kline & French Company, of Philadelphia, by the aid of their attorney, J. C. Jones, prevailed on the attorney of the internal revenue department to see the matter at issue in the light of the druggists, the ulterior purpose of the druggist, of course, being to make dispensing by physicians so troublesome that the latter will write prescriptions, thus bringing more grist to the druggists' mill."

I find that this statement in THE MEDICAL WORLD has made physicians antagonistic to us. I am therefore taking an opportunity to use the space which you so kindly have offered me to put myself straight before your readers.

It is perfectly true that I sent the opinion of our attorney to the internal revenue department in Washington. My motive in doing so, however, their rules and regulations as to prevent the prowas entirely that the department should so word miscuous dispensing of opiates from the offices of those physicians who are not legitimate members of the medical fraternity in the sense that they use their license to practise medicin to conduct an office wherein they dispense dope.

When I took this action I had no thought in