A CASE OF ABDOMINAL INJURY. BY DR C. W. PREVOST, PITTSTON, PA. READ NOVEMBER 4, 1903. M. S., American, blacksmith, was admitted to hospital December 10th, 1901. Was heating a piston rod when suddenly it exploded and one of the pieces struck the patient in the right side, tearing a hole in abdominal wall in the region of McBurney's point, and fracturing the crest of the ilium about two inches below the anterior superior spine. On examination I found the viscera protruding through the wound in abdomen and recognized the small gut, appendix and head of caecum and a portion of the ascending colon, all more or less covered by coal dirt and cinders. I called an assistant. Dr. Hubler soon came in and we improvised a table consisting of saw horses and boards. Sent out for boiled water and wash bowls. I sponged the coal dirt and cinders from protruding viscera and found two holes in head of caecum with discharge of fecal contents. I trimmed the edges of bowel and closed by using the Lembert's Suture, and used catgut, as I did not have fine silk. I returned all viscera to abdomen and used sterile pads of gauze over the wound, sent patient to hospital, where I was assisted by Dr. McFadden. Dressings were removed, abdomen flushed with warm salt solution and wound closed by through and through silk worm gut and no drainage, as the fracture of the Ilium and lacerated soft parts were in more danger of infecting the wound if I used drainage. Made a counter opening of the skin on back and put in gauze drain for lacerated wound of the compound fracture; brought bone up in place with adhesive plaster and many tailed binder. The patient's bowels did not move for seven days. His temperature was never above 102, mostly from 99 to 101, and came to normal on 26th day and remained so till patient went out of the hospital on the 78th day, perfectly well and is now a miner. The points of interest in this case are closing gut before re moving patient to hospital; and closing abdomen without drainage, as I believe some would say it was a hopeless case as everyone expected he would die before he reached the hospital. CASE 2. H. C., admitted to hospital July 28, aged 14 years. Was riding in a freight car, jumped off, and in trying to get a pail of berries fell under the car. Had his right arm torn off at shoulder, leaving about two inches humerus, the scapula ground in pieces and all the soft parts torn and coal dirt ground in tissues. The arm was completely severed and was found lying near the body, left ear was just hanging by the skin and large scalp wound. The boy was etherised, head of humerus dissected out, also whole of scapula; had to ligate the axillary artery and one other. As the patient had lost lots of blood, I hastily brought skin flaps over and sutured; stitched the ear on and closed scalp wound, put patient in bed, gave stimulants and infusion of salt solution under skin and by bowel. In three or four days the skin flaps all sluffed so I removed all sutures, cut away all sluff, dressed with moist gauze. In just two weeks began skin grafting and patient went out of hospital on September 21st. Fifty-six days in hospital. SIGNIFICANCE OF ALBUMINURIA. BY DR. H. L. WHITNEY, PLYMOUTH, PA. Since the writings of Richard Bright called attention of the profession to the various forms of kidney disease in which albumen was the chief symptom, much stress has been placed on its presence in the urine. In fact the term albuminuria has been almost synonymous with Bright's disease, and this is still the popular belief. All writers contend that the kidneys are either abnormal in structure or circulation. Albuminuria is not a disease nor invariably a symptom of disease. It may be a symptom of one of the most incurable diseases, or on the other hand, may appear in the urine of a person in perfect health with no disease what ever. Conversely we may have an advanced stage of Bright's disease with no albuminuria. Hence, if the above be true, albuminuria as a symptom per se, amounts to nothing. Some of the cases in which there is an abundance of albumen are amenable to treatment, while those in which the supply is scant are the most incurable and grow progressively worse. The source of albumen in the urine is necessarily some part of the genito-urinary tract, although pus cavities draining into some may cause a profuse supply of it. The causes of albumen in the urine may be divided as follows: First. Organic diseases of the kidneys or heart. Third. Catarrhal conditions of the genito-urinary tract. Fourth. Intermittent, cyclic or physiological albumunuria. It is not within the province of this paper to discuss organic diseases of the kidneys and heart but as far as the urine is concerned, the diagnosis can only be made by a microscopical examination and careful study of the sediment. In albuminuria of valvular disease of the heart the symptom is really a functional one, caused by venous stasis and microscopically shows no active kidney change. In cases of cirrhotic kidney we may have no albumen at all. I remember a case presenting all the symptoms of arterio-sclerosis, in which the urine was apparently normal except as to light specific gravity, but microscopically very small calibre hyaline and scarcely discernible fine granular casts were found. Later, the urine became very scant and dropsy set in but with a mere trace of albumen. On post-mortem it was found that almost nothing of kidney structure remained other than fibrous tissue. The functional diseases of the kidney and heart producing albuminuria are so many and well known that it is hardly necessary to more than enumerate them. Any undue action of the heart may produce a small amount of albumen in the urine. If the circulation is too strong we get arterial congestion, if too weak venous stasis, either of which will produce albumen in the urine. Pressure from the enlarged uterus, tumors, ascites, floating kidney and compensatory activity in doing the work of other disabled organs will produce it. Febrile diseases drugs, diets and epileptic seizures may cause small amounts to appear. Any catarrhal condition of the genito-urinary tract, such as pyelitis, cystitis, urethritis, spermatorrhoea and all pyogenic diseases of the uterus and appendages will cause small amounts of albumen, but all these are readily differentiated macroscopically and microscopically. It is the intermittent, cyclic or physiological albuminuria that causes so much dissension. Some authors deny its existence, alleging that there is always renal disease. Others explain it as a relaxed condition of the system which permits the exudation. The albumen which passes through the kidneys is nothing more or less than blood serum and at some point will coagulate and mould tube casts. Any detritus at point of coagulation will become adherent to the casts. Munn found albumen in eleven per cent. of cases presenting themselves for life insurance, supposing themselves healthy and having no Isions of heart or lungs. He does not give results of microscopical examination. The causes of intermittent albuminuria, as outlined by Edes and Delafield, are changes in the composition of the blood or in the walls of the renal capillaries. The subjects are young males in perfect health. I will close my paper by giving notes of two cases which were typical. CASE I. (Notes during the years 1886-7.) Male, aged 25; single. Graduated at college one year previously. Robust and compactly built. Never sick since childhood. Never had scarlatina or diphtheria. Studied law during two years under observation, exercising moderately, drinking one or two glasses of beer daily. Occasional indulgence in sexual intercourse. Eldest of a family of eight, all in perfect health. During an insurance examination albumen was found. A series of observations were taken with following results. All percentages are by bulk. November 21, 1886, I per cent. albumen. December 5, 1⁄2 per cent. albumen, p. m. urine. December 14, after breakfast, I per cent. s. g. 1020. Year 1887, January 1, on rising, 1⁄2 per cent. Same day, 8:00 p. m., after hearty new year's dinner, 20 per cent. January 2, 4:00 p. m., 10 per cent. The microscope showed three hyline casts on one slide. Another slide showed one large calibre hyaline cast with a tuft of epithelium resembling a glomerulus, one hyaline cast with round epithelial clump on it. January 9, after dinner, s. g. 1022, 3 per cent. March 16, after breakfast, s. g. 1030, neutral, 20 per cent. Same day, after dinner, 1028, neutral, 5 per cent. after supper, s. g. 1028, neutral 7 per cent. Microscopically these specimens showed two degenerated clumps of renal epithelium, five Malpighian epithelium groups on muco-hyaline casts; numerous imperfect hyaline casts and mucous-like strings; two fatty compound granule cells; some granular epithelium and granular debris; one large mucohyaline mass with degenerated epithelium on it. March 23, after dinner, 13 per cent.; March 25, after dinner, 14 per cent.; April 13, on rising and walking to office, I per cent.; at 5 p. m., same day, 60 per cent.; May 26, 5 per cent.; June 5, p. m., urine 5 per cent. microscopically numerous irregular hyaline casts, numerous clumps round granular epithelium, one imperfect waxy cast with some granules on it, one clump granular epithelium on a mucous cast; a few white blood corpuscles were found. The patient during all this time was under treatment by the usual remedies, mainly Basham's mixture, but with no diminution in the variable amount af albumen. I ceased my examinations and stopped treatment but had patient report at intervals of three months. I took no notes of these infrequent visits, but during a period of two years occasionally found albumen but in diminishing quantities. I have examined the patient once annually for past five years and have found no albumen. During these fifteen years the patient has emerged from a youth of 5 ft. 10 in., weight 145 lbs. to a weight of 185 lbs. He has indulged quite freely in alcoholics, been out late nights, eaten veary heartily and at irregular intervals, all of which predisposes to |