A TEST FOP. CELLULAR ELEMENTS IN TIIE URINE . MEDICALJOURNAL lhad developed. Blood pressure 110. There was no albumin in the turine. Nitriteswere given. Seven days later blood pressure was 95; the bruit and dilatation had gone. Six days later blood pressure was 96, and there was no bruit. The improvement in the heart did not occur until the blood pressure was lowered. W. B., male, aged 5, had scarlet fever in June, 1919. There was cardiac dilatation on the eleventh day, with suspicion of an

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... al systolic bruit. On the twelfth day blood pressure was 100, and on tl:e thirteenth 105. Nitrites were given; on the fifteenth day blood pressure 75, sounds clear, apex beat in the nipple line. On the twventy-fifth day blood pressure was 90, sounds clear; there was no a!bumin in the urine throughout. He was a highly strung child of a very neurotic mother. S. D., male, aged 12, had fibrositis with pyrexia in February, 1916. He was the only child of neurotic parents. He had a sudden attack of severe pain in the back, with tenderness to the left of the spine in the lower dorsal region. His temperature was 100°, but was quickly controlled by salicylates. After seven days the heart was rapid and dilated considerably; the sounds were not clear, but he had no bruit. Seven days later there was no improvement, though he was kept in bed; a systolic apical bruit had developed; blood pressure 140. He was given the nitrite mixture, and after three days blood pressure was 120; bruit doubtful. For the next two days nitrites were not taken because of indigestion, and the boy was allowed up without my orders. I found the blood pre,sure again at 140, with dilatation and bruit more marked. After another three days' treatment the blood pressure was 115, with bruit much fainter. Ultimately he became quite well. H. B., male, aged 7, had acute chorea in December, 1920. On the 26th the movements were very violent. Temperature 1010; blood pressure 103; -there was a systolic bruit at the apex. The bruit and increased blood pressure persisted after the acute phase had passed. On February 1st he was able to walk, and I thought it safe to give nitrites. Blood pressure on February 1st was 105. The bruit was heard both standing and-sitting, but was not transmitted to the back; it was intensified on lying down. On February 7th, after nitrites had been given for one week, blood pressure was 95; no bruit was heard in any position. Aly conclusions, as a result of this experience, are as follows: 1. To take regular blood pressure observations in all cases of "impure " heart sounds after fever. 2. A rise in blood pressure, usually after, but sometimes durinig, the acute stage of an infection in children shows that a want of control of the arterial system is developing, and explains a functional bruit when it occurs. 3. If the heart cofidition in children is relieved by lowering the blood pressure, rest in bed can be dispensed with after sufficient rest has been taken to ensure that the heart muscle has repaired the temporary damage of the pyrexia. To explain these cases is difficult. Three factors at least must be considered: 1. The patient's temperament. It is particularly the " nervy" children who suffer this disability. The neurotic element is a large one in modern etiology. Cannon2 has proved experimentally that the suprarenal secretion is much increased in emotional stresses, such as fear and pain. 2. The action of the toxin upon-(a) The arteries. Toxins are universally credited with a depressor action on the musculature of heart and arteries. I do not wish to (luestion this. My cases are a fairly common exception to the rule that the blood pressurn is lowered duringan infection. It must not be forgotten, as pointed out by Allbutt, that the same causes may operate to produce hyperpiesis in childhood as in adult life. These mnay be more active after a pyrexia. But this does Inot disprove my main contention, that the heart condition improves pan-i passmt with lowering the blood pressure. (b) The endocrine svstem. It is not unreasonable to assert that its delicate balance can be temporarily at fault during the toxaemia of childhood's illnesses, and that transient degenerative changes are present in these glands during a fever. It is quite possible, too, that the toxin may exhaust the svmpathetic nervous system which controls them. The frequent presence of a compensated acidosis in these cases will, I hazard, be explained in the same way. -Thle coniditiQn thus described is on all-fours withi the common "D.A.H." of the soldier. The very name is a glaring example of hasty and slipshod thinking, focusing the attention on the libart ipsteadl of on thie circulation as a whiole. Derangement of blood-pressure conitrol is the correct diagnosis; the heart is only involved in so far as it is overworked to maintain an efficient circulation. Earlier sym.ptoms, suggesting hypertbyroidism, were common in these cases. In 1921 this plhase has passed, and a raised blood pressure is often the only genuine sign of derangement that can be found, suggesting lhyperadrenalism. The soldier was taken from sedentary life and drilled to dropping point for some monthls; he lived for somue years on poisonous " dixie " tea and eternal stews, smnoked endless cigarettes, sulffered fear, Jack of sleep, and usually several distinct pyrexias of known or unknown origin. It is no wvonder thlat blood-pressure controlbroke down. and that whlen the vicious circle hias been confirmed it takes years to undo by reorganizing the endocrine system and building up the sympathetic nervous system wllich has become exhausted. REFERENCES. I Nicholson's Blood Pressure, chap. ix. THE object of publishing this note is to put into the hfias of the medical practitioner or the nurse a simple means of ascertaining the presence or absence of pus, blood, or bacteria in the urine. The principle of the test is not new, but I have not seen it in standard works on clinical pathology, and from extended observations it seems to me tllit it should have a useful place in clinical work. This method will frequently reveal pathological conditions inthe urinary system where none had been suspected, since' it has a wider scope and a much greater delicacy than the clinical methods ordinarily in use in general practice, where a centrifuge and 'Microscope are oftennot available. If the presence of cellular elements in tlle urine is shown by this test a further specimen must then be submitted to microscopical examination to ascertain their nature. If the test is negative it can, with a few rare exceptions, be stated that in this respect no further examination is required. Cellular elements are not normally present in a freslhly passed urine, if we except an occasional epithelial ceUl. If cells are present they may be either bacteria, or cells derived from the body. These latter may be casts from the kidney tubules, or epithelium derived from the urinary tract; or they may be either red or white blood cells, the latter almost invariably polymorphonuclear leucocytes. Nature ofthe Beaction.-The test is made to ascertain the presence of peroxide s'plitting enzymes in the urine. These enzymes have the power of setting free oxygen from hydrogen peroxide, and the reaction in a fluid medium gives rise to the ebullition of gas bubbles. In addition to enzymes certain other bodies have the power of setting ftee the oxygen, but for our present purpose haemoglobin is the only one that need concern us. If hydrogen peroxide is added to normal sterile urine no effervescence occurs even after a considerable time has elapsed. It follows that if the addition of the peroxide leads to effervescence we may take it that some abnormal element is present in the urine. Source of the Enzyzes.-These enzymes are present rn pus cells or leucocytes in large amount, and these, therefore, give a very free reaction. The enzymes are said not to be present in lymplhocytes, but in any case these cells are rarely present, alone at any rate, in urine. Epitlhelial squames give little reaction, unless heavily infected with bacteria, but the deeper epitlhelial cells react more freely. Tube casts may react vigorously. Red blood cells give the reaction on account of their haemoglobin. Of tlle albuminous fluids freslh blood serum gives an active reaction, probably on account of some blood cells remaining in suspension in it, since other albuminous fluids sucll as, hydrocele and ascitic are inert. The slight reaction usually obtained from an albumin-containing urine is probably due to the presence of casts and a few blood and pus cells sucli as are -usually present in sucli conditions. Bactertia.-In an investigation of the various bacteria isolated in the course of routine laboratory work for "A,considerable period I found tllat practically all of the bacteria, with tlle exception of the streptococcal group (wlhich includes the pneumococcus), gave active ebullition with hydrogen peroxide wlhen the cultures were treated directly with it. At the same time it was noted, when bacteria were grown on sugar-containing media (which they fermented with the production' of acid), that they were liable to give a negative reaction. This point has to be considered in dealing; -witll very acid urines, since the peroxide-splitting enzymes only act well in neutral or alkaline media. Miniial A?mounts Giving the Test. -These were ascertained experimentally,' using normal urine as a basis and adding the foreign substances in appropriate quantities. The