Wfii CHICIGOMEDICIILBOOKCD 35-37 Randolph 81. CHICAGO. H4-7 CORNELL UNIVERSITY. THE THE GIFT OF ROSWELL P. FLOWER FOR THE USE OF THE N. Y. STATE VETERINARY COLLEGE. 1897 Cornell University Library RB 53.H47 Urinary analysis and diagnosis by micros 3 1924 000 044 077 DATE DUE cr>f|«,--jp\ JTF ''■ pt3/=-^ ^■^. " -2f ( CAVUORO PRINTED INU-S-A. Cornell University Library The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000044077 URINARY ANALYSIS AND DIAGNOSIS BY MICBOSCOPICAL AND CHEMICAL EXAMINATION BY LOUIS HEITZMANN, M.D. NEW YORK Mlitt) SDne {gunliieti anS QBi^iit SDtiQtnal Illuettationis NEW YORK WILLIAM WOOD & COMPANY MDCCCXCIX Copyright bt WILLIAM WOOD & COMPANY 1899 Ho I Hi' Sgnunt ©Icasant ©tinterp J. Horace McFarland Company Harrisburg, Pa. CARL HEITZMANN, M. D. Whose Lipe-work was Devoted TO THE Science of Medicine tCfiifif l^olttme i& affectionately PEEFACE In adding another to the long list of works on the exami- nation of urine, the author has been guided by the fact that microscopical examination, and especially microscopical diagno- sis, have not received as much attention in the text -books as their importance calls for, while chemical analysis has been thoroughly treated in a large number of works. Many years of experience and teaching have shown him that correct diag- nosis by means of microscopical examination of urine can frequently be made in cases where chemical analysis is of little value. The work is divided into three parts : First, Chemical Examination ; second. Microscopical Examination ; and third, Microscopical Diagnosis. The first part is short, and only the simplest and most important tests, which alone can be carried out by the busy practitioner, are given, although care has been taken to omit none of great importance. This subject has been excellently treated by many authors, among whom Tyson, Purdy, and vonJaksch may be mentioned, and in many larger works, which should be referred to when more complicated chemical tests are required. In many cases in which the clinical symptoms, although pointing to an affection of the genito-iirinary tract, are vague, and, even with the aid of chemical analysis of the urine, will not admit of a positive diagnosis, microscopical examination, if carefully conducted, will completely clear up the case. It is evident that a mere description of the features found in different cases can not be sufllciently clear, but that illustra- tions made directly from nature are absolutely essential. In the present volume all the illustrations, without exception, VI PEE FACE have been drawn by the author directly from specimens in his possession. In the third part, devoted to Microscopical Diagnosis, full page illustrations have been added to elucidate the text, each drawing giving the features found in the case it illustrates. As the subject is of the greatest practical value, the author hopes that this volume may serve a useful end, and will con- sider his labors amply rewarded if he has thereby succeeded in simplifying this extremely important branch of Micro- scopy. LOUIS HEITZMANN New York, Pebraary, 1899 CONTENTS Page Introductory ... . 1 Pakt First CHEMICAL EXAMINATION CHAPTER I General Physical and Chemical Properties (page 7) Normal Urine . . 7 Amount of Urine . . . 7 Consisteney and Odor .8 Constituents of Normal Urine . . .8 Changes upon Standing . . 8 Color of Urine under Pathological Conditions ... 9 Amount of Urine under Pathological Conditions ... 9 Determination of Specific Gravity . ... 10 Determination of Solids 10 CHAPTER II Normal Constituents (page 12) Urea ... 12 Quantitative Tests . . ...... 13 Uric Acid Remaining Organic Constituents . . ... Chlorides ... Sulphates . Phosphates 14 14 15 15 16 CHAPTER III Albuminous Substances (page 17) Albumin . . . . 17 Detection of Albumin in Urine . . ... 18 1. Acetic Acid Test . . 18 2. Nitric Acid Test .... 19 3. Ferrocyanide of Potassium Test 19 4. Heller's Test 19 (vii) viii CONTENTS Page Quantitative Test for Albumin .20 Peptone .21 Globulin 21 Albumose ■ 21 Mucin .21 Fibrin .22 CHAPTER IV Grape Sugar (page 23) Detection of Sugar in Urine . . . 23 1. Moore-Heller Test . 23 2. Trommer's Test . . 24 3. Fehling's Solution ... 24 4. Haines' Test .... ...... .... 25 5. Bottger's Test . 25 6. Roberts' Fermentation Test . . . 26 Quantitative Tests for Sugar . . . 26 1. Fehling's Test 26 2. Whitney's Reagent 27 3. Einhorns' Fermentation Saocharometer 28 CHAPTER V Other Abnormal Oonstituents (page 30) Acetone . . . . . .30 Diacetic Acid . ... 30 Coloring Matters . . ... 31 Bile Pigments . . .... 31 Coloring Matter of Blood . . 31 Urobilin ... . . 32 Indiean .... 32 Fatty Matters . . 33 Part Second MICROSCOPICAL EXAMINATION CHAPTER VI General Considerations (page 37) Use of Centrifuge 38 Mounting of Sediment 39 Use of Antiseptic Substances . . . .... 39 Preservation of Sediment . . . .89 Magnifying Powers ... 40 CONTENTS ix CHAPTER VII Crystalline and Amorphous Sediments (page 42) I. Acids and Salts (page 42) Pase A. Add Sediments . . . 43 1. Uric Acid ... . . . 43 2. Urate of Sodium . . .... . . 47 3. Oxalate of Lime . 49 4. Cystine .... . . 52 5. Creatinine ... 52 6. Hippuric Acid .... . . .53 7, 8. Leucine and Tyrosine 55 9. Sulphate of Lime ... 56 B. Alkaline Sediments .... . ... . . 57 1. Triple Phosphates . . ... 57 2. Simple Phosphates . . .59 3. Urate of Ammonium 60 4. Carbonate of Lime ... . . . . 62 5. Phosphate of Magnesium .... 63 II. Other Unorganized Sediments (page 64) Pat Cholestearin ... Hsematoidin ... Indigo . ... Melanin . . .... Urinary Concretions ... 64 65 65 67 CHAPTEB VIII Blood- Corpuscles and Pus -Corpuscles (page 70) I. Blood-Corpuscles (page 70) Eed Blood-Corpuscles or -Globules .... 70 White Blood-Corpuscles or Leucocytes . .... .71 Fibrin . . . . .... 72 Blood-Clots . . . . . 72 II. Pus-Corpuscles (page 73) Constitution . 75 CHAPTEE IX Hpithelia (page 78) Bpithelia Common to Both Sexes 81 Epithelia from the Bladder . ... 81 Epithelia from Pelvis of Kidney .... 83 Epithelia from the Ureters . 84 Epithelia from the Uriniferous Tubules of Kidneys 84 CONTENTS Bpithelia Found in Urine of Male .... Epithelia from Urethra Epithelia from Prostate Gland . . Epithelia from Ejactilatory Ducts . Sperma Urethral and Gleet-Threads . Epithelia Found in Urine of Female . . . Epithelia from Vagina Smegma Epithelia from Bartholinian Gland . Epithelia from Cervix Uteri .... Epithelia from Mucosa Uteri . . . Page 86 86 89 91 91 93 93 94 94: CHAPTER X Mucus and Connective Tissue (page 96) II. I. Mucus (page 96) Connective Tissue (page 99) 1. Ulceration . ... 100 2. Suppuration 101 3. Haemorrhage . 101 4. Traumata . . . . 101 5. Tumors . 102 6. Hypertrophy of Prostate Gland 104 7, 8. Cirrhosis and Atrophy of Kidney 104 9. Intense Inflammations . . 104 CELAPTER XI 1. Hyaline Casts . 2. Epithelial Casts 3. Blood-Casts . . 4. Granular Casts . 5. Fatty Casts . 6. Waxy Casts . . 7. Mixed Casts . . Other Casts .... Tubular Casts (page 105) I. True Casts (page 106) II. False or Pseudo Casts (page 117) Urate Casts Bacterial Casts Pus-Casts Fat-Casts . . Pibrin-Casts . 108 110 110 112 113 114 116 117 117 119 120 120 120 CONTENTS XI CHAPTEE XII Micro -Organisms and Animal Parasites (page 121) I. Miceo-Organisms or Fungi (page 121) Non- pathogenic Micro-Organisms . . 1. Mould-Fungi .... 2. Yeast-Fungi . 3. Fission-Fungi .... . . . Pathogenic Sehizomyeet» . . ... Gonocoeei .... Other Cocci . . . . Tubercle Bacilli . . ... . . ... Typhoid Bacilli ... ... Bacterium Coli Commune ... .... Actinomyces . . . . . . ... Page . 121 121 . 123 . 124 126 . 126 . 129 . 130 . 132 132 . 133 II. Animal Parasites or Entozoa (page 134) Trichomonas Vaginalis Eehinococci . . Distoma Hsematohium . . . Filaria Sanguinis Hominis Ascaris Lumbricoides • . Other Parasites 134 135 136 138 138 139 CHAPTEB XIII Extraneous Matters (page 140) Cotton-Fibers . . Linen -Fibers Silk-Fibers . . . Wool -Fibers . . Human Hairs . . Feather . Scales from Moth Starch-Globules . Lyeopodium . Cellulose .... Cork Oil-Globules and Air-Bubbles Flaws in Glass . . Vegetable Matter . ... Faeces 140 141 141 141 142 142 142 142 143 144 144 145 145 146 146 Xll CONTENTS Paet Theee MICROSCOPICAL URINARY DIAGNOSIS Introductory Paob . 153 CHAPTER XIV Diseases of the Kidney and Pelvis (page 155) I. Inflammations of the Kidney and Pelvis (page 155) Classifleation ... Pathological Changes 1. Catarrhal Inflammation . 2. Croupous Inflammation 3. Suppurative Inflammation Irritation of the Kidney Causes Catarrhal or Interstitial Nephritis . . . Causes Clinical Symptoms Features Found in Urine . . .... Acute Catarrhal or Interstitial Nephritis . Chronic Catarrhal or Interstitial Nephritis Subacute Catarrhal Nephritis Cirrhosis of the Kidney . . Catarrhal Pyelitis . ... Croupous or Parenchymatous Nephritis . Causes Clinical Symptoms . .... Features Found in Urine Acute Croupous or Parenchymatous Nephritis Subacute Croupous Nephritis Chronic Croupous Nephritis Atrophy of the Kidney . Chronic Croupous Nephritis with Acute Croupous Beourrenoe . Suppurative Nephritis Causes .... . . . . Clinical Symptoms . . . . . . . . . Features Found in Urine . Tuberculosis of the Kidney Features Found in Urine II. Anomalies op Secretion (page 194) Causes . . Clinical Symptoms 155 158 158 159 161 161 162 162 163 163 164 165 166 169 170 172 172 172 173 173 174 178 180 184 185 187 187 188 188 191 191 193 194 194 CONTENTS xiii Page Lithwmia 194 Heemorrhage from the Pelvis of the Kidney 196 Pyelitis Caleulosa . .... 198 Oxaluria 199 Hcemoglobinuria .... . . . 199 Causes . 199 Features Pound in Urine .... . . 200 Chyluria .... 202 Features Found in Urine . . . . . 202 III. Maligkant Tumoks op the Kidney (page 204) Clinical Symptoms . . 205 Appearance of Urine . . . 205 Sarcoma . ... 205 Features Found in Urine 205 Cancer . ... 208 CHAPTER XV Diseases of the Bladder (page 209) 1. Inflammations of the Bladder (page 209) Causes . 209 Clinical Symptoms . 211 Appearance of Urine ... . . 211 Catarrhal Cystitis ... 212 Microscopical Features . . . 212 Chronic Catarrhal Cystitis 214 Acute Catarrhal Cystitis .... 212 Subacute Catarrhal Cystitis . .... 217 Ulcerative Cystitis . 217 Acute Ulcerative Cystitis . ... 217 Chronic Ulcerative Cystitis . . 219 Suppurative Cystitis . 219 ... 221 11. Tumors op the Bladder (page 223) Clinical Symptoms ....... . 223 Papilloma • • • 223 Microscopical Features . . . 223 Sarcoma ... 226 Microscopical Features ... . 226 Carcinoma • • 227 Microscopical Features . . 227 III. Parasites in the Bladder (page 280) xiv CONTENTS CHAPTEE XVI Diseases of the Sexual Organs (page 231) Pagb Urefhritis . ... 231 Acute Urethritis . . ..... 231 Chronic Urethritis .... . . . . 231 Prostatitis . . . 232 Causes . . .232 Cliuieal Symptoms 233 Features Found in Urine . . . . 233 Acute Prostatitis 233 Chronic Prostatitis 236 Hypertrophy of the Prostate Gland 238 Tuberculosis 238 Tumors 238 Spermatorrhoea . 239 Seminal Vesiculitis . 239 Clinical Symptoms 240 Features Found in Urine 240 Vaginitis 242 Features Found in Urine . 242 Catarrhal Vaginitis 242 Traumatic Vaginitis 246 Cervicitis and Endometritis 246 LIST OF ILLUSTRATIONS TIG- PAGE 1. Crystals of Urea and Nitrate of Urea (X 200) 13 2. Crystals of Uric Acid, Common Form (X 400) 43 3. Crystals of Uric Acid, Common Form (X 400) 44 4. Crystals of Uric Acid, from Over-acid Urine (X 450) 45 5. Uric Acid Grravel (X 500) 46 6. Urate of Sodium, Amorphous (X 500) 47 7. Urate of Sodium, Crystalline (X 500) 48 8. Urate of Sodium in Transition to Urate of Ammonium (X 500) . . 49 9. Oxalate of Lime Crystals (X 500) . . . ... 50 10. Cystine Crystals (X 500) ... . . . 51 11. Creatinine Crystals (X 500) ... 52 12. Sediment in the Urine of an Athlete (X 500) 58 13. Hippurio Acid (X 500) 54 14. Leucine and Tyrosine (X 500) .55 15. Complete Triple Phosphates (X 500) . .... 56 16. Incomplete Triple Phosphates (X 500) . 57 17. Amorphous Simple Phosphates (X 500) . . 58 18. Star-shaped Simple Phosphates (X 500) ... . . . . 59 19. Urate of Ammonium (X 500) 61 20. Acid Sediment in Fermentation and in Transition to Alkaline (X 500) 62 21. Carbonate of Lime (X 500) 63 22. Pat-Globules and Margario Acid Needles (X 500) 64 23. Cholestearin Crystals (X 400) ... 66 24. Hsematoidin Crystals (X 500) ... ... 66 25. Indigo Crystals (X 500) 67 26. Blood-Corpuseles (X 500) . 70 27. Fibrin and Blood-Clot (X500) . . 72 28. Pus-Corpuscles (X 500) 74 29. Pus-Corpuscles Showing DiflEerent Constitutions (X 500) . . 76 30. Epidermal Scales fX 500; 80 31. Epithelia from the Bladder (X 500) 82 32. Epithelia from Pelvis of Kidney and Ureter (X 450) 83 33. Epithelia from Uriniferous Tubules of Kidneys (X 500) 84 34. Comparative Sizes of Corpuscles and Epithelia (X 500) . . 85 35. Epithelia from Urethra, Prostate Gland, and Ejaeulatory Ducts (X 500) 87 36. Sperma as Found in Urine (X 500) 88 37. Gleet-Threads (X 500) 90 38. Epithelia from the Vagina (X 500) 92 39. Smegma from the Clitoris (X 450) .... . . 93 40. Epithelia from Bartholinian Gland, Cervix Uteri, and Mucosa Uteri ex 500) 94 (xv) XVI LIST OF ILLXJSTBATIONS 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 85. Mucus -Threads and -Corpuscles (X 500) . . Mucus-Casts, or Cylindroids (X 500) . . Connective -Tissue Shreds {X 500) . ... Connective-Tissue Shreds Found in Tumors (X 500) Hyaline Casts (X 500) ... Epithelial Casts (X 500) Blood Casts (X 500) . ... Granular Casts (X 500) ... ' . Fatty Casts (X 500) Waxy Casts (X 500) Mixed Casts (X 500) Casts of Urate of Ammonium and Urate of Sodium (X 500 False, or Pseudo Casts (X 500) . . Oidium Lactis (X 500) Penieillium Glaueum and Aspergilli (X 500) . . SaooharomyeetsB (X 500) SehizomycetsB (X 500) Acute Gonorrhoea (X 700) Chronic Gonorrhoea (X 700) . . . Tuberculosis of the Kidney (X 650) . .... Actinomyces (X 500) . . Trichomonas Vaginalis (X 500) ... . . Portions of Echinoooccus (X 400) . . . . Ova of Distoma Hsematobium (X 600) . Filaria Sanguinis Hominis (X 600) . . . . .... . . . Ova and Portion of Ascaris Lumbrieoides (X 500) Cotton-Fibers (X 500) Linen-Fibers (X 500) . Silk-Fibers (X 500) . ... Wool-Fibers (X 500) ... Feather (X 400) . . Scales from Wings of Moth (X 500) Starch-Globules (X 500) Lyeopodium-Globules(X 500) Cellulose (X 500) . Cork (X 500) ... Oil-Globules and Air-Bubbles (X 500) Flaws in the Glass (X 500) ... Vegetable Matter (X 500) . Normal Fseces (X 500) ... . . . ". . ... Acute Catarrhal Pyelo- nephritis (Acute Interstitial Nephritis) and Cystitis (X 500) : . . . . Chronic Catarrhal Pyelo-nephritis (Chronic Interstitial Nephritis) and Cystitis (X 500) .... Cirrhosis of the Kidney, With Chronic Catarrhal Cystitis (X 500) . . Acute Croupous, or Parenchymatous Nephritis, With Catarrhal Pyelitis and Cystitis (X 500) Acute Hsemorrhagic Croupous, or Parenchymatous Nephritis, With Catarrhal Pyelitis and Cystitis (X 500) . . Page 97 98 100 103 108 109 111 112 114 115 116 118 119 123 123 124 125 127 129 132 133 134 135 136 137 139 140 141 141 142 142 143 143 144 144 145 145 146 147 148 167 168 171 175 177 LIST OF ILLUSTRATIONS xvii Pig. Paqb 86. Subacute Croupous, or Parenchymatous Nephritis, With Catarrhal Pyelitis and Cystitis (X 500) . . ... . . . . 179 87. Chronic Croupous, or Parenchymatous Nephritis, With Fatty Degen- eration of the Kidney, Accompanying Catarrhal Pyelitis and Cystitis (X 500) 181 88. Chronic Croupous, or Parenchymatous Nephritis, With Fatty and Waxy Degeneration of the Kidney, Accompanying Catarrhal Pyelitis (X 500) 182 89. Chronic Croupous, or Parenchymatous Nephritis, With Fatty and Waxy Degeneration of the Kidney, and an Acute Hsemorrhagio Croupous Recurrence, Catarrhal Pyelitis and Cystitis (X 500) . 186 90. ChroniQ Pyo-nephrosis, or Chronic Suppurative Nephritis, With Catarrhal Pyelitis and Cystitis {X 500) 190 91. Acute Abscess of Pelvis of Kidney, or Acute Suppurative Pyelitis (X 500) 192 92. Lithsemia, With Subacute Catarrhal Pyelitis and Cystitis (X 500) . . 195 93. Haemorrhage from Pelvis of Kidney, Due to Uric Acid Calculus (X 500) .197 94. Hsemoglobinuria, Acute Heemorrhagio Croupous, or Parenchymatous Nephritis, With Catarrhal Pyelitis {X 500) . . ... 201 95. Chyluria, Catarrhal Cystitis (X 500) . .203 96. Sarcoma of Kidney, Chronic Catarrhal Pyelitis and Cystitis (X 500) 207 97. Acute Catarrhal Cystitis (X 500) 213 98. Chronic Catarrhal Cystitis (X 500) 215 99. Acute Ulcerative Cystitis (X 500) 218 100. Chronic Ulcerative Cystitis (X 500) . . 220 101. Pericystitis (X 500) . .222 102. Haemorrhage from the Bladder, Due To Papilloma of Bladder (X 500) 225 103. Villous Cancer of the Bladder (X 500) 229 104. Acute Abscess of the Prostate Gland (X 500) 235 105. Chronic Prostatitis (X 500) . .237 106. Spermatoeystitis, or Seminal Vesiculitis (X 500) 241 107. Chronic Catarrhal Vaginitis (X 500) . 243 108. Traumatic Vaginitis (X 500) 245 URINARY AI^ALYSIS AND DIAGNOSIS INTRODUCTORY Ueinabt analysis, in order to be thorough and of practical value, must necessarily be both of a chemical and a microscop- ical character. Chemical examination, although of great im- portance, can, alone, never lead to a correct diagnosis, as it is only through the use of the microscope that the nature of the disease in the genito- urinary tract, as well as its exact location, can be revealed. Every urine to be examined should, therefore, be fli'st subjected to different chemical tests, the extent of which wUl vary with the different cases, and then to a microscopical examination . As a rule, the simpler chemical tests alone will be required. These must be made, first, with a view of determining the normal constituents of the urine ; and, second, for the purpose of learning of the presence of any abnormal constituent. A general knowledge of the normal constituents is, therefore, necessary, and we must not lose sight of the fact that these may vary to a considerable degree, even in perfect health, partly from the diet, and partly by conditions of rest or activ- ity. An increased or diminished amount of any ingredient does not necessarily mean a pathological condition, although when this increase or diminution lasts for a long time a diseased condition becomes certain. In selecting a specimen for examination, it is undoubtedly best to obtain samples of urine passed during the whole twenty- four hours, wherever this is possible ; the more so since the quantity voided is important in diagnosing different affections. When this is not practicable, the most concentrated urine, which is usually that firsf voided in the morning, should be obtained, although different pathological ingredients, such as albumin, may be absent in the morning and yet present in (1) 2 VBINABY ANALYSIS AND DIAaNOSIS varying amounts at other times, especiallj' after meals; so that, if any doubt remains as to the exact condition, two samples, passed at different times, must be tested. Care should be taken that the bottles in which the urine is kept are scrupulously clean and well corked, and that the urine be obtained in as fresh a condition as possible. When the whole twenty-four hours' urine is collected, the bottle should be kept in a cool place and the urine poured into it as soon as possible after being voided. Even then, secondary changes can not always be guarded against. In cold weather such changes will usually not take place for many hours, but in warm weather decomposition is apt to set in at the end of a few hours, and bacteria develop in varying numbers. When not absolutely necessary, it is not advisable to add any preservative to the urine until after the chemical tests have been made. Extra- neous subjects can easily find their way into the urine when care is not exercised as to cleanliness, and these not infrequently lead to confusion in examination. When urine is received for examination, it should be set aside for at least six hours, that a sediment may be deposited, unless it is preferred to use the centrifuge, when examination can proceed at once. In the former case the upper part of the urine is used for chemical tests, and the sediment for microscop- ical examination ; while in the latter, a small amount is used for the centrifugal apparatus, and chemical examination can at once be conducted with the remainder. After determining the amount of urine voided in twenty -four hours, we must note the color, transparency, and reaction, and carefully determine the specific gravity. By the amount of urine voided, and its specific gravity, we can, in many cases, ascertain if its chief organic constituent, urea (which forms about one -half of all the solid ingredients of urine), is above or below normal ; but if the approximate amount of urea is desired, chemical tests must be resorted to. The next step should always be to determine the presence or absence of albumin, as well as its approximate amount, and by boiling the urine an increase of phosphates at once becomes apparent. Whenever the specific gravity is above normal, or any clinical symptoms lead to a suspicion of the presence of sugar, even at a low specific gravity, tests for sugar must be resorted to. Should it be desired to know the approximate INTBODVCTOBT 3 amount of chlorides, phosphates, and sulphates present (though this is not always necessary), the simpler tests for these salts will, as a rule, be all that are required. Before resorting to microscopical examination, the nature of the sediment, whether it is present in small or large amount, its color, and its general character should be noted, and then all the elements found under the microscope, as well as their comparative number, should be carefully observed. It will always be safest to examine a number of drops before coming to a conclusion and determining upon the diagnosis.. Part Fiest k CHEMICAL EXAMINATION Pakt Fikst CHEMICAL EXAMINATION Chapteb I GENERAL PHYSICAL AND CHEMICAL PROPERTIES Normal urine is a yellowish, transparent liquid, of a peculiar odor and, usually, of an acid reaction, though the latter may be either neutral or slightly alkaline, according to the influence of diet. The average amount passed in twenty-four hours is between 50 and 60 ounces, or 1,500 and 1,800 cubic centime- ters, and its specific gravity varies from 1.015 to 1.025. In determining the exact color and specific gravity of urine, it is of great importance to have the entire quantity passed in twenty-four hours, since both color and specific gravity may vary considerably at different hours. As a rule, the more highly colored the urine, the higher is its specific gravity. The color may vary from an extremely light yellow to a dark yellow, or even a reddish hue. The amount of urine voided is greatly influenced by different factors. It is greater the more liquid is taken into the body, and as the amount of solids, which determines the specific gravity, usually remains about the same, it follows that the specific gravity will be lower, the greater the quantity voided. The amount of the perspiratory excretion, too, has a great bearing upon the quantity of the urine, and in cold weather, when the perspiration is lessened, the urine increases in amount. Different articles of diet, such as tea and coffee, undoubtedly stimulate the excretion of urine. Nervous excite- ment, anxiety, and hard mental work have the same effect. Bodily exercise, though increasing the quantity of excreted salts, does not increase the watery constituents of the urine. The (7) 8 VBINABY ANALYSIS AND DIAGNOSIS specific gravity of urine voided at different hours of the day may, therefore, vary to a great degree, sometimes being as low as 1.002 or 1.003, and at other times 1.030, without indicating, in any manner, a pathological condition. Consistency and odor. — Normal urine is of a watery consis- tency, and foams if shaken, though the foam soon disappears when at rest. It has a peculiar odor, varying in intensity, being most pronounced in concentrated urine. If it has become alkaline, it acquires a disagreeable ammoniacal odor. After ingestion of certain articles of diet, such as asparagus, and after taking different medicines, such as oil of turpentine, cubebs, or copaiba, it emits a more or less characteristic odor. The constituents of normal urine are partly organic and partly inorganic. The organic constituents, held in solution, are numerous, though many of them are present in extremely small amounts, and are unimportant ; the more important are urea, uric acid, oxalic acid, hippuric acid, creatinine, lactic acid, coloring matters, and a minute amount of grape sugar. The coloring matters which may exist in normal urine, though all are not necessarily found in every case, are urobilin, uroxan- thin, uroerythrin, and uroindican. The inorganic constituents are chloride of sodium, phosphate of soda, phosphates of magne- sia and lime, sulphates of alkalies, and ammoniacal salts. The gaseous constituents are carbonic acid, nitrogen, and oxygen, the latter in very small amount only. The total amount of solids voided with the urine in twenty -four hours is between 60 and 70 grammes, or 925 and 1,080 grains ; the organic elements being present in the proportion of 25 to 30 in 1,000 parts, and the inorganic in the proportion of 10 to 15 in 1,000 parts. Changes upon standing. — If normal urine is left at rest for a few hours, a cloudy sediment, more or less pronounced, will be formed, and is usually more marked in the urine of females. This sediment will disappear entirely upon shaking. It consists of mucus, with a few flat epithelia from the bladder, and, in the urine of females, from the vagina. In addition to these features, epidermal scales from the prepuce and nymphae will always be found, and at the time of menstruation a large num- ber of blood -corpuscles. Spermatozoa may also be present. After the urine has remained standing for one or more days, bacteria will develop, their number and rapidity of development PHYSICAL AND CHEMICAL PBOPEBTIES 9 depending upon the temperature. In warm weather they may- appear in the course of a few hours. In highly acid urine conidia and mycelia will not infrequently form, though cocci and bacilli may also be found. In alkaline urine fission-fungi, — both cocci and bacilli, — are seen in large numbers. When ammouiaeal decomposition of the urine sets in, the urea is gradually transformed into carbonate of ammonium through the activity of the micro-organisms. Saccharomycetae, or yeast- fungi, may also be present in the urine, and are most common in that containing sugar. Under pathological conditions the urine may be passed as a cloudy liquid of varying consistency. The highest degree of viscidity is usually found in chronic cystitis, when the urine, being strongly alkaline and decomposing in the bladder, appears as a viscid, stringy, muco-purulent mass, with a repulsive ammoniacal odor ; it contains a varying number of bacteria and a large amount of phosphates. The color of the urine will be greatly changed by an increase or decrease of the normal coloring matters, or the abnormal presence of biliary matter. When the urine is mixed with blood it will be more or less dark colored. In febrile conditions it is, as a rule, highly acid in reaction, and has a reddish or reddish brown color, partly due to an excessive amount of urea and the urates, and partly to a red extractive matter known as uroery- thrin. The same may be the case in many slight disturbances of the system. The amount of urine is usually, though not invariably, in- creased in diabetes, and its specific gravity is generally high — 1.030, 1.040, or more. In some cases of diabetes, however, the specific gravity may not only be normal, but below normal — 1.015, or even 1.010 — and still a large amount of sugar may be present. The quantity of urine is also considerably increased in cirrhosis of the kidney, but here the solid constituents, and with them the specific gravity, are greatly decreased. Patients suf- fering with cirrhosis constantly void large quantities of pale, almost colorless urine, nearly destitute of salts, with a specific gravity frequently below 1.010. The amount of urine is de- creased in acute inflammations of the kidney, as well as in acute inflammatory conditions of the other organs. Any intense bodily strain, accompanied by free perspiration, will lessen the amount and increase the specific gravity. 10 UBINABY ANALYSIS AND DIAGNOSIS Determination of Specific Gravity.— The simplest method of testing the specific gravity is by means of the urinometer, which, if carefully constructed, will be sufficiently accurate for all prac- tical purposes. If tested with plain water, such a urinometer will sink to the 1.000 mark at the average temperature of the room. The specific gravity of a specimen should only be taken after it is cooled ; otherwise errors will result. The glass cyl- inder supplied with the instrument should be fluted, so that the latter will not cling to the side of the glass. The test is made as follows : Fill the cylinder four -fifths full of urine, removing the froth, if any is present, with filtering paper. Place the urinometer in the urine, being careful not to allow it to come in contact with the walls of the vessel. Bring the eye on a level with the surface of the urine, and read the corresponding division of the urinometer, but not the upper rim of the fluid, raised a little by capillary attraction. Touch the stem, causing the urinometer to sink slightly in Ihe fluid, and, after it has come to rest, read again. If the amount of urine is small, dilute the specimen with one, two, or even three volumes of water ; test as before directed, and multiply the number of the division -mark by the number of volumes used in the process of dilution. For exam- ple, if two volumes of water have been added to one volume of urine, thus making three volumes in all, and the urinometer stands at 1.006, the real specific gravity of the original urine is 1.018. The solid materials upon which the specific gravity depends, which were dissolved in one volume, are, after dilu- tion, dissolved in three volumes, and the specific gravity is therefore only one -third of the original. Determination of Solids. — If we wish to determine the amount of solids present in the urine voided during twenty -four hours, we must know the exact quantity passed during this time, as well as its specific gravity. The approximate amount of the solids can be obtained by multiplying the last two figures of the specific gravity by the coefficient of Haeser, which is 2.33, and it will give the number of grammes of solid matter in 1,000 cubic centimeters of urine. For example, suppose we have 1,500 cubic centimeters passed in twenty -four hours, of a specific gravity of 1.020. To estimate the amount of solids in 1,000 cubic centimeters, or 32 ounces, we multiply the last two figures, 20, by the coefficient, 2.33, which PHYSICAL AND CHEMICAL PROPERTIES 11 gives us the product, 46.60, the amount of solids, in grammes, in 1,000 cubic centimeters ; this is equal to 720 grains. The quan- tity present being 1,500 cubic centimeters, or 48 ounces, the amount of the solids will be 69.90 grammes, or 1,080 grains. Valuable conclusions as to the amount of solids may thus be obtained from the specific gravity in a very short time. In diabetes, for instance, the quantity of urine voided being large and of a high specific gravity, the amount of solids is consid- erably increased ; in inflammations of the kidney, on the other hand, where the quantity of urine is decreased and the specific gravity is low, the amount of solids is diminished. Since urea composes nearly one -half of the solid constituents, it can easily be seen that in the latter case it has not been excreted in sufficient quantity. Chapter II NORMAL CONSTITUENTS Urea. — Urea is the chief organic constituent of urine, and its most important nitrogenous product. The greater portion of nitrogen taken into the system with the food is excreted by the kidney in the form of urea. The quantity excreted varies greatly under different physiological conditions, but averages between 25 and 40 grammes, or 375 and 600 grains, in twenty- four hours, it being about one -half of the solid ingredients voided. The specific gravity of the urine alone will, therefore, give an approximate idea of the amount of urea therein, pro- vided no sugar is present and the amount of chlorides is nor- mal. A specimen of normal urine with a specific gravity of about 1.020, and voided in a quantity of about fifty ounces, will contain approximately two or two and one -half per cent of urea. Normally the amount of urea excreted varies greatly with the diet, being most abundant after eating nitrogenous food. It is also increased after muscular exercise and mental activity. Pathologically, it is increased during fevers and in diabetes, in the latter condition sometimes to an enormous extent. It is decreased in diseases of the liver — the liver being the chief seat of the formation of urea, — in diseases of the kidney, and in chronic affections impairing the vitality of the patient. Urea is always held in solution, and can never be found under the microscope without chemical means. It crystallizes in the form of colorless quadrilateral plates, or prisms, and in needles of varying sizes. It can easily be detected as nitrate of urea by placing a few drops of urine upon a glass slide, adding a drop of nitric acid, warming the slide carefully, and placing it aside to crystallize. Under the microscope, more or less regular rhombic or hexagonal plates, either single or overlapping each other, will now be found. These plates have a little color, and are perfectly characteristic. (See Fig. 1.) (12) NORMAL CONSTITUENTS 13 Quantitative tests. — The quantitative tests for determining the exact amount of urea present in the urine are numerous, but more or less complicated. The simplest is the hypobromite method, the principle of which depends upon the fact that, when FiQ. 1. Crystals op Ukea and Nitrate of Urea (X 200). urea in solution comes in contact with a sodium -hypobromite solution, nitrogen is set free as a result of the total decomposi- tion of the urea. The quickest way of carrying out this method is by means of Doremus' ureometer. The hypobromite solution necessary for this test does not keep well, and it is, therefore, best to keep the bromine and the caustic sodium solution sep- 14 URINARY ANALYSIS AND DIAGNOSIS arate. Have on hand a solution of sodium hydrate — 100 grammes of caustic soda to 250 cubic centimeters of water (3 ounces to 8)— and the bromine in separate bottles. To prepare the solution, take ten parts of the sodium hydrate solution and one part of bromine, and dilute with equal parts of water ; the solution is then ready for use. Doremus' apparatus consists of a bulb and graduated tube, and a small curved nipple -pipette to hold one cubic centimeter of urine. The bulb of the ureometer is filled with the hypo- bromite solution, and by inclining the tube, the long arm is filled to the bend at the bulb. By means of the nipple -pipette one cubic centimeter of urine is drawn up, the pipette passed through the bulb of the ureometer as far as it will go in the bend, and the nipple compressed gently and steadily. The urine will rise through the l^hypobromite and the urea instantly decomposes, giving off nitrogen gas. The decomposition of urea is complete in ten or fifteen minutes, and the graduation on the tube will indicate the quantity of urea in one cubic centi- meter of urine. To obtain the percentage, multiply the num- ber of divisions on the tube by 100. Uric Acid. — Of the other normal organic constituents in the urine, the most important are uric acid and the urates. Uric acid is normally voided in small amount only, and is in direct proportion to the urea, being about 1 to 45 ; the average quan- tity voided in twenty -four hours is from 7 to 12 grains (0.4 to ■0.8 grammes). The simplest method of determining the presence of this acid is by microscopical examination. Occasionally, however, it may become necessary to employ a chemical test for its recognition, and the quickest is the murexide test. A small portion of the sedi- ment, or the residue after evaporation, is placed on a poi'celain dish, a few drops of a strong solution of nitric acid are added, and the solution carefully warmed. When dry, a few drops of liquor ammonia are added, and a beautiful purple color will at once appear, which soon spreads over the dish, and will change into violet upon the addition of caustic potash. For the remaining organic constituents, which, so long as they are held in solution, have no practical significance, chemical tests are not necessary. Oxalic acid never occurs in the urine in a free state, but always in combination with lime, and, as such, is seen under the microscope. Creatinine and hippuric acid will NORMAL CONSTITUENTS 15 always be found under the microscope when present in abnor- mally large amounts. Coloring matters, found in small quan- tities in normal urine, are increased in pathological conditions, and will be considered later on. The chief inorganic constituents of the urine are the chlo- rides, sulphates, and phosphates. Chlorides. — The chlorides present in the urine are chloride of sodium (the most abundant) and small quantities of chloride of potassium and ammonium. The amount of the chlorides voided varies considerably with the diet, being most abundant when a "large amount of salty food is ingested. The average quantity voided is between 10 and 16 grammes (2% to 4 drachms) in twenty -four hours. The excretion of chlorides is diminished in all febrile conditions, especially when attended by serous exuda- tions. In pneumonia they are greatly decreased, and may be entirely absent in severe cases ; they may also be diminished in cases of chronic nephritis. The chlorides may be detected by treating the urine with nitric acid and adding a solution of nitrate of silver ; a cheesy precipitate, soluble by the addition of ammonium, shows the presence of chlorides. A test of the approximate amount of chlorides present may be made with this method as follows : To a small amount of urine in a test-tube add a few drops of nitric acid, and to this one or two drops of a nitrate of silver solution, one part to eight. If a white, flaky precipitate is formed, which quickly sinks to the bottom of the test-tube with- out diffusing through the urine, the chlorides are present in normal amount (from one -half to one per cent) . If a simple cloudiness appears, readily diffusing through the urine without the appearance of flakes, the chlorides are diminished to one- tenth per cent ; and if no precipitate whatever is formed, they are entirely absent. Sulphates. — The sulphates occurring in the urine are mostly those of sodium and potassium, the former predominating. The quantity excreted by the kidneys varies from 2 to 3 grammes (30 to 45 grains) in twenty -four hours. An increased excretion takes place after a meat diet and as a result of active exercise ; this is also the case in acute fevers with an increased excretion of urea. Sulphates are diminished after a vegetable diet. They may be detected by adding to a given quantity of urine in a test-tube one-third as much of an acidulated solution of 16 UBINABY ANALYSIS AND DIAGNOSIS barium chloride (2 parts to 8 of water, with one -half part of hydrochloric acid). An opaque, milky cloudiness will appear when the amount of the sulphates is normal. If, the opacity is intense, and the mixture has the appearance of cream, the sulphates are increased ; but if there is only a slight cloudiness, they are diminished. Phosphates. — The phosphates present in the urine consist partly of earthy and partly of alkaline phosphates. The earthy phosphates are insoluble iu water, and are held in solution in acid urine, but are precipitated in alkaline urine. The alkaline phosphates are soluble in water, and are not precipitated from solution by alkalies. The earthy phosphates are phosphates of calcium and magnesium, and the amount excreted in the urine is from 1 to 1% grammes (15 to 23 grains) in twenty -four hours. If the acid -magnesium phosphate be acted upon by ammonium, the ammonio -magnesium phosphate — so-called triple phosphate — is formed. The alkaline phosphates are the acid phosphate of sodium and , phosphate of potassium ; their amount varies from 2 to 3 grammes (30 to 45 grains) in twenty-four hours. The phosphates vary considerably in amount with the diet, being more abundant after taking vegetables and alkaline waters. The earthy phosphates are increased in diseases of the bone, as osteomalacia and rhachitis, and diseases of the nerve-centers, but are diminished in pronounced diseases of the kidneys. The earthy phosphates may be detected by rendering the urine strongly alkaline with caustic potash and gently heating, which causes them to precipitate. To detect the alkaline phosphates, remove the earthy phosphates by precipitation, and add to a given quantity of urine one-third the quantity of magnesian fluid (1 part each of magnesium sulphate and ammonium chloride, 8 parts of water, and 1 part of pure liquor ammoniac). All the phosphates are precipitated in the form of a snow-white deposit. If the entire fluid presents a milk -like, cloudy appearance, the alkaline phosphates are present in normal amount ; if it is denser and more cream-like, there is an increase, but if the fluid is only slightly cloudy, the phosphates are diminished. Chapter III ALBUMINOUS SUBSTANCES Albumin. — Of all the chemical tests, one of the most im- portant is undoubtedly that for albumin, by which term serum- albumin is always meant. The presence of albumin does not necessarily signify the presence of a renal trouble, and, if found in small amount only, may be due to a variety of causes. Even a comparatively large amount may exist without any kidney- lesion whatever, and it is a grave mistake to conclude that a nephritis must exist because albumin has been found. It is undoubtedly true that in the larger number of cases in which albumin is present a nephritis exists, yet in such cases a microscopical examination must always be made, and then only if pus -cor- puscles and kidney -epithelia, with or without casts, are found can a diagnosis of a nephritis be made. On the other hand, a nephritis may exist and yet albumin be found in such minute quantities as to occasionally escape detec- tion altogether. This is sometimes the case in cirrhosis of the kidney, where a large amount of albumin is rarely seen, and it may be entirely absent for a few hours. In such cases the urine of the entire twenty -four hours should be tested before concluding as to the presence of albumin. In all cases where pus -corpuscles in moderate numbers are found in the urine, albumin will always be detected, if careful tests are made, though there maybe no more than a faint trace. It can thus easily be seen that in such widely different lesions as pyelitis, cystitis, prostatitis, urethritis, and vaginitis, it might be present in the urine, and a microscopical examination will be necessary to determine its origin. In haemorrhage from any portion of the genito- urinary tract, a considerable amount of albumin is usually found. The rare cases of chylous urine, in which the kidney may be perfectly intact, are always associated with the presence of a large amount of albumin. Disturbances of circulation, due to a variety of different B (17) 18 USINABT ANALYSIS AND DIAGNOSIS causes, may bring about the presence of albumin without any- structural changes in the kidney or any pus -corpuscles in the urine. Such cases are often roughly termed functional albu- minurias. It is not always easy to trace the cause of such albuminurias, though they may be due to nothing but prolonged muscular exercise, to lesions of the nervous system, or to organic heart -lesions, etc. If long continued, these cases will sooner or later cause inflammations of the kidney. Albuminuria of pregnancy, due to the pressure of the pregnant uterus, is very common, and in many of these cases an organic lesion of the kidney will develop. Changes in the composition of the blood with a broken down constitution, as seen in anaemia, tuberculosis, malaria, leuctemia, pyaemia, etc., will cause the appearance of albumin, and this may also be the case in any other febrile condition. Detection of Albumin in Urine. — 1. Acetic Acid Test. — The tests for albumin are quite numerous, but one of the most reliable is the following : Fill an ordinary test-tube about one- fourth or one-third full of urine, and boil thoroughly ; then add two or three drops of a solution composed of equal parts of glacial acetic acid and water. If albumin is present, the urine becomes cloudy, the cloudiness being the more pronounced the larger the amount of albumin. The unboiled urine, as brought for examination, is either transparent or cloudy. When the urine is boiled, the results may be the following : a. The urine is transparent, and upon boiling, remains unchanged. This indicates normal urine. 6. The urine is transparent, but after boiling becomes cloudy. By adding a few drops of acetic acid, it clears up entirely. This shows the presence of an increased amount of phosphates. If effervescence occurs upon the addition of the acid, either carbonate of lime or carbonate of ammonium (the latter being always held in solution, and never precipitated so as to be found under the microscope) is present. c. The urine is transparent, but after boiling becomes cloudy, and the cloudiness remains or becomes more pronounced upon the addition of the acid. This indicates the presence of aliu- min, which, in larger quantities, will be thrown down in flakes ; when very abundant, the urine may be converted into a jelly- like mass. The acetic acid test will show the presence of the ALBUMINOUS SUBSTANCES 19 smallest traces of albumin, though these may escape detection if not carefully observed. The best plan in such cases is to take a second test-tube and pour into it unboiled urine ; then com- pare the two test-tubes in strong light. When this is done, the faintest trace of albumin can be detected by the slight cloudiness in the test-tube containing the boiled urine. d. The urine is cloudy, but upon boiling clears up entirely and remains clear upon the addition of the acid. This indicates an excess of urates, especially urate of sodium. e. The urine is cloudy, the cloudiness becoming more pro- nounced upon boiling and the addition of the acid. This shows an excess of urates, in addition to the presence of albumin. f. The urine is cloudy, and remains unchanged by boiling and by the addition of acetic acid. This proves the presence of micro -orgg,nisms, such as micrococci and bacilli. 2. Nitric Acid Test.— A common test for albumin is the nitric acid test, the urine being boiled, and a few drops of nitric acid added. This test is not as reliable as the preceding, since if a small amount only of albumin be present and the acid added be in excess, the albumin may become redissolved. On the other hand, if the amount of acid added is small and the phosphates are present in excess, a part only of the basic phos- phates will be acidified and a soluble albuminate will be formed, which remains in solution. 3. Fereocyanide of Potassium Test. — Another good test is the following : Fill a test-tube with clear urine, filtering it first if not clear ; add 5 to 10 drops of acetic acid and a few drops of a 10 per cent ferrocyanide of potassium solution. If albumin is present, a cloudiness will at once appear, and become more pronounced upon shaking. 4. Heller's Test. — Still another frequently employed test is Heller's. It is used as follows : Upon a quantity of pure nitric acid in a small test-tube allow an equal amount of clear urine to trickle from a pipette down the side of the inclined tube, so that the urine overlies the acid. If albumin is present, a sharp white zone will appear at the point of contact between the acid and the urine, varying in thickness according to the amount of albumin present. If only a trace of albumin be present, fifteen to thirty minutes may elapse before the zone becomes visible. Although a large number of other tests are occasionally used, 20 URINARY ANALYSIS AND DIAGNOSIS these few will be all that are necessary for practical purposes. Perhaps the most reliable is the first one given— the heat and acetic acid test. If doubt remains as to the presence of albu- min, any of the other tests given will clear up the question. Quantitative Test for Albumin.— It is of the utmost impor- tance to have an approximate idea of the quantity of albumin present in any given case, and too many errors are constantly made in this respect. It is by no means rare to hear of a urine containing 25, 40, or even 50 per cent of albumin. What is thereby meant is, of course, per volume ; yet such statements are absolutely misleading. As a matter of fact, one-tenth of 1 per cent is a moderate amount of albumin, one -twenty -fifth of 1 per cent being a small amount ; one -half of 1 per cent is a large amount, and it is only in- comparatively rare cases that 1 per cent or more is present ; more than 3 or 4. per cent is probably never found. The simplest method of estimating the approximate amount of albumin is by means of Bsbach's albuminometer. This in- strument consists of a graduated glass tube, which is filled with urine to the letter U marked upon the tube, and with the test- solution to the letter R. The latter consists of one part of picric acid to coagulate the albumin, two parts of citric acid to hold the phosphates in solution, and distilled water to make one hundred parts. The tube is now closed with the rubber stopper supplied with it, and the contents thoroughly mixed. It is then set aside for twenty -four hours to allow the precipitate to settle thoroughly, and the amount of the precipitate carefully noted. The tube contains seven main lines of division, each one of which signifies one gramme of albumin in 1,000 grammes, — that is, one-tenth of one per cent. It will be seen that the instru- ment is only graduated for seven -tenths of 1 per cent, and this is sufficient for most cases. In those rare cases in which more than that amount of albumin is present, the urine must be di- luted with one, two, or even three parts of water before testing. It must always be borne in mind that this method can never be absolutely accurate, since picric acid will also precipitate urates, peptone, and vegetable alkaloids ; but it undoubtedly gives an approximate idea, which is all that is required in most cases. Besides serum -albumin, the urine sometimes contains a number of similar but less important substances, among which may be mentioned peptone, globulin, albumose, mucin, and fibrin. ALBUMINOUS SUBSTANCES 21 Peptone. — Peptone is uever present in normal urine, but is frequently seen in many different conditions in which there is a formation of pus and disintegration of pus -corpuscles somewhere in the body. It has been found in the following conditions : Croupous pneumonia, pulmonary tuberculosis, gangrene of the lungs, empyema, cancer (especially of the gastro- intestinal tract and the liver), different abscesses, acute yellow atrophy of the liver, phosphorus poisoning, typhoid fever, typhus fever, variola, scarlet fever, erysipelas, acute arthritis, etc. It has, however, also been found in physiological conditions, such as the involution of the pregnant uterus, so that its presence does not necessarily signify a diseased condition. Peptone is easily soluble in water, does not coagulate by heat- ing, and does not precipitate by the addition of most of the reagents used for the detection of albumin, such as nitric acid, acetic acid, and ferrocyanide of potassium. It may be detected by the following method : To ui-ine which has been slightly acidified by acetic acid, add a solution of sulphate of ammonium to saturation, and filter out any pre- cipitate having formed, which may consist of albumin, globulin, or albumose. If potassio- mercuric iodide or picric acid is now added, and a precipitate occurs, this will be peptone. Globulin. — Globulin is almost always associated with serum- albumin, and its clinical significance is nearly identical with the latter. It can be detected by the method of Pohl in the following manner : Render the urine slightly alkaline by the addition of ammonium hydrate, and filter after standing one or two hours ; then add an equal volume of a saturated solution of ammonium sulphate. If globulin is present, a precipitate forms. Albumose. — Albumose is an intermediate product in the con- version of albumin into peptone. It has been found in the urine in a number of different conditions, such as osteomalacia, ulcerations of the intestines, and multiple sarcomata. Its clinical significance is not yet positively known. It is not precipitated by heat, but if the urine be made strongly acid with acetic acid, and a concentrated solution of table salt be added, it becomes precipitated. If the cloudy fluid be now heated, it becomes transparent, but turbid again upon cooling, and if more table salt be added, it remains precipitated in spite of heating. Mucin. — Mucin is present in small amount in every normal urine, being more abundant in the urine of females. It is con- 22 VBINABY ANALYSIS AND DIAGNOSIS siderably increased in quantity in catarrhal inflammations of the genito- urinary organs, more especially those of the bladder, the prostate gland, and the urethra. When present in large amount, the urine will appear cloudy soon after it is voided, and it may form a ropy, jelly-like mass, which sinks to the bottom of the vessel. To detect its presence in urine, dilute with equal parts of water and add an excess of acetic acid. If mucin is present, a more or less pronounced precipitate forms. To detect it in urine con- taining albumin, precipitate the albumin by boiling, and test again with acetic acid. Even small amounts can be detected with the microscope. Fibrin. — Fibrin is found in the urine in greater or less amount in hsematurias, due to various causes, and is also seen in chylous urine. In tumors of the bladder, such as papilloma and cancer, where htemorrhages often take place, it is of frequent occurrence. It is usually present in the form of coagula when the urine is voided, or may be precipitated upon standing. Fibrin is in- soluble in water and in salt solutions, as well as in weak acids and alkalies. The latter cause it to become gelatinous upon cooling, becoming soluble again after prolonged boiling. The solutions give the general reactions of albumin. It is, however, much easier to detect its presence by the microscope. Chaptee TV GRAPE-SUGAR There can be little doubt that the urine may contain small amounts of sugar under normal conditions, but the amount present in such a physiological glycosuria is so minute that a positive reaction will never be obtained with the general methods of detecting grape-sugar (dextrose). Pathological glycosuria may appear in the urine as a tempo- rary condition in the course of a number of diseases, such as Asiatic cholera, intermittent fever, cerebro- spinal meningitis, diseases of the heart, lungs, liver, and brain, especially those involving the fourth ventricle, and in gout. It may, further- more, be present in poisoning with certain substances, such as morphine and carbonic oxide. Whenever sugar is persistently present in appreciable quantity, we always have to deal with diabetes mellitus. If a large amount of straw-yellow colored urine of a high specific gravity is voided, suspicion must at once be directed toward this dis- ease, and the urine tested for sugar, even if no other symptoms of the affection are as yet present. Detection of Sugar in Urine. — The tests for sugar are numerous, and in mild cases it may be necessary to resort to two or even three different tests before we are positively able to determine the presence of sugar. 1. Moore -Heller Test. — Perhaps the simplest is the Moore -Heller test. Although by no means absolutely reliable, it is in many cases sufficient to determine the approximate amount of sugar. The method is the following : Pour into a test-tube two parts of urine and one part of a 10 per cent caustic potash solution ; boil the upper portion for two or three minutes. Phosphates, if precipitated in large amount, must be filtered off. When sugar is present, a change of color will take place after boiling, which can be approximately estimated as follows : One per cent or less of sugar gives a canary -yellow (23) 24 VBINABY ANALYSIS AND DIAGNOSIS color, the color being somewhat more intense than that of the original unmixed urine ; between 1 and 2 per cent gives a wine -yellow color ; between 2 and 3 per cent a sherry color ; between 3 and 4 per cent a rum color, and above 4 per cent a dark brown or even black color. By the addition of a few drops of nitric acid, the liquid loses its dark color, and gives out an odor similar to molasses. This test is only a tolerably reliable one, but in many cases will answer the purpose. The addition of caustic potash to cold urine may produce a dark color, which is due to the presence of coloring matters of the bile. The white flocculent precipitate, which is almost invariably seen with this test, is partly due to the phosphates which caustic potash may precipitate in cold urine, and partly to mucine. 2. Trommer's Test. — To four parts of urine in a test-tube add one part of caustic potash or soda, adding, drop by drop, a 10 per cent solution of sulphate of copper, and shake until the mixture shows a blue color. Heat the upper part of the mixture, and if sugar is present a precipitate of yellow cuprous hydroxide will result, which at first shows plainly in the bluish liquid, but gradually spreads over the entire fluid, and a red sediment of cuprous oxide is formed. If this reaction takes place upon heating, a similar mixture may be made and set aside for a number of hours without heat- ing ; if sugar is present in rather large quantities, a similar precipitate will form. Should the reaction by heating be at all doubtful, the second test must always be made, since many of the other organic substances, which reduce the salts of copper, do so only after heating and boiling. This test is open to a number of objections. Albumin, if present in large quantities, must first be removed, since it in- terferes with the reduction of the cupric oxide. A number of substances are, furthermore, found in urine which have the property of reducing oxide of copper in an alkaline solution, among which may be mentioned uric acid, creatinine, hippuric acid, and mucine. Again, a small amount of sugar may be present in urine, and fail to reduce the oxide in the presence of other substances, such as urate of ammonium, chloride of am- monium, and other ammoniacal compounds. 3. Feeling's Solution.— This solution is prepared in the following manner : First dissolve 34.639 grammes of pure OBAPE-SUGAB 25 crystallized sulphate of copper in a sufficient quantity of water under gentle heat, and dilute with water to 500 cubic centime- ters. Next dissolve 173 grammes of chemically pure crystallized neutral sodium tartrate and 100 cubic centimeters of caustic soda solution, of a specific gravity of 1.12, in sufficient water to make 500 cubic centimeters. It is best to keep these two solutions separate, and mix equal volumes before using. Ten cubic centi- meters of this solution will be reduced by 0.05 grammes of sugar. The solution may be used by pouring a small quantity into a test-tube and diluting it with two or three times the amount of water. The mixture should be boiled for a few seconds. If it remains clear after boiling, which will usually be the case when the two solutions are kept separate and are not too old, add the urine to be tested drop by drop, at the same time con- tinuing the boiling. If sugar be present in any quantity, the first few drops will usually cause a yellow precipitate ; if the addition of urine is continued, a yellowish red. sediment will soon fall to the bottom of the test-tube. Should no such precipitate occur, the addition of urine may be continued until an equal volume of urine has been added ; if then no yellow precipitate appears upon boiling, the urine is free from sugar. 4. Haines' Test. — Take 30 grains of pure sulphate of cop- per and one -half ounce of distilled water ; make a perfect solution, and add one -half ounce of pure glycerin ; mix thoroughly, then add five ounces of liquor potassse. The so- lution keeps indefinitely if well prepared. In testing with this solution, pour about one drachm into a test-tube and boil it gently. Next add 6 to 8 drops of the urine and again boil. If sugar be present, a copious yellow or yel- lowish red precipitate is formed. If no such precipitate appears, no sugar is present. ■ 5. Bottger's Test. — Pour one part of urine into a test-tube and add an equal quantity of a concentrated solution of car- bonate of soda, or caustic potash, and a small quantity of sub- nitrate of bismuth. Boil for a short time. If sugar is present, it reduces the bismuth salts to the black suboxide of bismuth, which will be deposited on the sides of the test-tube. If the quantity of sugar is small, the bismuth will assume a grayish color. Albumin, if present in large quantities, must first be eliminated by boiling and filtration. 26 UBINABT ANALYSIS AND DIAGNOSIS 6. Roberts' Fermentation Test. — This is an excellent and simple test, being used as follows : Into each of two bottles, one of 4 ounces, the other of 12 ounces capacity, pour 4 ounces of urine. Add a piece of fresh yeast the size of a walnut to the urine in the larger bottle, which must be closed with a cork nicked for the escape of gas evolved by fermentation. The smaller bottle must be tightly corked, and the two bottles placed side by side in a uniform temperature of 68° to 75° F. — the average temperature of the room. At the end of twenty-four hours, fermentation will be completed. The specific gravity of each specimen must then be carefully taken by . means of the urinometer, and any difference of the specific gravity will indi- cate sugar, the number of degrees of difference indicating the number of grains per fiuid ounce. For example, if the specific gravity of the unfermented urine is 1.035, and that of the fer- mented urine 1.020, the urine contains 15 grains of sugar to the fiuid ounce, or 3 per cent. This test, although not absolutely accurate, is sufilciently so for practical purposes. These six tests represent only a fraction of those in use, but are the more important and more simple. The others, among them the phenylhydrazin test, are more complicated, and offer no advantages over those described. Quantitative Tests for Sugar. — For the quantitative deter- mination of sugar in the urine, a number of the tests here given afford an approximative idea, as, for instance, the Moore-Heller and the Roberts tests. The former, however, is not very accu- rate, and is of little value if the amount of sugar is below 1 per cent. Fehling's solution may also be used for this purpose, and pretty accurate results can be obtained with Einhorn's fer- mentation saecharometer. Whitney's reagent likewise gives good results. 1. Fehling's Test.— The principle upon which Fehling's solution depends lies in the fact that in the reduction of oxide of copper by grape sugar, the blue color disappears by the addi- tion of a definite quantity of the sugar. As before said, ten cubic centimeters of the solution correspond to 0.05 grammes of sugar. The test may be conducted in the following manner : Dilute one cubic centimeter of Fehling's solution with four cubic centimeters of water in a test-tube, and after heating, add one- tenth cubic centimeter of the urine to be examined from a graduated pipette. Heat must be then re-applied, the precipitate GRAPE-SUGAR 27 watched, another one-tenth cubic centimeter added, and the heat again applied, until after allowing it to stand for a short time, it is found that all the blue color is removed from the solution. If, in doing this, one cubic centimeter of urine has been added, it contains one-half of 1 per cent of sugar; if more than one cubic centimeter, it contains less than one-half per cent, but more than one-fourth per cent. If two cubic centimeters are used, it contains one -fourth per cent, and if one-half centimeter is used, it contains 1 per cent of sugar. If the proportion of sugar is large, as is usually the ease with a high specific gravity, the urine should be diluted five to ten times. 2. Whitney's Reagent. — This reagent has given good results, and for practical testing, ten minims of urine only are used. The advantages claimed for it are accuracy, stability, simplicity, and reliability. The formula of the standard solution (parts by weight) is : Ammonii sulphatis (C.P.) . . Cupri sulphatis (C. P.) Potassii hydroxide (C. P.) . . Aquse ammon. (Sp. gr. 8.80) Glyoerini (C.P.) . . . Aqusg (dest.) Orammes 1.2738 2.5587 19.1620 312.2222 60. q.s. One cubic centimeter of the reagent is the equivalent of ; Cupro-diammonium sulphate Cuprie hydroxide . . . Grape sugar, anhydrous . Orammes 0.03832 0.41062 0.00526 The following table gives the amounts of sugar in analytical testing If reduced by — It contains to the ounce— Percentag 1 minim. . 16. grains or more . 3.33 2 minims 8. 11 1.67 3 tt . 5.33 " . . 1.11 i (t . 4. " 0.83 5 " 3.20 li 0.67 6 li . 2.67 1 1 0.56 7 ii . 2.29 11 . . . 0.48 8 1 1 2. u . 0.42 9 (( .... 1.78 i I . . 0.37 10 a . 1.60 ti . 0.33 The method of procedure is the following : Heat one drachm of the reagent in a test-tube to boiling ; add the urine slowly. 28 VBINABT ANALYSIS AND DIAGNOSIS drop by drop, until the blue color begins to fade, then more slowly, boiling three to five seconds after each drop, until the reagent is perfectly colorless, like water, or until ten drops only are added. On cooling, the reagent resumes the blue color, the change being due to the absorption of oxygen from the atmos- phere. "When the urine contains a large amount of albumin, the reduction takes place without interference by the albumin present, but leaves the reagent more or less of a yellow tint. A large amount of coloring matter has a similar effect. If the urine contains a considerable amount of sugar, it is best to dilute it from one to ten times, multiplying the amount found in the table by the amount of dilution. 3. Einhoen's Fermentation Saccharometer.— One of the simplest tests, which will be found to answer all purposes, is by means of Einhorn's fermentation saccharometer. The apparatus is put up in the form of a set, consisting of two saceharometers and one graduated test-tube. The method is the following : Take one gramme (about fifteen grains) of fresh commercial com- pressed yeast, and shake thoroughly in the graduated test-tube with ten cubic centimeters of the urine to be examined. Then pour the mixture into the bulb of the saccharometer. By in- clining the apparatus, the mixture will easily flow into the cylin- der, thereby forcing out the air. Owing to the atmospheric pressure, the fluid does not flow back, but remains there. Leave the apparatus undisturbed for twenty or twenty-four hours in a room of ordinary temperature. If the urine contains sugar, the alcoholic fermentation begins in about twenty to thirty minutes. The evolved carbonic acid gas gathers on the top of the cylinder, forcing the fluid back into the bulb. On the following day the upper part of the cylinder will be found filled with carbonic acid gas. The changed level of the fluid in the cylinder shows that the sugar reaction has taken place, and indicates, by the numbers upon the cylinder to which it corresponds, the approximate amount of sugar pres- ent. If the urine contains more than 1 per cent of sugar, it must be diluted with water before being tested ; urine of a specific gravity of 1.018 to 1.020 may be diluted twice ; of 1.021 to 1.028, five times ; 1.029 to 1.038, ten times. In carrying out this test, it is always advisable to take, besides the urine to be tested, a normal specimen, and make the same fermentation test with it. The mixture of the normal GBAPE-SUGAB 29 urine with yeast will, on the following day, have only a small bubble on the top of the cylinder. This proves at once the ef&cacy and purity of the yeast. If, in the suspected urine, there is also a small bubble on the top of the cylinder, no sugar is present ; but if there is a much larger gas volume, we are sure that the urine contains sugar. It may be mentioned that the urine may, in rare cases, con- tain other saccharine substances, such as lactose, levulose, and inosite, but they are of no practical importance. Chaptee V OTHER ABNORMAL CONSTITUENTS Acetone.— Acetone is found in varying amounts in febrile conditions, in diabetes, in some malignant tumors, in cases of starvation, and in psychoses. It is said to be present in minute amount in many normal urines, and is greatly increased by a meat diet. It may be detected by Lichen's iodoform test as modified by Ralfe : Dissolve twenty grains of iodide of potassium in a drachm of liquor potassse and boil ; float the urine upon the surface of the fluid in a test-tube. At the point of contact, a precipitation of phosphate will occur, which, if acetone be present, becomes yellow and studded with yellow points of iodoform. Another method of detection is by Legal' s test : Prepare a fresh, strong solution of sodium nitro-prusside by dissolving a few fragments in a little water in a test-tube. To a few cubic centimeters of the urine add enough liquor sodse or liquor po- tassse to secure a distinct alkaline reaction, and to this add a few drops of the nitro-prusside solution, when a red color will at once appear. This color will quickly disappear, but if acetone is present, the addition of a few drops of concentrated acetic acid will produce a purple or violet -red ; if no acetone is present, the latter change will not occur. Diacetic Acid. — In advanced stages of diabetes, diacetic acid is not uncommon, and is usually of grave significance. It may occur in severe fevers, and also in nervous disturbances. The best test is the one described by v.Jaksch: To fresh urine carefully add a few drops of a moderately strong watery solution of chloride of iron. If a precipitate of phosphates is produced, remove it by filtration, and to the filtrate add more of the chloride of iron solution. If a red color develops, heat a portion of the urine to boiling, acidulate a second portion with sulphuric acid, and extract with ether. If the urine which ha^ been boiled shows little or no change, while the chloride of iron (30) OTHER ABNORMAL CONSTITUENTS 31 reaction with the ethereal extract pales after twenty -four to forty-eight hours, and the urine as well as the distillate contains large quantities of acetone, diacetic acid is present. Coloring Matters. — Bile Pigments. — When biliary coloring matters appear in the urine, the urine always has an abnormal color — dark yellow, brown, or greenish, and a yellow froth or foam is produced by shaking. The coloring matters are bili- rubin and biliverdin, and are met with in the urine in jaundice, from whatever cause it arises, as well as in numerous pathologi- cal conditions of the liver, with or without jaundice. They may, furthermore, appear as a result of blood- changes, and after haemorrhage into the tissues. One of the best methods for detecting bile -pigments in the urine is by Gmelin's test, which consists of placing a small quantity of strong nitric acid, containing a little yellow nitrous acid, into a test-tube and gently floating a similar amount of urine upon it. If biliary coloring matters are present, a set of concentric colored rings will appear at the point of union between the acid and the urine ; these rings, from above down- wards, will be green, blue, violet, red, and yellow, the green being the most predominant, and is indispensable in proving the presence of bile, the others being sometimes more or less indistinct and even entirely absent. A moderate amount of albumin has no influence upon this reaction. A modification of this test by Bosenbach is also good : The urine is filtered through pure white filtering paper, and, after filtration, a drop of the acid is applied to the inside of the filter ; around the nitric acid the same concentric rings will be observed. Another simple test is Ultzmann's : To ten cubic centime- ters of urine add three or four cubic centimeters of a 25 per cent caustic potash solution and an excess of pure hydrochloric acid. If bile -pigments are present, the mixture assumes a beautiful green color. Coloring Matter op Blood — Haemoglobin, the coloring matter of the blood, may be found in the urine, either enclosed in the red blood -globules, in cases of hematuria, or, in rare instances, dissolved in the urine, the affection being called hemoglobinuria. Heematuria is common, and may occur from diseases of any portion of the genito- urinary tract. Haemoglo- binuria, on the other hand, is only found occasionally in severe 32 If BINARY ANALYSIS AND DIAGNOSIS infectious diseases, especially yellow fever; in extensive burns, and poisoning by different substances, such as carbolic acid, phosphorus, and naphthol ; also, as a disease by itself, called paroxysmal hsemoglobinuria. The simplest method of detecting haemoglobin chemically is by Heller's test: The earthy phosphates are precipitated from the urine by the addition of caustic potash and heat ; as they become precipitated they carry with them the coloring matter, and are therefore not white, but blood -red. Under the micro- scope the coloring matter can easily be detected, whenever present in any form. Urobilin.— Urobilin is present in small amount in every normal urine, but may be abundant in diiferent pathological conditions, especially those in which a rapid destruction of red blood -corpuscles takes place. The urine will in such cases have an intense reddish brown color, similar to that containing bile -pigments. It can be detected in the following manner : Render the urine alkaline by the addition of ammonia ; filter, and to the filtrate add a few drops of a 10 per cent chloride of zinc solution. If urobilin be present, a green fluorescence will be observed by reflected light. Indican. — Indican is undoubtedly present in minute amount in every normal urine, is increased by a meat diet, is found in intestinal disturbances and in a number of widely different diseases, though its pathological significance is not yet under- stood. Having frequently been found in persons suffering from malignant tumors in any part of the body, but more especially the liver, it was at one time considered to be characteristic of such tumors ; but this is undoubtedly incorrect. In general, it may be said that large amounts of indican in the urine are caused by an increased albuminous putrefaction in the in- testines. Its detection by Jaffe's method is the following : Pour into a test-tube a small quantity of urine, and mix with an equal amount of strong hydrochloric acid ; add ten or fifteen drops of chloroform and, drop by drop, a moderately strong fresh solu- tion of chloride of lime, shaking after each drop. The chloro- form readily dissolves the freshly formed indigo, and a blue color appears, which is more or less pronounced, according to the amount of indican present. OTHER ABNORMAL CONSTITUENTS 33 Fatty Matters. — In rare cases a varying amount of fat, rendering the urine more or less turbid, may be found. Such a condition, in which the fat is present either in a state of minute subdivision or in the form of larger oil-drops, is called Lipuria when no albumin is present, or Ohyluria, when a large amount of albumin is found with an abundance of small fat- globules. The microscope will, of course, reveal its presence at once. Chemically, the addition of ether quickly dissolves the fat, and the urine becomes clear. Paet Second MICROSCOPICAL EXAMINATION Paet Second MICROSCOPICAL EXAMINATION Chapter YI GENERAL CONSIDERATIONS Whenever urine is to be examined under the microscope, it should be set aside in a well stoppered bottle or conical vessel, preferably in a cool place, for at least six hours, but better twelve. At the end of this time it will be seen that in every urine, even if perfectly normal, a sediment has appeared at the bottom of the bottle, which is to be used for microscopical examination. This sediment, in normal urine, will be in the form of a cloudy deposit, and consists of mucus, flat epithelia from the bladder and vagina, and a varying number of epidermal scales from the genital organs. Spermatozoa may be present in both male and female urine after sexual intercourse, and in the former after nocturnal emission. It may, furthermore, contain a number of different salts, the character of which will greatly depend upon the diet, their number depending upon the degree of concentration of the urine. It will be found that the sediment of normal urine may contain even a large number of salts in the early morning, when the urine is highly concentrated, while these salts may be almost entirely absent at other times. After standing for some time, every urine undergoes a change, the rapidity of which depends upon the temperature as well as upon the reaction when passed. An acid urine, which will be perfectly clear when passed, may become turbid upon cooling, owing to the presence of a large amount of urates. Micro- organisms, especially of the class of hyphomycetse, or mould- fungi, and saccharomycetse, or yeast -fungi, may sooner or later develop, and in a small degree, schizomycetse, or fission-fungi. A neutral or even slightly alkaline urine may be clear when voided, but will soon become more or less cloudy, the change (37) 38 JJBINABY ANALYSIS AND DIAGNOSIS depending partly upon the salts, but mostly upon the develop- ment of bacteria belonging to the class of fission -fungi. This change takes place quickly in warm weather, and is, as a rule, more pronounced in the urine of females than in that of males, on account of the bacteria, which are normally found in the vagina. In pathological urine, the sediment will always be more abundant than in normal urine, though in mild cases the dif- ference is not pronounced. In severe cases, however, it may be very abundant, this being due to pus -corpuscles, blood -corpuscles, epithelia, casts, etc., which it contains. Frequently such urine will be cloudy when voided, and when an excessive amount of mucus is present, will be ropy in character. Use of Centrifuge. — To overcome the necessity of waiting for precipitation to take place, the centrifuge has of late years been considerably used and highly recommended. Much has been said for the centrifugal method, and at times it undoubtedly has its advantages ; but, as a rule, it is better to adhere to the old method and wait for six hours, the only pre- cautions necessary being to keep the bottle tightly corked and in a cool place. One of the chief advantages of the centrifuge is that bacteria are thrown down in large numbers, so that the search for them is more successful. This is especially pronounced in cases of tuberculosis, as tubercle bacilli are found more readily in cen- trifuged than in non-centrifuged urine. On the other hand, the great force necessary to eifect sedi- mentation will undoubtedly change some of the minute particles to a greater or less degree. In a number of cases, some of the pus -corpuscles have been seen to assume different forms, partly irregular in character and partly commencing to break down, not present in the non-centrifuged urine, though their number is the same in both. The same can be said of the different epithelia and the spermatozoa, which latter have been seen to assume peculiar forms after the use of the centrifuge. The number of casts has never been found to be appreciably different, though here, too, some have undergone changes. Mucus-threads are more abundant and more likely to take on the form of cylindroids, and this has been found to be quite pronounced in healthy urines, in which no pathological features were present, though these cylindroids often resemble hyaline easts to such a degree as to GENERAL CONSIDERATIONS 39 be easily mistaken for them. Extraneous fibers, such as eotton- flbers, have been seen to break into minute fibrillfe, and to resemble connective -tissue shreds, when the latter are not present. When care is exercised in microscopical examination, and only the perfectly distinct features are taken into consideration, the centrifuge can be used ; but, with the sole exception men- tioned, does not present any advantages over the old method. Mounting of Sediment. — The urine, in an amount of at least four or six ounces, having been allowed to stand at rest for the required time, the upper portion is carefully decanted or used for chemical tests, and a drop of the lower sediment transferred to a slide for microscopical examination. Although a glass pipette can be used for this purpose, it is simpler to pour the sediment into a small dish and use a camel's hair brush to trans- fer a drop to the slide. Such a brush can be thoroughly cleansed with water after each examination, and is kept clean easier than a pipette. The drop of urine is put into the center of the slide, and a cover-glass slowly dropped upon it, great care being taken not to press the cover down, since even the small amount of force used may be sufficient to change the epithelia or casts. Use of Antiseptic Substances. — In order to avoid decompo- sition of the urine as much as possible, when it can not be examined within twelve or twenty -four hours after being passed, large numbers of antiseptic substances, such as salicylic acid, chloroform, thymol, formaldehyde, and bichloride of mercury have been recommended to be added in small amount to the urine ; but when not absolutely necessary, it is better to avoid them. Urine kept in a cool place and in a clean bottle can be examined, even thirty -six hours after being voided, without the danger of having to deal with too many putrefactive changes. In all cases, the chemical analysis should be made as soon as possible. The sediment for microscopical examination can be mixed with a little alcohol, if necessary, or still better, chromic acid. Preservation of Sediment. — If it is desired to preserve a specimen for a variable length of time, the best method is to add from two to five drops of a 5 per cent chromic acid solution to it ; the only change that will take place is that the albumin becomes coagulated, appearing, under the microscope, in the form of irregular granular matter, irregularly scattered through- out the field. The chromic acid will preserve all the features 40 UBINABT ANALYSIS AND DIAGNOSIS permanently, not even causing any changes in the casts. Per- manent microscopical or slide -specimens are made by adding a few drops of chemically pure glycerin to a small amount of the sediment previously treated with chromic acid, until a jelly-like mass is formed, and waiting for a few days until all the super- fluous water has evaporated. It is not advisable to add the glycerin to the sediment mixed with chromic acid until the watery constituents of the urine have become evaporated, which will be the case at the end of one or two weeks. If the sedi- ment has become too thick on account of the evaporation, a little more glycerin is added, a drop then mounted upon a slide, a cover-glass placed upon it, and the whole surrounded by asphalt. Specimens preserved in this manner can be kept for many years without change. Should it be desired to preserve a large amount of the urinary sediment in a bottle, the chromic acid is added as before ; but in that case it will be better to add a larger amount of a weaker solution (about 1 or 2 per cent). After a few weeks the upper part of the liquid is poured off, and a small amount of a 40 or 50 per cent solution of alcohol added, to prevent the growth of mildew. Microscopical specimens can be made years afterwards from urine so preserved, by taking a drop of the sediment, mixing it with a drop of glycerin, and mounting upon a slide in the regular manner. Magnifying Powers. — Great difficulty is frequently encoun- tered in seeing all the features present in a specimen of urine under the microscope, this being in many cases due to the want of a proper magnifying power. For the study of urine, the mag- nifying power should always be between 400 and 600 diameters, the average being 500. A good one -sixth dry lens (make imma- terial), together with a one-inch eye-piece, will be all that is required. An Abbe condensor should not be used, except for the study of bacteria, nor will an immersion lens be always necessary even then. Both tubercle bacilli and gonococci can be seen with a power of 500 diameters, if the specimen is well stained, although a somewhat higher power, 700 to 800, which can be obtained by using a one-eighth dry lens, is undoubtedly superior. Should it be desired to use an immersion lens for the study of bacteria, an Abbe condensor is essential. The custom of trving to find casts with a lower power, 150 to 200 diameters, can not be recommended, since it is impossible to recognize the other fea- GENERAL CONSIDERATIONS 41 tures present in the case with such a power, and there are many cases of great importance in which no casts are present. In studying a case under the microscope, it will be found of great advantage to keep a record of all the features as they are found, and also to note their comparative numbers. Sketches of the fea- tures will still further simplify the study. Too much stress can not be laid upon the fact that, in the study of epithelia, the com- parative sizes of corpuscles and epithelia can alone lead to correct diagnoses, so that the advantages of rough sketches can readily be appreciated. Chaptee VII CRYSTALLINE AND AMORPHOUS SEDIMENTS The crystalline and amorphous or chemical sediments found in urine are mostly the different acids and salts, though a number of other unorganized sediments may also be present. I. ACIDS AND SALTS The salts which may be found under the microscope are seen partly in acid and partly in alkaline urine, and the sediments are the following : A. ACID SEDIMENTS 1. Uric Acid 2. Urate of sodium (a) Amorphous • Common. (6) Crystalline 3. Oxalate of lime 4. Cystine 5. Creatinine 6. Hippurio Acid Rare. 7. Leucine 8. Tyrosine ■ Common. To these we might add (9) sulphate of lime, which, however, is extremely rare. B. ALKALINE SEDIMENTS 1. Triple phosphates or ammonio-magnesian phosphates (a) Complete (6) Incomplete 2. Simple phosphates or phosphate of lime (a) Amorphous (6J Star- shaped, or stellate 3. Urate of ammonium 4. Carbonate of lime. (ffl) Amorphous. (ft) Crystalline, in combination with magnesium salts. 5. Phosphate of magnesium. — Very Rare. (42) Bare. CRYSTALLINE AND AMORPHOUS SEDIMENTS 43 ACID SEDIMENTS 1. Uric Acid. — Uric acid is a constant ingredient of the urine, and is frequently seen under the microscope. Its amount is greatly increased after a rich, nitrogenous diet, more especially Fig. 2. Crystals of Ukic Acid, Common Pokm (X 400). of meat, and after physical exercise. It is also augmented in acute febrile diseases and in impeded function of the heart, lungs, and kidney. It is diminished in profuse secretion of the urine, and in the more severe cases of nephritis. When present in small quantities, it may be held in solution. 44 UBINABY ANALYSIS AND DIAGNOSIS Uric acid varies greatly in shape and size, and is of a yellowish brown or reddish brown color, except when precipitated in very thin plates, when its color is pale yellow, or it may appear almost colorless. It may be divided into three principal varieties: Fig. 3. Crystals of Uric Acid, Common Form (x^OO). (a) The common form ; (6) as seen in over -acid urine ; (c) gravel from the pelvis of the kidney. When present in larger amount, it becomes precipitated in the form of reddish masses, producing the so-called brick dust -sediment. The common form of uric acid (see Fig. 2) consists of rhomboidal prisms — lozenge shape. The lozenges may be large CRYSTALLINE AND AMORPHOUS SEDIMENTS 45 or small, single or multiple, with round or pointed ends, and at times quite irregular. There may be two lozenges together, giving the twin form, or they may be seen either half -edge or edgewise, or they may be in more or less regular barrels. Be- Fie. 4. Crystals op Uric Acid, from Over- acid Urine (X450). sides these, complicated formations, crosses, and rosettes, are seen (see Fig. 3), the latter being a conglomeration of lozenges, either in front-view or edgewise, and frequently smaller crystals, sometimes quite irregular, are found within the larger ones. The second form (see Fig. 4), is often seen in over -acid urine, and is usually found with gouty or rheumatic processes, or 46 UBINABT ANALYSIS AND DIAGNOSIS with the formation of uric acid concretions in the bladder. These crystals appear in peculiar spear, comb, and brush shapes, or in exaggerated lozenges. The spear shapes are, in many Fig. 5. Ueio Aoir> Gkavel (X 500). cases, very pronounced. In persons in whom the so-called uric acid diathesis exists, these forms are frequently seen. The third variety of uric acid (see Pig. 5), is the so-called gravel, which originates in the pelvis of the kidney. Here we meet with concretions of varying sizes, irregular plates, masses, and needles, either single, double, or conglomerated in the form of stars. Occasionally dumb-bell forms are also met with. The passage of such gravel, when at all abundant, is almost inva- CRYSTALLINE AND AMORPHOUS SEDIMENTS 47 riably accompanied by more or less severe pain. When in larger masses, we have the uric acid calculi or stones, which form the largest number of renal stones, being, perhaps, 70 per cent of all calculi passed. Quite frequently we may have any two, or even all three, of these varieties of uric acid combined, in large numbers, together ^ ^ ..^. ,a Fig. 6. Ukate of Sodium, Amorphous (X 500). with a varying amount of urates and oxalate of lime crystals. When these features are present, the diagnosis of Lithcemia is justified. Although in almost all cases there will be no difficulty in recognizing uric acid under the microscope, there may be ex- tremely thin, practically colorless lozenges or irregular plates which might be mistaken for phosphates. In order to ascertain their exact character, a small amount of some alkali, such as caustic potash or soda, may be added while the specimen is examined under the microscope, when the crystals will be seen to dissolve readily. If now a drop or two of acetic acid be added, small characteristic crystals will soon re,appear. Urate of Sodium. — Urate of sodium (see Fig. 6), when present in large amounts, forms the so-called clay -water sedi- ment, which renders the urine turbid upon cooling. It may be found alone or in combination with uric acid and urate of 48 VBINABT ANALYSIS AND DIAGNOSIS potassium, from which it can hardly be distinguished. Such a sediment is the so-called sedimentum laieritium. Urate of sodium usually consists of groups of light or dark brown, fine, amorphous granules in a moss-like arrangement, which easily adhere to foreign siibstances as well as to mucus and epithelia. The groups vary greatly in size, and are- at times quite large. This salt is of common occurrence, and will be found in all slight febrile derangements, after mental and physical exertion, in colds, catarrhs of the stomach and intestines, on the first day of menstruation, and in general malaise ; and it may also occur in perfectly healthy individuals where the urine is highly concen- trated. It is held in solution while the urine is warm, but quickly becomes precipitated upon cooling. It is the effete material of oxidation, the so-called materia peccans of old physicians. In rare cases urate of sodium is crystalline (see Fig. 7), appearing in the form of needle -like clusters or arranged like sheaves of wheat, or of a fan -shape arrangement, pointed toward Fig. 7. Urate of Sodium, Ckystalline (X 500). the center, and broader toward the periphery. This sediment has been found in various conditions, such as diseases of the stomach and intestines, and in healthy individuals during pro- longed physical exertion. The accompanying illustration was taken from a case of dermoid cyst of the kidney, where the crystals occurred in large numbers with uric acid crystals. CBTSTALLINE AND AMOBPMOUS SEDIMENTS 49 Urate of sodium frequently undergoes a change a few hours after the urine is voided, the length of time required for the change depending upon the temperature. The granules com- mence to change into small brown globules, which are either single or grouped in twos ; the latter soon coalesce, and form small dumb-bells, which gradually enlarge (see Fig. 8). This is Fig. 8. Urate op Sodium in Transition to Urate of Ammonium (X 500). the first stage of the formation of urate of ammonium, the urate of ammonium in statu nascenti, and denotes a commencing transi- tion of the original acid sediment into an alkaline. When the alkaline change is more or less complete, we have the fully formed globules of urate of ammonium. 3. Oxalate op Lime. — Calcium oxalate, when present in small or moderate amount in the urine, without an increase of specific gravity, has no clinical significance. Oxalic acid, nor- mally present in all urine in small quantities, has a special afilnity for calcium, and appears in the urine as oxalate of lime. It is frequently found after eating certain kinds of fruits and vegetables, such as apples, oranges, bananas, certain berries, grapes, tomatoes, rhubarb, asparagus, spinach, and turnips. It occurs in a variety of forms (see Fig. 9), but it is always colorless, and of a high refraction. The most common forms are those of quadrilateral octahedrons, greatly varying in size, with single or double lines running from one end of the crystal to the other, crossing each other in the center and giving the charac- 50 UBINABT ANALYSIS AND DIAGNOSIS teristic so-called letter- envelope shape ; when these are seen edgewise the octahedral form is more marked. These regular forms often commence to break down, so that the lines become lost. A number of these crystals may be arranged together, Pig. 9. Oxalate OF Lime Crystals (X 500;. either in twos, giving the twin form, or in groups of three, four, or more. With these we often see small, more or less regular squares or dot-like irregular formations, the so-called amorphous shapes. A number of small squares may combine together, giving concretions sometimes of large size, which are especially abundant under the microscope when oxalate of lime calculi are present. They are often massed together upon mucus-threads or foreign substances. Besides these, there are rarer forms, con- CRYSTALLINE AND AMORPHOUS SEDIMENTS 51 sisting of more or less concentrically striated discs or barrel- shapes, and of variously sized dumb-bells. The latter may assume large proportions, and are easily differentiated from the dumb-bell forms of uric acid or urate of ammonium, by their being colorless. Oxalate of lime crystals can hardly be mistaken for anything else, if it is borne in mind that they are always without color Pig. 10. C7STINB Ckystals (X 500). and of a high refraction. Although usually present in acid urine only, they may be found in neutral or slightly alkaline urine in small amount. When the reaction of an originally acid urine has become alkaline, they may be transformed into triple phosphates. Should there be any doubt as to their character, they will be found to be insoluble in acetic acid, but soluble in muriatic acid. When oxalate of lime is present in large amount, with a high specific gravity, 1.028, 1.030, or even 1.040, it often denotes the existence of Oxaluria. This affection, although very common, is frequently overlooked. It gives the symptoms of neurasthenia, dyspepsia, melancholia, general malaise, headaches, and ill- defined pains in the lumbar region. Those afflicted are usually of sedentary habits, and are accustomed to live well. In rare eases, especially when concretions of considerable size are present. 52 VBINART ANALYSIS AND DIAGNOSIS hEematnria, often severe and protracted, is a pronounced symp- tom. It may last for months, but its cause can at once be ascertained by an examination of the urine. As soon as the Fig. 11. Creatinine Ckystals (X 500). patient's diet is regulated, and he takes considerable outdoor exerci*se, the oxalates decrease and the symptoms will improve. With such cases inflammation of the pelvis of the kidney, and sometimes, also, of the kidney proper, though, as a rule, mild in character, is of common occurrence. 4. Cystine. — Cystine is a comparatively rare sediment, but may produce concretions in the bladder. It consists (see Fig. 10) of hexagonal, colorless plates of moderate sizes, of high refrac- tion, which, in side-view, present one perfect facet and two imperfect neighboring facets. A number of plates may lie to- gether, one upon another, or they may form more or less regular masses. It is readily soluble in ammonia, one of the features distinguishing it from uric acid, and contains considerable sulphur as a constituent. Cystine seems to occur in all members of certain families instead of uric acid ; in such families it appears to replace uric acid, and in them cystine calculi are not rare. 5. Creatinine. — Creatinine, normally present in the urine in very small amount, is found under the microscope in rare CRYSTALLINE AND AMORPHOUS SEDIMENTS 53 instances only. It consists (see Fig. 11) of colorless prisms or plates, partly lozenge- and partly barrel -shaped. Frequently there will be two, three, or even more plates, one within the other, or the plates may conglomerate in groups. Occasionally, more particularly when the urine has stood for some time, pecu- liar configurations will appear in the interior of the plates. Creatinine is found most frequently after prolonged muscular exercise, as is seen in athletes during active training. A rare sediment, found in the urine of a perfectly healthy athlete, is shown in Fig. 12. This sediment contains plates and lozenges of creatinine, the rare crystalline form of urate of sodium, and peculiar formations, consisting partly of fan -shaped and partly of angular crystals, from which a varying number of long needles are seen to emanate. Some of these crystals resemble rarer forms of urate of ammonium. Clinically, creatinine has been found in cases of severe acute parenchymatous nephritis, associated with uremic convulsions. Pig. 12. Sediment in the Ubine of an Athlete (X 500). and has also been seen in the urine of females suflfering from puerperal eclampsia. 6. HiPPURic Acid. — Hippuric acid, which is present in all normal urine, is almost always held in solution, though it may 54 TJBINABT ANALYSIS AND DIAGNOSIS be found in small amount after a vegetable diet, and after eating certain fruits, such as cranberries and plums. In the urine of herbivorous animals, especially in horses, it is of common occur- rence. It will be found in larger amount after the administration Fig. 13. Hippukio Acid (X 500). of benzoic acid, or one of the benzoates ; also, sometimes, in diabetes. It consists (see Pig. 13) of variously sized, colorless prisms and plates, often conglomerated into larger or smaller masses. The plates may be thin and extremely long, at times resembling needles. Hippurie acid might occasionally be mistaken for some CRYSTALLINE AND AMORPHOUS SEDIMENTS 55 forms of phosphates, but can easily be differentiated from them by its insolubility in acetic acid. 7, 8. Leucine and Tyrosine. — Leucine and tyrosine are rare sediments, and usually occur together. They are never seen in normal urine, but mostly in severe acute and usually fatal Pig. 14. Leucine and Tyrosine (X 500). diseases of the liver, such as acute yellow atrophy of the liver, yellow fever, and phosphorus poisoning. They have also been found in cases of small- pox, scarlet fever, and typhoid fever. Leucine (see Fig. 14) appears under the microscope in the form of flat, yellowish or brown globules of different sizes, with delicate radiating and concentric striations. Tyrosine is found 56 URINARY ANALYSIS AND DIAGNOSIS in the form of needle-shaped crystals, grouped in clusters or sheaves, crossing at various angles. Both leucine and tyrosine somewhat resemble fat, the former the fat -globules, the latter the needles of fat — so-called margaric acid, — but differ from fat by being insoluble in ether. Pig. 15. Complete Triple Phosphates (X 500). 9. Sulphate op Lime.— Sulphate of lime has been de- scribed as occurring in the urine in an extremely small number of cases. It consists of thin, colorless prisms or needles, either single, in groups, or in rosettes, resembling crystalline phosphate of lime, but more regular. Its clinical significance is not known. CBTSTALLINE AND AMORPHOUS SEDIMENTS B. ALKALINE SEDIMENTS 57 1. Triple Phosphates. — Triple phosphates, the combined ammonio-magnesian phosphates, may be divided into complete and incomplete. They may be found under the microscope in small numbers in urines which still give a slightly acid reaction, Pig. 16. Incomplete Triple Phosphates (X 500). but invariably denote a change to alkalinity. When present in large numbers, the urine is always alkaline. Acid oxalate of lime is frequently seen to undergo a transformation into alkaline phosphates. As all urates are colored to a greater or less de- gree, all phosphates are invariablj' colorless. 58 UBINARY ANALYSIS AND DIAGNOSIS Complete triple phosphates (see Pig. 15) are colorless, trian- gular prisms or rhomboidal . crystals, highly refractive, with beveled ends,— the so-called coffin -lid shapes. They vary greatly in size and shape, the latter being different when the crystals are seen in front-, side-, or top-view. Some of the smaller ones can hardly be differentiated from oxalate of lime crystals. Incomplete triple phosphates (see Fig. 16) are seen in many forms and sizes. It seems that these crystals are in part not yet fully developed (especially the smaller varieties, which may in - 0- 0"-' ''\"'°o °: ' : ; -, ' <> ;• • » 0.0 .'■ ,° .' »,•„ , cr "' '• ,,.".;' •f'-;-c'-;.-o\°.\.', .. ,, '. . -,;■• • ' (? " -•'.'*- ? *0 o o Fig. 17. Amorphous Simple Phosphates (X 500). time grow and become complete) , and in part have become broken down from previously complete forms. All the different transi- tions can be seen in the same specimen when it is studied on two or three successive days, which can easily be done by simply adding a drop of glycerin to the iirine upon the slide. The incomplete forms represent irregular plates, either without any interior marks or with irregular lines, the result of the transfor- mation of the complete crystals. The crystals may be broken down in the center, or there may be peculiar cross-like formations, or even irregular star-shaped crystals, which can be likened to a fern leaf. Triple phosphates may be found in varying numbers in normal urine after a vegetable diet. Their amount is greatly increased in chronic inflammatory conditions of all kinds, in rheumatic processes, in inflammation of the bones, etc. They are CRYSTALLINE AND AMORPHOUS SEDIMENTS 59 especially abundant in cases of chronic cystitis, where an alkaline putrefaction of the urine takes place in the bladder, and may be Fig. 18. Stak-shaped Simple Phosphates (X 500). precipitated in large, flaky deposits, the urine having a pro- nounced ammoniacal odor. 2. Simple Phosphates. — Simple phosphates, or phosphates of lime, are of two distinct varieties : first amorphous, and second star- shaped or stellate. Amorphous simple phosphates (see Pig. 17) appear in the form of highly refractive, colorless globules or granules, either single or clustered together in variously sized groups, but never 60 UBINABY ANALYSIS AND DIAGNOSIS in a moss-like arrangement, as the urate of sodium. These phosphates are abundantly found after a milk diet, as well as after drinking different alkaline mineral waters. Star-shaped or stellate simple phosphates, although of less frequent occurrence than the other variety, are by no means rare, and are often found in conjunction with the triple phosphates. They consist (see Fig. 18) either of slender, colorless rods, or of pointed spiculas of various sizes, at times containing smaller ones in their interior. Although they may be found single, their characteristic grouping is in the form of stars or rosettes, more or less complete. The spiculae, of which the rosettes are composed, are united in the center of the rosette, while each spicula may have a uniform diameter, or be broadened at the periphery and narrowed in the center. Much has been written about the significance of the phos- phates in the urine, and great stress has been laid upon their continual increase or diminution, the latter being said to be of constant occurrence in cases of nephritis. It is an undeniable fact that the phosphates will be diminished in severe and usually advanced cases of nephritis, but not more so than the other salts, there being a pronounced decrease of all salts in such cases. In rare cases, there is a continual increase of the phosphates in the urine, without any apparent cause. Such cases have been designated by the term Phosphaturia, and they may give similar symptoms to those of oxaluria. The phosphates precipitating in the urine being frequently secondary formations, such a diagnosis must only be made when their amount is found to be greatly increased immediately after the urine is voided, and the presence of inflammatory conditions of any kind in the body can be excluded. A change of diet will often rectify this trouble in a , short time. All phosphates are easily soluble in acetic acid, I which will quickly clear up any doubt as to their character. 3. Urate op Ammonium. — Urate of ammonium is a common sediment in alkaline urine, especially in connection with triple and simple phosphates, and is seen in fresh urine only when it is passed in an alkaline condition. It is the result of an alkaline change of either urate of sodium or uric acid. It appears (see Fig. 19) in the form of brown globules of various shapes and sizes, usually exhibiting pronounced concentric and radiating striations. The globules may appear singly or in clusters, some- times forming large, coalesced masses. They are either smooth or CRYSTALLINE AlsD AMORPHOUS SEDIMENTS 61 provided with thorny, sometimes branching and curved offshoots, — the so-called thorn-apple shapes. The offshoots vary greatly in size and number, there being either one or many upon a single globule. When uric acid changes to urate of ammonium, the masses are large and irregular, at first showing the lozenge shape of the uric acid, but gradually becoming transformed. Not Fig. 19. Ukate of Ammonium (X 500). infrequently the globules, especially the smaller ones, will con- glomerate so as to form concretions, sometimes of large size, and this may also be the case when mucus-threads or foreign sub- stances, such as cotton- or linen -fibers, are present. The alkaline change, which may take place in an originally acid urine, is illustrated in Fig. 20. When the urine was voided it contained nothing but a large number of uric acid crystals of different forms, both plates and needles, some groups of urate of sodium, and crystals of oxalate of lime. After about twelve 62 URINARY ANALYSIS AND DIAGNOSIS hours fermentative changes commenced to appear, and fungi, in the form of eonidia and myeelia, developed. The urate of sodium granules were now found to have partly changed into small globules and dumb-bells, the first formed urate of ammo- PiG. 20. Acid Sediment in Fermentation and in Transition to Alkaline (X 500). U, uric acid plates ; UN, uric acid needles ; US, urate of sodium in transition to urate of ammonium ; UA, urate of ammonium : 0, oxalate of lime ; 0, couidia ; M, myeelia. Ilium in statu nascenti. This change gradually continued until larger globules of urate of ammonium, as well as more irregular forms, had developed. Triple phosphates had not formed. 4. Carbonate op Lime. — Carbonate of lime is a rare alka- line sediment, occurring either alone or in combination with the CRYSTALLINE AND AMORPHOUS SEDIMENTS 63 phosphates. It is usually found (see Fig. 21) in the form of amorphous granules and gloTjules of small size, though larger than the globules of amorphous simple phosphates, either singly or in groups of varying sizes, and of very high refraction. Occasionally dumb-bell forms are also seen. Besides the amor- phous variety, it occurs in combination with magnesium salts, in crystalline shape, as small, delicate prisms, somewhat resembling yyJl^Jirs:^ O a ^A " -^<^<^^^^^!^-M .■lift;.--, 'fi;: '■■:^' '. ':.■ -> ~~^-^'- ^•■■'•li^;:\[~' : -;^= m Fig. 57. Schizomycet^ (X 500j. B, bacilli ; St, streptococci ; Sa, staphylococci ; L, leptothrix ; MU, micrococcus urese r Z, zooglcea ; S, sarcinsB. These bacilli are found to have a varying amount of motion, some being very active, others only slightly movable, and some without motion. Besides the single bacilli, the urine not infrequently contains threads, composed of individual rods,— the leptothrix threads,— which may be quite abundant. There are cases of chronic cystitis, in which the urine, when voided, contains leptothrix threads in large numbers, and in which the cystitis seems to be 126 URINARY ANALYSIS AND DIAGNOSIS caused by the leptothrix ; these threads may lie upon as well as between the epithelia. In such cases whitish masses of small size are found in the freshly voided, cloudy urine, and when examined under the microscope are seen to consist of conglom- erations of bladder epithelia with many leptothrix threads. Cases of this kind may last for many years, and frequently recur in spite of all local treatment ; such a case might be termed Mycosis leptothricia cystidis. Pathogenic ScmzoMYCETiB. — Among the pathogenic bac- teria, the most important are undoubtedly the gonococci and tubercle bacilli, which are not infrequently found in urine, and for which careful search must, when necessary, be made. For the detection of these, it will always be necessary to color the specimens, and the mode of procedure is the following : Select the thickest portion of the urinary sediment or the threads, if any are present, as will be the case in every chronic gonorrhoea, and bj' means of a sterilized needle spread carefully over per- fectly clean cover -glasses, taking never less than four, but pref- erably six or more. Allow the glasses to dry thoroughly, and draw them through the flame of an alcohol lamp or a Bunsen burner in a moderately quick manner, specimen side upward, three times, partly to fix the specimen upon the cover-glass, and partly to coagulate the albuminous substances present. Then •color the specimen with an aniline color, either fuchsine, methy- lene blue, or gentian violet. Gonococci. — In searching for gonococci in the urine, the cover- glasses are best colored, for a few seconds to one or two minutes, either with a plain watery fuchsine solution, made by taking one part of a concentrated alcoholic fuchsine solution (one part of fuchsine in substance to four or five of absolute alcohol) to eight, ten, or twelve parts of distilled water ; or with a methylene blue solution— twelve or fifteen drops of a concen- trated alcoholic solution to one ounce of water, to which one drop of a 5 per cent Caustic potash solution has been added. Either one of these solutions, if carefully made, will keep a long time, and is always ready for use. After having passed the cover -glasses through the flame, as just described, a small amount of the coloring solution is dropped upon the specimen and allowed to remain for from a few seconds to a minute or two, the former being sufficient when fuchsine is used, the latter being necessary when methylene blue MICBO-OHGANISMS AND ANIMAL PARASITES 127 is employed. After coloring, the cover-glass is rinsed in water, the lower surface dried, and the specimen either at once mounted upon a slide and examined in water, or dried and mounted in a drop of Canada balsam. Although the gonococci can be seen with a power of 500 diameters, it will always be better to use a power of at least 700 or 800 diameters and an Abbe condenser. In specimens so prepared, the gonococci, as well as the nuclei of the pus-cor- puscles and epithelia, are colored. The pus -corpuscles will be seen to contain one or more nuclei. In cases of acute gonorrhoea (see Fig. 58) the gonococci, or Fir. 58. Acute Gonoeehcea (X 700j. G, groups of gonococci ; G- P, pus-corpiiscle, containing gonococci ; M S, mucus-thread. micrococci gonorrhcece, are found in large numbers in the urine, not as numerous as in the gonorrhceal pus taken directly from the orifice of the urethra, but still very abundant. They are seen both in the piis-corpuscles and lying free in variously sized groups. The pus -corpuscles are numerous and mucus -threads in small numbers are always present. Urethral epithelia are also usually found, and may contain groups of gonococci. Gonococci were first discovered by Neisser in the year 1879, and cultivated by Bumm in 1885. They are, as a rule, found in twos, either singly or in groups, with the adjacent surfaces 128 UBINABY ANALYSIS AND DIAGNOSIS flattened and separated by a colorless interspace, giving the so-called biscuit shape. The more or less regular groups of diplococci are found either entirely within the pus -corpuscles or epithelia, or lying entirely free, but never half-way within and half-way free, though large groups, completely filling the pus- corpuscles, may slightly overlap the periphery. Again, no mat- ter how completely the pus -corpuscles are filled with them, the nucleus or nuclei will always remain free, though here, again, individual cocci may be found upon the periphery of the nucleus. These' features, though perhaps not absolutely characteristic, are sufflciently so for all practical purposes. If any doubt remains about their character, a few specimens should be colored with a gentian violet solution, either a 1 per cent aqueous solution (gentian violet 1 part, distilled water 99 parts), or an aniline water solution, made by adding 5 parts of a concentrated alcoholic solution to 100 parts of aniline water (aniline oil 1 part, distilled water 20 parts, and filter) for a few minutes and subjected to Gram's solution (pure iodine 1 part, iodide of potash 2 parts, and distilled water 300 parts) for one or two minutes. The specimens are now washed in alcohol, then rinsed in water and recolored with a 1 or 2 per cent vesuvin solution (vesuvin 1 or 2 parts, distilled water 99 or 98 parts) for a few minutes, again rinsed in water, and either examined in water or dried and mounted in Canada balsam. When subjected to this method, the gonococci will have lost their original violet stain and have taken up the vesuvin, being, therefore, colored brown. This method at once differentiates them from the staphylococci, which retain their violet color. If all the features enumerated, especially their characteristic grouping within the pus-corpuscles, and the loss of their violet color by the last-named method, are present, no doubt whatever will exist as to the character of the cocci. In acute cases of gonorrhcea, the search for gonococci is very easy ; but this becomes a more dif&oult matter in the chronic cases, where only a small number of gleet-threads are found in the urine. Frequently it is of the utmost importance to determine the presence or absence of gonococci in such cases, and the gleet- threads are subjected to the methods just described, and care- fully examined. In this work it is never advisable to depend upon a power of 500 diameters, but higher powers, even a homo- geneous immersion lens, should be used, and a large number of MWBO-OBGANISMS AND ANIMAL PARASITES 129 specimens carefully examined. The features found in such a gleet-thread, containing gonococci, are shown in Pig. 59. Pus -corpuscles are never so abundant in these cases as in the acute, and may even be quite scanty, but mucus -threads as well as corpuscles are numerous ; epithelia from the urethra, and usually from the prostate gland, will also be seen. The gonococci are ^®/® Fig. 59. Chkonic Gonorkhcea (X 700). GP, pus-eorpuseles containing gonococci ; GE, epithelium from the prostate gland contain- ing gonococci ; St, pus-corpnscles, containing staphylococci pyogenes ; Sr, streptococci pyogenes ; MU, micrococcus nrese ; MS, mncus-threads ; MP, mucus-corpuscle. always found in smaller numbers, but only singly or in small groups, and the cocci seen should never be diagnosed as such, unless some are found within the pus -corpuscles. Besides gono- cocci , such threads will always contain irregular groups of staphy- lococci ; these may be either free or in groups, lying partly within pus -corpuscles and partly outside. In some cases, strepto- cocci, usually in rather small chains, are also present, as well as the micrococcus ureae in chains or irregular small groups. Other Cocci. — Besides gonococci, other pyogenic cocci, both staphylococci pyogenes and streptococci pyogenes, are found in urine, but as may be expected, only wherever there are large num- bers of pus-corpuscles ; they, therefore, have little practical sig- nificance. The staphylococci are the staphylococcus pyogenes aureus, albus, and citreus, which can only be differentiated by 130 VRINARX ANALYSIS AND DIAGNOSIS , culture methods. Besides the streptococcus pyogenes, a strepto- coccus, which can not be distinguished from it, but has been described by Pehleisen as being the cause of erysipelas, may be found in all cases of erysipelas in which a nephritis is at the same time present. Micrococci have also been seen in the urine in septic processes, as well as in endocarditis. Tubercle bacilli. — The presence of tubercle bacilli in mod- erate numbers in the urine is always a symptom of tuberculosis somewhere in the genito- urinary tract. Its exact location can easily be determined by the characteristic epithelia. As a rule, they will be found in larger numbers only when an ulceration has taken place ; and whenever the diagnosis of an ulceration can be made from the different features found in the urine, together with an impaired or broken down constitution, it will be best to examine for tubercle bacilli, even though distinct clinical symp- toms of a tubercular process have not as yet developed. The search for tubercle bacilli in the urine is by no means an easy one, and many drops may have to be examined before arriving at a definite conclusion.. The appearance of the urine is no criterion, since bacilli may be present in small numbers in rather clear urine, though as a rule, it will be more or less turbid. They can be found in either an acid, neutral, or alkaline urine, though a large number of salts renders their detection still more difficult. The thickest portion of the sediment only should be used for the preparation of cover-glass specimens, and here the use of the centrifuge offers an undoubted advantage, the bacilli being more easily discovered in a centrifuged than in a non-cen- trifuged urine, since the centrifuge throws down all bacilli in larger numbers than is the case with urine which has been allowed to settle for a number of hours. The methods employed for detecting tubercle bacilli are numerous ; but the best are the Koch-Ehrlich-Weigert aniline water and the Ziehl-Neelsen carbolic acid water methods. Whether fuehsine or gentian violet is used with the former method is per- fectly immaterial. An aniline water fuehsine solution is made by adding enough of a concentrated alcoholic fuehsine solution to aniline water until saturation takes place ; that is, until a, distinct film appears at the top of the solution ; this will usually be one part of the alcoholic solution to six, eight, or even ten parts of aniline water. The aniline water is- prepared by thoroughly mix- ing one part of aniline oil with 20 parts of distilled water, MICRO- ORGANISMS AND ANIMAL PARASITES 131 aud filtering through a double layer of filter- paper. This solution must be perfectly clear. The cover-glasses, which, when dried, have been passed through the flame, are now dropped upon the solution, specimen side downward, so as to float, if possible, and allowed to remain in it for twelve hours, if kept at the tempera- ture of the room, or forty minutes if the solution is kept warm. It is not advisable to heat the cover-glasses over the flame for a. few minutes after having dropped the coloring solution upon them, as such specimens are usually not as clear as they should be. It has been shown by Koch that while tubercle bacilli take on the coloring matter slowly, they are then not readily decolor- ized, in contradistinction to other bacteria, which will quickly lose their color when subjected to the action of strong acids. The cover- glasses, after being colored, are, therefore, placed into a strong acid solution, preferably a 25 per cent nitric acid, for a few seconds or half a minute, and are then thoroughly washed in a 60 per cent solution of alcohol until all color has disappeared, rinsed in absolute alcohol and in water, and may either be ex- amined at once, or, better, are recolored with methjlene blue,, again rinsed in water and examined in water or Canada balsam. The tubercle bacilli, if any are present, will now be seen in the form of red rods, while all other features in the specimen are colored blue. Instead of aniline fuchsine, aniline gentian violet can be used, and vesuvin employed as a recoloring agent. Muri- atic or sulphuric acid may be used instead of nitric acid. A specimen of tuberculosis of the kidney, colored in this manner, is shown in Fig. 60. The features which can easily be recognized are tubercle bacilli in moderate numbers, pus -cor- puscles, epithelia from the convoluted tubules of the kidney, epithelia from the pelvis of the kidney, mucus -threads, mucus- corpuscles, and various cocci. Although specimens prepared with an aniline water solution give excellent results, there is one objection to this method, which is that the solution does not keep, and has to be prepared fresh every week. Many bacteriologists, therefore, prefer to use Ziehl- Neelsen's carbolic acid fuchsine inethod. The solution is pre- pared by taking 90 parts of a 5 per cent carbolic acid solution, 10 parts of alcohol, and 1 part of fuchsine in substance. This is undoubtedly the simpler method, and gives good results as long as the solution is not too old. With it the specimens need not be colored longer than one or two hours, when kept at the tempera- 132 UBINABT ANALYSIS AND DIAGNOSIS ture of the room, or twenty minutes when dropped in a warm solution. The decolorizing and reeoloring processes are exactly the same as with the Koch-Ehrlich-Weigert method. Since examination for tubercle bacilli in urine is not an easy matter, it is invariably best to use those methods which will yield uniformly good results, and not to hasten the process of coloring. With the two methods just described, the tubercle bacilli can Fig. 60. TuBEKCULOSis of the Kidney (X 650). TB, tubercle bacilli ; PC, pus-corpuscle ; CE, epithelium from convoluted tubules of kid- ney : PE, epithelium from pelvis of kidney ; MS, mucus-threads ; MC, mucus-corpuscle. always be detected if present, though they may be very scanty, and found only after a long and patient search. Typhoid bacilli. — Among the other pathogenic bacilli found in urine, the typhoid bacilli have been discovered in large numbers in cases of typhoid fever, though never at the commencement of the disease, and they are not, therefore, of much practical value for the diagnosis. Poniklo, in the year 1892, was the first to call attention to the presence of typhoid bacilli in the urine, and since then the bacilli have been found by different observers. In most cases described, the evidences of a more or less pronounced nephritis or of a heemorrhage were also present. The bacilli may persist in the urine for weeks and even months, and may be extremely abundant. Bacterium coli commune. — The bacterium coli commune is not infrequently present in urine, especially in pronounced in- MICRO- ORGANISMS AND ANIMAL PARASITES 133 flammations, such as severe cystitis ; it may be found in large numbers, and is mentioned by some writers as a common cause of cystitis. In the year 1895, Pluym and Laag described it as the sole cause of a urethritis which gave all the symptoms of a gonorrhoeal infection, in which gonococci were entirely absent, but the bacterium coli commune was found in large numbers, lying mostly within the pus -corpuscles and epithelia. Other bacilli have also been described as being present in various diseases of the genito-urinary tract, but they are of no diagnostic value. Actinomyces. — The fungus known as actinomyees (see Fig. 61), is of rare occurrence in the urine, but is undoubtedly found in actinomycosis of the internal organs, where the disease affects the genito-urinary tract. The classification of this fungus has long Pio. 61. Actinomyces (X 500). been undecided, though later researches place it among the fission- fungi. The fungus consists of variously sized conglomerations of highly refractive, irregular, club-shaped masses. The club-shaped, cylindrical, or pear-shaped masses terminate toward the center in a point or fibrilla, which loses itself in a mass of granules, amidst other similar fibrillEe. The individual club-shaped elements greatly vary in length, but all terminate in the center. The urine from which the accompanying drawing was made 134 UBINABT ANALYSIS AND DIAGNOSIS was turbid when passed, and gave all the macroscopical evi- dences of a chronic cystitis. It contained a few small granular masses which proved to be aetinomyces. The features present under the microscope were numerous, and conclusively showed a chronic ulcerative process in the bladder ; there were pus- corpuscles in large numbers ; epithelia from the bladder, espe- cially cuboidal and columnar ; numerous connective -tissue shreds ; fat -granules and -globules ; large zoogloea masses ; mucus- threads and -corpuscles, and the aetinomyces fungus, which was perfectly characteristic, so that the diagnosis of a chronic ulceration of the bladder, due to aetinomyces, could easily be made. The reaction of the urine was alkaline. II. ANIMAL PARASITES OR ENTOZOA Trichomonas Vaginalis (see Fig. 62). — Of all the animal parasites, the most common is the trichomonas vaginalis, which belongs to the class of infusoria. It occurs in the urine of Fig. 62. Teiohomonas Vaginalis (X 500). females, being a frequent but perfectly harmless inhabitant of the mucosa of the vagina in cases of leucorrhcea. Although it has no pathological significance, its occurrence and shapes must be known, since it otherwise might be mistaken for different formations, especially when small. MICBO-OEGANISMS AND ANIMAL PARASITES 135 Trichomonas is of an oval or somewhat irregular form, and usually has a tail-like extremity. This extremity, mostly of the same size as the body or a little longer, may occasionally be three or four times that size, of considerable thickness, and striated. It may, however, be nothing but a small filament Pig. 63. Portions of Eohinooocous (X 400). like a flagellum. In the interior of the body one, two, or more small formations, similar to nuclei, may be seen. In many cases one or more cilia are given off from one extremity or side. Echinococci (see Pig. 63). — These entozoa, although rare, do occasionally occur in the urine, and may either have developed directly in the urinary organs, or have ruptured from some neighboring organ. The characteristic parts of the echinococci, found in the urine, are the booklets as well as portions of the membrane ; scolices may also be found. The echinococci cysts, as such, will never be seen in the urine, and in a suspected case it may become quite difficult to find the characteristic portions. The scolices are small, usually round, and supplied with a wreath of hooklets. The individual booklets do not vary in size to a great degree, and their shapes, although differing somewhat, are more or less identical. Parts of the membrane which have a concentric striation may at 136 UBINARY ANALYSIS AND DIAGNOSIS times be present. In the specimen from which the illustration was taken, the different portions here shown could only be found after patient search, but were characteristic. In all cases in which parts of the echinococci are found in the urine, evidences of a haemorrhage or an ulceration, or both, will be present. As a rule, red blood -corpuscles are numerous, together with epithelia and connective -tissue shreds from the organ in which the cysts are located. Pus -corpuscles are usu- ally abundant. When the echinococci have directly developed in the ilrinary organs, the kidney is the general location, and epithelia from both the convoluted and straight collecting tubules are present. Distoma McematoMum (see Fig. 64). — The parasite, distoma - r' . / Fia. 64. Ova op Distoma H^matobium (X 600). hwmatobium, or Bilharsia hwmatobia, so called from Bilharz, who first described it, has probably never been found in the urine, but -its eggs do occur in some cases. It is common in hot climates, especially in Egypt, and is found in the portal vein and its branches, the splenic and mesenteric veins, as well as in the venous plexuses of the rectum and urinary bladder. MICBO-OBGAJSriSMS AND ANIMAL PARASITES 137 In our climate distoma hagmatobium is rarely found, but does occur. A case of this kind was recently described by Brooks and Sondern, who found the eggs in the urine in con- siderable numbers. The illustration was taken from this urine, and in every drop examined a dozen or more of the ova were Fig. 65. Filaeia Sanguinis Hominis (X GOO). present. They have an oval or flask -like shape, are large and taper considerably at one extremity, the other being rounded. They consist of a moderately thick, highly refractive capsule, are coarsely granular, and contain quite a number of small, roundish, granular bodies within a membranous formation. When these ova are found in the urine, blood-corpuscles, pus- corpuscles, and epithelia, usually from the bladder, are seen, show- 138 URINARY ANALYSIS AND DIAGNOSIS ing a haemorrhage or inflammation of the bladder. In most cases fat-globules and -granules are also present in considerable num- bers. The parasites may invade any portion of the urinary tract, especially the ureters and pelves. Filaria Sanguinis Hominis (see Fig. 65) . — This parasite is also of rare occurrence in our climate, but common in other climates, as in the West India Islands, Egypt, China, and Japan. It seems to be transferred to human beings through mosquito bites, and may be extremely abundant in the blood ; in urine it may be found in varying numbers in such cases. It consists of a cylindrically shaped body, a short, rounded head, and a long, thread-like, pointed tail. It is granular and frequently striated. When the parasite appears in the urine, it may either cause severe haematuria or the condition known as chyluria, or more frequently both. It is claimed that it may be present in perfectly clear urine, but this must be very rare, since, as a rule, the urine presents a milky appearance when voided, and upon examination is found to contain a large amount of fat, in the form of small globules and granules, as well as the evidence of a more or less pronounced heemorrhage. Pus -corpuscles, as well as different epithelia, will usually be present in small numbers. When such a milky urine, denoting chyluria, is examined, filaria must always be looked for, since the parasite is almost invariably the cause of this condition. It may be present in large numbers in the urine, so that there will be no difficulty in finding it ; but on the other hand, it may be scanty. In examin- ing for filaria, it is advisable to take the first urine voided in the morning, since it is a well known fact that the parasite is active at night, or rather during the resting hours of the patient, and can then be found in large numbers in the blood, while it is quies- cent during the working hours, and can not be found. Ascaris Lumbricoides (see Fig. 66). — Although in rare in- stances only, the round worm, ascaris lumbricoides, of such com- mon occurrence in the intestinal tract of children, may be found in the urine, having passed into the bladder through the urethra. Portions of the parasite and a number of ova will then be present in the urine. The urine from which the illustration was taken gave all the features of a severe acute catarrhal cystitis. It contained a small number of minute particles, which proved to be the ova; also a part of the body of an ascaris. The ova, of a yellowish MICRO- ORGANISMS AND ANIMAL PARASITES 139 "brown color, are round formations, inclosed in a thin, irregular capsule and a somewhat thicker membrane ; the interior is coarsely granular and contains a nucleus. The parasite itself is ■of considerable size, has a cylindrical body, a narrower, tail -like Fig. 66. Ova and Poktion of Asoaris Lumbricoidbs (X 500). extremity, and a head consisting of three papillaBform nodules; it is only found in the urine in very rare instances. Other Parasites. — Other parasites which may possibly be found in the urine are the Strongylus gigas, Oxyuris vermicu- laris, and the Gercomonas urinarius. The strongylus gigas resembles the ascaris lumbricoides, although it is much larger, and its head contains six papillteform nodules instead of three. The oxyuris vermicularis is a small, thread-like formation, and the cercomonas urinarius a small infusorium, which consists of an oval, granular body, and contains a number of cilia. These parasites are extremely rare and of no practical importance. Chaptek XIII EXTRANEOUS MATTERS Extraneous matters are common occurrences in urinary sedi- ments, and must be well known, as they might frequently lead to errors in diagnosis. Their presence in the sediment may be due to many causes, such as exposure to air, from which various objects may fall into the urine, pouring the urine into bottles which are not perfectly clean, the use of salves or dusting pow- ders for the genital organs, or admixture of particles from the Fig. 67. Cotton-Fibeks (X500). fffices. Many of these formations are characteristic enough, but others may closely resemble various features of normal or pathological urine, from which they must be carefully diiferentiated. The different fibers of cotton, linen, silk, and wool are fre- quently found in the urine. Cotton-Fibers (see Pig. 67). — Cotton-fibers are coarse, some- (140) EXTRANEOUS MATTERS 141 what wavy and twisted. They are highlj^ refractive, their edges being more com- pact than the center. The central portion may appear slightly folded, and often shows irregular markings. When the fibers are very small, the diagnosis must be made from the wavy, com- pact appearance. lAnen- Fibers (see Fig. 68). — Linen-fibers are va- riously sized, sometimes broad, and at other times narrow. They are composed of smaller fibrillse, which, although quite refractive, are less so than cotton -fibers. At different parts of the fiber, are seen, which are caused by the finest fibrillse will be found broken Fig. 69. Silk-Pibeks (X 500.) Fig. 68. Linen-Fibbbs (X 500). irregular transverse breaks process of hatcheling. The off in a very irregular manner from the surface of the main fiber, being either long or short, and at times branch- ing in different directions." Silk-Fibers (see Fig. 69). — Silk -fibers are homogene- ous, moderately shining ; their cut ends are flattened by the blades of the scissors, and rendered slightly jagged. If from woven goods, the fibers assume wavy or spiral impressions. Wool-Fibers (see Fig. 70). — Wool -fibers are coarse, and have saw-teeth like ser- rations along the edges, cor- responding to the edge of the imbricated scales covering 142 UBINABY ANALYSIS AND DIAGNOSIS Pig. 70. Wool-Fibeks (X 500;. the cuticle ; their structure is faintly striated. Hairs of dif- ferent animals have different forms, and we may observe the central medullary canal and a varying amount of pig- ment. Any of these fibers may be found dyed in different colors, which is sometimes quite misleading. Human Hairs. — Human hairs are also not infrequently found in the urine, and may be known by the flat epider- mal scales, firmly attached to each other, which form the main mass of the hair, and by the varying amount of pigment. Feather (see Fig. 71). — Feather may appear in the shape of branching formations, which have their origin at the quill, and run in different direc- tions, or in single barb- ules. The quill is striated. The barbules are composed of different sized links, and gradually taper toward the ends, which are whip- like. Scales from Moth (see Fig. 72).— Scales from the wings of insects, such as moths, may also be found. They are more or less deli- cate, serrated plates with a stem -like projection, and vary considerably in length and breadth. Starch - Olohules (see Fig. 73).— Starch -globules are frequently seen in the iio. 71. Feather (x 400). EXTRANEOUS MATTERS 143 Pig 72. Scales teom Wings of Moth (X 500). urine. They are more commonly found in the urine of females, starch powders being extensively used for dusting purposes, but individual globules from the un- derwear are also seen. They are oval or round, highly refractive, and vary greatly in size, with a more or less central hilum or umbilicus, around which are con- centric striations. The hilum may be either round, oval, or irregu- lar, at times quite large, at times small, and occasionally appearing as if split. The different varieties of starch, although having the same charac- teristics, vary in shape as well as in size. The three most frequently found in the urine are rice- starch, corn-starch, and wheat-starch. Rice-starch always ap- pears in the form of oval or oblong, quite regular globules of medium size. Corn- starch is smaller, ir- regular, at times al- most hexagonal, and contains an irregular hilum. Wheat -starch consists of large glob- ules, as well as of small, irregular form- ations, in which latter the hilum may be en- tirely absent, or is present only in the form of a dot. Lycopodium (see Fig. 74) . — Lycopo- dium, somewhat simi- lar to starch, and also „ ,„ „ _ ,_ „„, considerably used for Fig. 73. Staech-Giobules (X 500). . ■' K, Eiee-starch ; C, com-stareh i W, wheat-starch. dusting purpOSeS, COU- 144 TJBINABT ANALYSIS AND DIAGNOSIS Fig. 74. LYCopoDiuM-GiiOBULJSs (X 500). sists of globular formations of different sizes, with a distinct shell, and studded with peculiar thorny projections. Many glob- ules seen in urine are partially broken, and in some an irreg- ular or triangular division is noticeable. Cellulose (see Fig. 75). — Cellulose occurs in the urine in a variety of forms, some- times in small, sometimes in large masses. It varies consid- erably, according to the plant or portion of plant from which it is derived, and may be brown, pale yellow, or practically color- less. It may be seen in the urine in the form of a framework, sometimes angular, the individual cells being connected with each other by the inter- cellular substance. In the interior of many, though not in all cells, a nucleus, usually somewhat irregular, wUl be present, and both the cells and the nucleus are granular. Instead of the irregular angular cells, perfectly reg- ular, either rectangular or square cells, with large, reg- ular, oblong nuclei, may be seen, and these may also be found singly or in masses. Cork (see Fig. 76).— A common variety of cellulose seen in urine is cork. This occurs either in single cells or smaller conglomerations, and has a yellowish brown or reddish brown color. The individual cells are irregular and greatly vary in size. They are either perfectly Via. 75. cellulose (x 500). EXTRANEOUS MATTERS 145 Pig. 76. CoEK (X 500). homogeneous or contain a small number of indistinct granules. At times, many of these cells will be found closely packed together. "When the cells are thin, they may possibly be mis- taken for epidermal scales, but their color is always sufBeient to differentiate them from the latter. Oil- Globules and Air-Bub- iles (see Fig. 77). — Extraneous fat- or oil -globules are of com- mon occurrence in urine. They may be very large or extremely small, and are either perfectly round or irregular. They have a high refraction, and can fre- quently be differentiated by their yellowish color. The smallest globules might perhaps be mistaken for fat -globules voided with the urine, but are almost invariably associated with the larger, more irregular, yellowish globules. Air -bubbles also vary in size to a great degree, and may be either round or irregular ; they have a sharply defined, double contour and a blue or bluish black refraction. Flaws in Glass (see Fig. 78).— Flaws in the glass, as well as scratches in the cover -glass, maj^ easily lead to a mistaken diagnosis. The flaws are irregular in size and shape, and frequently resemble the wings of a butterfly. FIG. 77. OiL-GLOBnLES AND Al«-BUBBLES ^j^^^ j^^^^ ^ ^^.^^ ^j^^ p, fat- or oi]-giobuies ; A, air-bubbles. rcfractiou and are usually 146 TJBINABT ANALYSIS AND DIAGNOSIS pale. A little care is sufacient to diagnose them, and if their identity is not plain, a change of the glass will suffice to note their character. Rust -particles in both the cover -glasses and slides also occur, and are larger or smaller, dark or rust -brown irregular masses, which must not be mistaken for coloring matter in the urine. The smaller masses somewhat resemble haematoidin crys- tals, but are always more irregular. Vegetable Matter (see Fig. 79).— Vegetable matter of dif- erent forms may be found in the urine as an admixture from Fig. 78. Flaws in the Glass (X 500). the fseees. Different plants, which remain partially undigested and may be passed with the fseces in small masses, will present a variety of features. Spiral fibers from the air t vessels of plants are quite numerous in such masses. Hairs of pMnts, as well as vegetable -fibers, the latter resembling connective -tissue shreds, will be found, besides particles of cellulose. We may furthermore see starch- and chlorophyl- globules, masses of spores, fat -globules and margarie acid needles. Fceces (see Fig. 80). — Normal faeces may occasionally be found mixed with urine, and their constituents must be known. If they are present, and their accidental admixture can be EXTRANEOUS MATTERS 14T excluded, the diagnosis of a fistula can be made. Although their features vary greatly, depending upon the food, the most common with a mixed diet are the following : Partly digested muscle -fibers of a yellowish or brown color Fig. 79. Vegetable Matter (X 500). Sp, spiral fibers from air-vessels of plants ; V, vegetable-fibers ; H, hairs of plants : C, cellulose ; St, starch -globule ; Oh, chlorophyl-globule ; F, fat-globules ; M, margario acid needles ; So, spores. are almost constantly seen ; in many the striations will be plainly visible, while in others no structure can be made out. Connective-tissue shreds from the meat diet, in small numbers, are also present. Spiral fibers, hairs of plants, and different 148 UBINABY ANALYSIS AND DIAGNOSIS forms of cellulose are almost constant ingredients, as well as starch- and chlorophyl- globules, and fat in the form of globules and needles. Mucus -threads and mucus -corpuscles are usually found in Fig. 80. Normal F^oes (X 500). MF, muscle-fibers ; CT, connective-tissue shreds ; Sp, spiral fiber : C, cellulose ; H, hair of plant; MS, mucus-thread; MC, mucus-corpuscle; E, epithelia ; Ph, triple phosphates; St, starch-globules ; D, debris ; M, mycelium ; S, sarcina ; Sa, saecharomyees ; F, fat-globules coutaiiiiug margaric acid needles ; BC, bacilli and cocci. normal fseces, as well as different varieties of epithelia. The latter are mostly of the flat variety, derived from the mucous membrane of the anus, although a few columnar epithelia are EXTRANEOUS MATTERS 149 not rare. Crystals of various kinds, but most commonly triple phosphates, may be quite abundant. Different non- pathogenic bacteria, such as conidia and mycelia in small numbers (un- doubtedly secondary products), saccharomyces, and large numbers of bacilli and cocci, may be found. Besides these features masses of debris, digested material, in smaller or larger con- glomerations, will be seen. The extraneous matters here enumerated as occurring in the urine are those which are more commonly found ; but other features may be seen at one time or another. For instance, water-fungi of different varieties, although rare, are known to occur in urine. It will, however, be a comparatively easy matter to recognize most of the extraneous objects. Part Three MICROSCOPICAL URINARY DIAGNOSIS Paet Thkee MICROSCOPICAL URINARY DIAGNOSIS Although it has been customary, in arriving at a correct diagnosis of diseases of the genito -urinary tract, to consider the microscopical examination of the urine as only of secondary importance, and, in diagnosing the different inflammations of the kidney, to rely solely upon the presence of casts, a perusal of the previous pages will show that the microscope, is not only of the utmost importance in all these affections, but is frequentlj' the only means of arriving at correct conclusions as to the nature of the case. It is a well known fact that in many cases in which a small amount of albumin is present in the urine, and in which the clinical symptoms seem to point to a nephritis, even if only slight, that diagnosis will not be made, because frequent exami- nations of the urine fail to reveal any tubular casts, and the physician is apt to rest satisfied with the diagnosis of "functional albuminuria ; " yet a large number of not infrequently severe cases of nephritis exist which never show casts in the. urine. In cirrhosis of the kidney, for instance, the presence of casts is extremely rare, and when they are present at all, are so scanty, in most cases, as to be entirely overlooked. • On the other hand, many cases of nephritis, often lasting for years, will give such ill -defined clinical symptoms that a kidney inflammation is rarely thought of ; and the examination of the urine, if made at all, is done rapidly, and merely with the idea of satisfying oneself that casts are not present. Many of these cases will show only a trace of albumin in the com- mencement stage, and might not only be greatly benefited, but entirely cured, if a proper diagnosis were made soon enough. Such a diagnosis can always be made from a micro- scopical examination of the urine, even without the presence of casts, and the larger number of the mild cases never show casts in the urine at any time. (153) 154 URINARY ANALYSIS AND DIAQNOSIS The diagnosis of an inflammation or otlier affection of the kidneys is undoubtedly the most important ; but a microscopical examination of the urine may also be the only means of positively diagnosing the nature of a disease of the pelvis of the kidney, the bladder, and the prostate gland, as well as of clearing up a suspected ease of inflammation of the seminal vesicles. In the female, an inflammation or ulceration of the vagina, the cervix uteri, and the mucosa of the uterus can often be positively identified from the examination of urine, without the necessity of an examination of the patient. It can thus easily be seen that the microscope plays an extremely important role in genito- urinary affections, either giving the first evidence of a disease, or helping to clear up a doubtful diagnosis. In the following pages only those affections will be con- sidered which can be positively diagnosed from a microscopical examination of the urine. Chaptee XIV DISEASES OF THE KIDNEY AND PELVIS I. INFLAMMATIONS OF THE KIDNEY AND PELVIS Classification. — There are probably no diseases in which the opinions of pathologists differ so much, and in which the nomenclature is so varied, as in inflammations of the kidney, — nephritis. The result must necessarily be confusion. Such different terms as Bright's disease, interstitial, desquamative, exudative, parenchymatous, and diffuse nephritis are met with, and congestion, hypersemia, glomerulitis, pyelo- nephritis, and amyloid disease are all looked upon as different affections. While some authors use the term Bright's disease as indicat- ing all the different varieties of nephritis, others call diffuse nephritis Morbus Brightii ; others, parenchymatous nephritis ; and still others, combinations of different varieties. One classification* gives no less than seven different varieties of Bright's disease: (1) Congestion of the kidney; (2) acute parenchymatous nephritis ; (3) chronic parenchymatous nephri- tis ; (4) acute diffuse nephritis ; (5) chronic diffuse nephritis ; (6) acute interstitial nephritis ; (7) chronic interstitial nephritis. Besides these, this classification gives suppurative nephritis and pyelo - nephritis separately . Another classificationt of Bright's disease is the following : (a) Acute nephritis (acute Morbus Brightii), in which acute hsemorrhagic nephritis and acute glomerulo- nephritis are in- cluded; (6) chronic nephritis (chronic Morbus Brightii), which is again divided into four varieties — ( 1 ) large white kidney (inflammatory fatty kidney), (2) large red kidney (chronic hEeraorrhagic nephritis); (3) secondary cirrhosis of the kidney, and (4) contraction of the kidney (cirrhosis, granular atrophy of the kidney) . Besides these, this author speaks of interstitial *Delafleld and Prudden, "A Handbook of Pathological Anatomy and Histology." New York, 1885. + Birch-Hirsohf eld, " Lehrbuch der Pathologischen Auatomie." Leipzig, 1887. (155) 156 UBZNABY ANALYSIS AND DIAGNOSIS suppurative nephritis (pyelo- nephritis and embolic suppurative nephritis), as well as of fatty, calcareous, and amyloid degenera- tion of the kidney. "Without going any further into the different classifications, which no two authors give alike, the latest classification* only will be mentioned : This simply gives the varieties as acute and chronic nephritis, dividing the latter into chronic paren- chymatous and chronic interstitial nephritis (cirrhosis, granular atrophy of the kidney). It is, therefore, not at all surprising that the pathology of nephritis is considered to be one of the most complicated chap- ters in pathology ; yet it will become perfectly plain, and the features found in urine easily explained, if we consider the anatomical structure of the kidney, which is that of a compound tubular gland, consisting of epithelial and connective tissue ; the latter alone carries the blood-vessels, the contents of which, the blood, furnishes the material from which the epithelia pro- duce the secretions. Experiments have frequently been made to show that patho- logical conditions of the epithelia can exist independently of the underlying connective tissue carrying the blood-vessels. It has been asserted that in acute cases of poisoning, such as with cantharides and phosphorus, the pathological process is confined to the kidney epithelia alone. Other experiments have, how- ever, conclusively proved that an independent pathological con- dition of the epithelia does not exist. The poison, before it reaches the epithelia, must pass the walls of the blood-vessels and the connective tissue lying between the epithelia and the walls of the blood-vessels, and has an irritating influence upon the latter. In this connective tissue, changes are always found, though they may be confined to serous transudation, sufficient to show that the epithelium can not become diseased primarily and independently of the surrounding connective tissue. It is, therefore, plain that the classification by Virchow, of I inflammations into interstitial, that is, confined to the connec- tive tissue, and parenchymatous, confined to the epithelia, is not strictly correct. Every inflammation is primarily an interstitial one, and every parenchymatous inflammation must also at the same time be an interstitial one. It is perfectly true, however, * Hubert, in " Bibliothek der gesammten medicinischen Wissensehaften." Vienna, 1898. DISEASES OF THE KIDNEY AND PELVIS 157 that the pathological changes may be more pronounced in the «pithelia than in the connective tissue ; the latter may not pass beyond the stage of serous transudation, while in the former coarse granulation, so-called cloudy swelling, may occur ; in cases of phosphorus poisoning fatty degeneration may be present. The character of an inflammation depends to a great degree upon the nature of its exudate, which may be either serous, fibrinous, or albuminous. In former years inflammations of mucous membranes were divided into catarrhal and croupons ; in the first a serous or sero -mucous exudate is formed, while in the second it is fibrinous in its character. These names, though not of great significance, are perhaps preferable to Virchow's terms, interstitial, desquamative, and parenchymatous, which, as has been shown, can not be carried out. An inflammation in an organ composed of connective and epithelial tissue will affect all its component parts to a greater or less degree, so that it will be diffuse to a certain extent at the outset. The difference exists only in the degree in which the different tissues are affected. We may, if we wish, speak of an interstitial inflam- mation when the pathological changes are more pronounced in the connective tisstie, and of a parenchymatous inflammation when they are more pronounced in the epithelia. As every inflammation of the kidney is bound to be more or less diffuse in its character, and the term Bright' s disease conveys no meaning as to the character of the inflammation, which may run an acute, subacute, or chronic course, all cases of nephritis may best be divided in the following manner .- 1. Catarrhal, interstitial, or desquamative nephritis. (a) Acute. (&) Subacute. (c) Chronic, terminating in cirrhosis of the kidney. 2. Croupous or parenchymatous nephritis. (a) Acute. (6) Subacute. (c) Chronic, terminating in atrophy of the kidney. 3. Suppurative nephritis or pyonephrosis. (ft) Acute. (6) Chronic. It is hardly possible to speak of a subacute abscess, since all such cases which have lasted for a number of weeks are properly chronic. 158 V BINARY ANALYSIS AND DIAGNOSIS Congestion or hypersemia of the kidney can not be considered as a separate affection, since it is either the first stage of a commencing inflammation, or a mere irritation, which can not be properly termed inflammatory as yet, but which sooner or later will undoubtedly develop into an inflammation. Glomerulitis or glomerulo- nephritis, again, is not an inde- pendent inflammatory process, but only a symptom of one of the inflammations, since the glomeruli will always be attacked to a greater or less degree in every nephritis. Fatty and waxy, or amyloid, degenerations of the kidney are always secondary products, due to a chronic inflammation, and part of such an inflammation. Pathological Changes. — Let us now briefly consider the pathological changes which take place in these different inflam- mations of the kidney : 1. Catarrhal Inflammation. — In catarrhal or interstitial in- flammation of a mild character, an cedematous swelling of the connective tissue is present, with swelling and granular cloudi- ness of the epithelial covering and subsequent desquamation of the epithelium. The blood-vessels show a more or less complete distension with blood -corpuscles, without apparent alteration in the structure of their walls. The cedematous swelling of the connective tissue, as well as the desquamation of the epithelia, are due to a serous exudation from the blood-vessels. On account of this serous exudation, the epithelia may become partly changed to mucus. In severer cases an inflammatory infiltration of the connec- tive tissue, which leads to hypertrophy, takes place, with pro- liferation, desquamation, and, finally, hyperplasia of the epi- thelium. In the highest degree of catarrhal inflammation, all the constituent parts of the kidney -tissue -have disappeared in the inflammatory infiltration. At the very commencement of an inflammation, the produc- tion of pus -corpuscles takes place, partly from the interstitial connective tissue and partly from the epithelium, which latter undoubtedly enters into the formation of pus -corpuscles to a great degree by division and endogenous cell -proliferation, as has been already shown by George Johnson, in the year 1852. As long as the newly formed corpuscles remain in connection with the tissue, we have inflammatory corpuscles ; but as soon as they are torn from their connection with the tissue and DISEASES OF TBE KIDNEY AND PELVIS ISS appear in the urine, the term pus -corpuscles must properly be applied to them. When the disease has become chronic, the surface of the kidney is marked by irregular, shallow depressions, or by granulations, the capsule being adherent in most cases. The irregular depressions are due to retractions of newly formed connective tissue, which is formed at the expense of the uri- niferous tubules. Chronic catarrhal or interstitial nephritis invariably leads to a shrinkage — cirrhosis — of the kidney. The whole kidney is considerably reduced in size and the irregularities on the surface are well marked. Both the cortical and medullary substances are much narrower than in the normal condition ; this being more particularly the case in the cortex, of which, in advanced stages, only slight remnants are left, corresponding with the elevations of the surface. There is a partial destruction of tufts or glomeruli, tubules, and blood- vessels. The newly formed connective tissue is more or less regularly distributed throughout the kidney structure, the urinif- erous tubules being in part transformed into connective tissue, while still retaining the outlines of their original configuration. The obliteration of a number of the narrow tubules, including the ascending and descending branches, explains the clinical fact that persons affected with cirrhosis of the kidney void large quan- tities of urine almost destitute of salts. It is well known that i the tuft excretes water only, which becomes thicker by the addi- j tion of the saline constituents excreted by the narrow tubules. ' It is in the narrow tubules that much of the watery part of the urine is restored to the thickened blood running in the neighbor- ing capillaries. If the function of the tubules be much interfered with, the interchange between the liquid contents of the tubule and the solid constituents of the blood will not take place, and consequently the urine will be voided in about the same condition in which it was pressed into the capsule from the tuft. Numbers of the convoluted tubules perish also through the increased for- mation of connective tissue, while from others the epithelia are simply desquamated and appear in the urine. 2. Croupous Inflammation. — In croupous or parenchymatous inflammations, the surface becomes partially or completely de- nuded of its epithelium, a coagulated albuminous or fibrinous exudate is formed upon the surface, there is considerable hyperemia of the blood-vessels, and a pronounced swelling and inflammatory 160 UBINABY ANALYSIS AND DIAGNOSIS infiltration of the connective tissue. E. Wagner has shown that the epithelia enter very actively in the formation of the so-called croup membrane, and their protoplasm becomes almost completely destroyed in the fibrinous exudate. In this variety of inflammation, the emigration of colorless blood -corpuscles is quite pronounced. Epithelia alone can not produce a croup membrane, but require the presence of an exudate from the blood, and the essential constituent of the croup membrane is the coagulable albuminoid body from the blood. We now have the formation of casts ; the epithelia lining the tubules become saturated with the albuminous exudate, swell, grow pale, and finally, by coalescence of the epithelia thus de- generated, produce the mass called a tubular cast. In chronic croupous nephritis, the kidney has an entirely dif- ferent appearance from that found in chronic catarrhal nephritis and cirrhosis of the kidney. It is more frequently enlarged than diminished in size. The surface is often nodulated, and between the nodules are seen deep cicatricial retractions. These retrac- tions are never found uniformlj^ over the surface, and the capsule is adherent to the retractions. The cortical substance is a,bsent in those parts corresponding with the retractions of the surface, while in other places the cortex may be unaltered or even increased in bulk. The pyramidal substance may be unchanged or may be diminished. In contradistinction to the more or less uniform shrinkage of the kidney, to which the name cirrhotic is given, the partial destruction of the tissue which occurs in chronic croupous nephritis may be termed atrophy, since in the most diseased portions only traces of the original kidney structure will be found. In the depressed cicatricial portions of the cortical substance, a large amount of connective tissue, only scantily supplied with blood-vessels, is found. There is no regularity in the arrange- ment of the connective tissue, and only remnants of the former tubules are found, together with irregularly scattered sections of tubules, from which the epithelial lining has entirely disappeared. In the most pronounced cases, in addition to the atrophied por- tions, the large amount of newly formed connective tissue present in different places constitutes a regular hypertrophy. Both fatty and waxy degeneration may be present in cirrhotic as well as in atrophied kidneys ; but these changes are much more pronounced in the latter than in the former. In the so-called DISEASES OF THE KIDNEY AND PELVIS 161 large white kidney, the highest degree of fatty degeneration occurs as a secondary result of chronic croupous nephritis. Cystic degeneration may also be present in these cases, and is more pronounced in chronic croupous nephritis. 3. Suppurative Inflammation. — The most intense variety of inflammation of the kidney is the suppurative, which is similar to the formation of an abscess in other organs. For a long time this variety was considered to be a purely interstitial inflammation, since the opinion prevailed that pus -corpuscles could only be formed from connective - tissue cells. There is, however, no doubt, as previouslj' stated, that the epithelia take an active part in the formation of pus. The blood-vessels soon become destroyed in this variety. Pus is disintegrated tissue, and in its formation all the elements of the tissue take part. There may be either a number of small disseminated foci of suppuration or a large abscess, usually, if not invariably, caused by an invasion of pyogenic cocci. Besides the abscess, the kidney may present either the features of a catarrhal or of a croupous inflammation. When the abscesses become chronic, a dense connective -tissue capsule, the pyogenous membrane, may occasion- ally be found, and the pus becomes inspissated . into a cheesy mass. With these remarks upon the pathology of the different varie- ties of nephritis, we are ready to understand the features found in the urine of these cases. Although it is not possible to diagnose an acute, subacute, or chronic inflammation from the urine alone, in all cases of nephritis, it can undoubtedly be done from the dif- ferent features seen in most cases, especially the more pro- nounced. IRRITATION OF THE KIDNEY From what has been said before, it is evident that the diag- nosis of an inflammation can be made as soon as pus -corpuscles are found iu the urine ; without these, no such diagnosis is possible. In some cases, in which a trace of albumin is present, •or no albumin whatever is found, an extremely small number of .^US-corpuscles, perhaps one or two in every fleld of the micro- scope, is seen, together with the same number of epithelia from the convoluted tubules of the kidney, and a few red blood -cor- puscles. These features, when present in such very small num- bers, are not sufficient for the diagnosis of an inflammation. 162 UBINABT ANALYSIS AND DIAGNOSIS though the urine can not be called normal. In such cases the diagnosis of an irritation of the kidney is possible, and in them ; we will never find casts. As soon as casts are present, even if ' the features are very scanty, an inflammation must be diagnosed. In some, though not in all cases of irritation, an increase of mucus, both in the form of threads and corpuscles, is noticeable. When this is present, caution is necessary, since such an increase of mucus is often seen as a pre -stage of an inflammation, es- pecially in acute eruptive and inflammatory diseases, such as scarlet fever, diphtheria, and pneumonia. Causes. — Irritation of the kidney is of common occurrence, but is frequently overlooked. It may be present accompanying almost any disease, and may be produced by different medicinal agents, such as cubebs, copaiba, turpentine, cantharides, and i mineral acids. Occasionally it seems as if simple exposure to I cold and moisture is sufficient to produce it. In cases of catarrhal or gonorrhcBal urethritis, especially if accompanied by slight prostatitis;, irritation of the kidney is often found. The presence of an increased amount of salts, such as uric acid or oxalate of lime, will not infrequently be responsible for the condition. If the caiise which has produced the irritation be quickly removed, the affection may disappear at once ; but if not, an inflammation will sooner or later result. If the irritation is pronounced, a more or less severe hcem- orrhage from the kidney may take place, even without an inflammation. In such cases, red blood -corpuscles will be numerous, epithelia from the convoluted tubules may be some- what more abundant, and, in addition, scanty, delicate shreds of connective tissue will appear in the urine. All the features may have a yellowish hue from the coloring matter of the blood. CATARRHAL OB INTERSTITIAL NEPHRITIS Catarrhal, interstitial, or desquamative nephritis frequently runs a comparatively mild courfee, being, as a rule, the mildest of the three varieties of inflammations. Severe acute cases, which may cause the death of the patient, do however, occur. Catarrhal nephritis is a much more common affection than is generally supposed, and may exist for many years without giving any pronounced clinical symptoms. It is by no means DISEASES OF THE KIDNEY AND PELVIS 163 rare that a urine which is examined microscopically with a view of detecting other affections will show the presence of such an inflammation before the clinical symptoms are clear, though the patient may have suffered for a long time from occasional headaches and general depression. Causes. — Catarrhal nephritis often exists in a mild degree without any known cause. Exposure to cold and moisture seems to be a frequent cause, as are also different medicinal agents, such as arsenic, iodine, phosphorus, mercury, turpen- tine, and cantharides. In lead -poisoning the disease is often present. It is not infrequently found in persons of sedative habits and in those with a so -called gouty or rheumatic diath- esis. That persons suffering from gout and rheumatism usu- ally void a large amount of uric acid is well known ; but there are others who continually void uric acid and oxalate of lime in excess without giving any rheumatic symptoms. In these cases — lithaemia and oxaluria — catarrhal nephritis frequently occurs, and it seems that the excess of the salts, or the concen- tration of the urine itself, has an irritating tendency upon the kidney tissue. The continued use of alcohol is an important factor in the production of the disease. In acute contagious diseases, croupous nephritis is of more common occurrence than catarrhal, but the latter, contrary to the general belief, undoubtedly occurs. If the urine is care- fully examined in these diseases, a small amount of albumin, perhaps not more than a trace, may be found in the milder cases, and upon microscopical examination the features of a catarrhal inflammation are seen. Even in some fatal cases, an examination of the kidney may reveal a catarrhal and not a croupous inflammation. In pregnancy, also, catarrhal nephritis may occur, though rarely. As a secondary affection, this variety of inflammation may be present in many acute and chronic fatal diseases, so much so that, upon post-mortem examinations, absolutely healthy kid- neys are usually found only after death by accident. Finally, catarrhal nephritis is common as a result of vari- ous genito- urinary affections, as, for instance, in some cases of gonorrhoea, when flrst a prostatitis, then, in succession, a cystitis, pyelitis, and nephritis will develop. In syphilitic and tubercular affections it is frequently seen. Clinical Symptoms. — The clinical symptoms of the disease 164 UBINAET ANALYSIS AND DIAGNOSIS vary greatly, but in the milder eases are aneemia, occipital headache, pain in the lumbar region, loss of appetite, sleep- lessness, and genei'al depression. In cirrhosis of the kidney the symptoms are pronounced, loss of flesh and strength is well marked, vomiting may be frequent, there may be dyspnoea, and the pulse is tense, hard, and often full. The acute cases may occur at any age, but the chronic cases are mostly found in persons more advanced in years, especially after the age of forty years . Features Found in Urine. — Albumin, although present in most of the cases, may be found in very small amount only, and in some it seems to be entirely absent. A large amount of albumin is rare in catarrhal nephritis, and is seen only in the severe cases. In many, a trace of albumin only will be found, and unless a careful observation is made, it may escape detec- tion entirely. The question whether a pronounced inflammation of the kidney may exist with entire absence of albumin is still an open one. Many authors claim that it does occur, but many times when albumin is said to be absent, careful examination will show a trace. It is undoubtedly a fact that in catarrhal nephritis albumin may be absent at certain times ; but frequent examination will almost invariably show at least a trace in every case. The specific gravity, amount, and appearance of the urine will vary greatly. In milder cases, these may be perfectly nor- mal. In acute catarrhal nephritis the specific gravity is, as a rule, somewhat higher than normal, the amount slightly de- creased, and the color darker. The amount of urea is usually increased, and salts may be present in rather large numbers. In chronic cases the amount of ui'ine is invariably increased, sometimes to a great degree ; the specific gravity is low, and the color pale. In such cases the specific gravity is not infre- quently below 1.015 or 1.012 continually, the amount of urea and salts being diminished. The sediment found in the urine varies, but is usually small, and may, at times, be no more abundant than in normal urine. A positive diagnosis of catarrhal or interstitial nephritis is in many cases possible only by a microscopical examination of the urinary sediment. This will vary in acute, subacute, and chronic cases. The diagnosis of a nephritis can be made when pus -corpuscles and epithelia from the convoluted and narrow DISEASES OF THE KIDNEY AND PELVIS 165 tubules of the kidney are present in the urine. Columnar epi- thelia from the straight collecting tubules are of rarer occur- rence, and indicate an invasion of the pyramidal substance. Before the presence of epithelia from the convoluted tubules of the kidney can be diagnosed, pus -corpuscles must be found and taken as a standard, since the latter vary in size to a cer- tain degree in every given case. Kidney epithelia from the convoluted tubules are invariably one -third larger than the pus- corpuscles. These epithelia are never found in normal urine, and to render their diagnosis positive, should always be com- pared with pus- or white blood -corpuscles. A single kidney epithelium is of no value for the diagnosis, as a small number, at least, should always be found, in order to render the diagnosis positive, since, as is well known, pus-corpuscles will vary in size to a small degree even in the same case. This difference is, however, small, and never so pronounced as to render the diagnosis between pus -corpuscles and kidney epithelia difficult. The difference in size between the two can alone determine the nature of the epithelia, since the presence or absence of a nucleus has no significance whatever. A nucleus may be seen in pus -corpuscles as well as in epithelia, though it is found more frequently in the latter than in the former. In finely granular pus - corpuscles a nucleus will always be visible, while in coarsely granular epithelia it may not be seen. Kidney epithelia from the convoluted, as well as those from the narrow tubules will, in urine generally, have a round form ; angular or irregular forms are rarely seen. When the urine is still warm at the time of examination, or in a warm temperature, the pus -corpuscles may not infrequently show amoeboid movement, and assume a variety of different shapes while the kidney epithelia will, as a rule, retain their round form. In this variety of nephritis easts are usually absent ; if they are present at all, they are found in extremely small numbers, and then we almost invariably see small hyaline casts from the narrow tubules only. The diagnosis, however, hinges upon the presence of epithelia from the convoluted and narrow tubules and pus -corpuscles, together with other features to be presently mentioned. Acute Catarrhal or Interstitial Nephritis (Fig. 81). — In an acute catarrhal nephritis the pus -corpuscles and cuboidal epi- 166 URINARY ANALYSIS AND DIAGNOSIS thelia from the convoluted tubules of the kidney are present in at least moderate but usually large numbers ; the more numerous these features, the severer is the nephritis. Besides these, we usually find red blood -corpuscles in moderate or large numbers, though they are not sufficiently numerous to admit of the diagnosis of a haemorrhage. Larger numbers of red blood -corpuscles always indicate an acute inflammation. These three features are perfectly sufficient for the diagnosis, but are rarely found alone. In many cases different salts, such as oxalate of lime, uric acid, and urate of sodium, will be found in small amount. In the severer cases a few columnar epi- thelia from the straight collecting tubules are also present. As a general rule, an inflammation of the pelvis of the kidney is associated with the nephritis, though this may be absent. When present, the irregular, lenticular, pear - shaped, or angu- lar epithelia from the pelvis will also be seen in varying numbers, and the diagnosis of a Pyelo- nephritis can be made. Such a diagnosis does not by any means suggest an abscess of the kidney, as is frequently supposed, but simply the ex- tension of the inflammatory process to the pelvis of the kidney. Besides these, epithelia from the ureters in small numbers, which are twice the size of pus -corpuscles, and therefore larger than the kidney epithelia, are rarely absent. If the nephritis is at all pronounced, symptoms of an accom- panying cystitis are also seen, and we will then find larger cuboidal epithelia from the middle layers of the bladder — which in urine appear round or oval in most cases — as well as flat epi- thelia from the upper layers with the other features. The severer the acute inflammation the more certain are the accompanying features of pyelitis and cystitis. In such severe cases hyaline casts from the narrow tubules are occasionally present ; if these are seen in small numbers only, the diagnosis does not necessarily become changed. The latter feature is com- paratively rare, and in most cases casts of any kind are entirely absent. Chronic Catarrhal or Interstitial Nephritis (Pig. 82). — As soon as the inflammation has become chronic, the features in the urine are different. Red blood -corpuscles are now either entirely absent, or, when present, are found in small numbers only. We observe, however, a varying number of small, glistening, highly refractive globules and granules, partly lying free, partly in the Fifi. 81. Acute Catarrhal Pyelo-nephritis (Acute Interstitial Nephritis) AND Cystitis (X 500). RB, red blood-corpuscles ; PC, pus -corpuscles ; CB, epithelia from the convoluted tubules of the kidney ; UE, epithelia from the ureter ; PE, epithelium from the pelvis of the kidney ; UB, epithelium from the upper layers of the bladder ; MB, epithelium from the middle layers of the bladder. (167) (^ @ Fig. 82. Cheonio Catabrhal Ptelo-nephkitis (Chronic Interstitial Nephritis) and Cystitis {X 500). PC, pus-corpuscles containing fat-globules; CE, epithelia from the convoluted tubules of the kidney containing fat-globules ; SE, epithelium from the straight collecting tubules of the kidney containing fat-globules j UE, epithelia from the ureter containing fat-globules ; PE, epithelia from the pelvis of the kidney ; MB, epithelia from the middle layers of the bladder ; FG, free fat-globules. fl68) DISEASES OF THE KIDNEY AND PELVIS 169 pus -corpuscles and epithelia. These are fat -globules and -granules, and the more numerous they are, the more chronic is the inflammation. They are found in larger or smaller groups scattered throughout the field, and are seen in varying numbers in the pus -corpuscles and epithelia. In milder cases only two or three may be present in some epithelia, while they will be absent in others ; but in the old, chronic eases, almost every epithelium will be seen filled with the glistening globules. When very numerous, they not only denote chronicity, but also a commencing fatty degeneration of the kidney, which, in this variety of nephritis, is never pronounced. Pat -globules are not seen in acute cases. The features found in a chronic catarrhal nephritis are, there- fore, the following : Pus-corpuscles, some containing fat-globules and -granules ; cuboidal epithelia from the convoluted tubules of the kidney, a few, or the larger number, containing fat-globules ; free fat-globules in different groups ; in the severer cases, also, columnar epithelia from the straight collecting tubules, usually in small numbers only. Irregular or round epithelia from the pelvis of the kidney, cuboidal (round) epithelia from the ureters, and still larger cuboidal epithelia from the middle layers of the blad- der, either with or without fat-globules, may be present in small or moderate numbers. Another feature of chronicity which may occasionally be found is hsematoidin, in the form of rust -brown needles and plates. These may either lie free, or when of small size may be seen in the pus -corpuscles and epithelia. They denote a pre- viously existing hsemorrhage, and show that the pathological process can not be an acute one. Red blood -corpuscles, as previously mentioned, are either entirely absent in a strictly chronic case, or, when present, are found in small numbers only. Not infrequently, however, all the features of a chronic inflammation are seen, and yet blood- corpuscles are numerous. This invariably denotes a fresh acute outbreak engrafted upon the chronic process. Such acute attacks are not rare in cases of long standing, and may be produced by the slightest cause, such as exposure to cold, derangements of digestion, etc. Again, the chronic inflammation may be confined to one kidney and an acute process affect the second kidney. In Subacute Catarrhal Inflammations some features of both the acute and the chronic form will be found. We have a small 170 UBINABY AJ^ALYSIS AND DIAGNOSIS or moderate number of red blood -corpuscles and a small number of fat- globules, the latter being rarely seen in groups, but only in a few pus-corpuscles and epithelia, and there may be only one, two, or three in them. The other features remain the same. When the features as here described are present, it will not be difficult to tell whether an inflammation is acute, subacute, or chronic ; but some cases may at times be seen where neither red blood- corpuscles nor fat -globules can be discovered, and then the diagnosis of a simple catarrhal or interstitial nephritis can alone be made. These cases are usually of a mild character. Besides all these features, the appearance of the pus-corpuscles, as noted in a previous chapter, must be taken into consideration, and may help to clear up the case where the clinical features and the history are vague. As long as the constitution of the patient is still fairly good, which can easily be determined by the number of coarsely and finely granular pus - corpuscles present in the case, we may feel confident that the nephritis can not have lasted any length of time, nor be a severe one. Cirrhosis of the Kidney (Fig. 83) . — The outcome of chronic catarrhal nephritis is always a shrinkage — cirrhosis — of the kidney, the so-called hob-nail kidney. The features of this, as seen in the urine, are so characteristic that a positive diagnosis can always be made. They are the following : 1. A large amount of urine, being occasionally increased to double the normal quantity, and the color being pale. 2. A continuously low specific gravity, usually below 1.012 or 1.010, or even not more than 1.006 at any time. 3. The presence of a small amount or perhaps but a trace of albumin. 4. The absence of all salts. 5. Pus -corpuscles, present in small numbers, some contain- ing fat -globules. 6. Epithelia from the convoluted and straight collecting tubules of the kidney, in small numbers, some or even all eon- tainin g fat - globules . 7. Free fat -globules and -granules. 8. Connective -tissue shreds, of small sizes and in small numbers only. 9. Broken down constitution, as seen by the pale, finely granular pus -corpuscles, in which not infrequently one or more nuclei become plainly visible. Fia. 83. Cirrhosis of the Kidney, with Chronic Catarrhal Cystitis (X 500). PC, pus-corpuscles ; CE, epithelia from tlie convoluted tubules of the kidney, containing fat-globules ; SE, epithelium from the straight collecting tubules of the kidney ; TIE, epi- thelium from the ureters ; PE, epithelium from the pelvis of the kidney ; MB, epithelium from the middle layers of the bladder ; CT, connective-tissue shreds ; PG, free fat-globules. (171) 172 URINARY ANALYSIS AND DIAGNOSIS Epithelia from the pelvis of the kidney, the ureter, and the middle layers of the bladder may also be present. As previously explained, a badly diseased kidney can never void any salts. In some cases, in which all the other features of a cirrhosis are present, a large amount of salts, such as uric acid or phosphates are also seen. The conclusion which can then be reached, is that only one kidney has sa far become affected, the salts being voided by the other kidney. The prognosis will, in such cases, be better than when all salts are absent. Catarrhal Pyelitis. — A few words should here be said about catarrhal pyelitis, which is occasionally a primary, independent affection. When it occurs as such, it is easily diagnosed from the urine, the features being the same as in catarrhal nephritis, except that pelvic epithelia instead of kidney epithelia are found. Being in many cases due to an abundance of salts, these will usually be present in such cases. As a rule, pyelitis is an accompanying element of a nephritis, giving us a catarrhal pyelo- nephritis, with the features as above described. CROUPOUS OR PARENCHYMATOUS NEPHRITIS Croupous nephritis is usually a severer affection than the catarrhal, and is not quite as frequent as the latter. When pres- ent, its symptoms are always more or less pronounced, and only in rare cases will it exist for some time without giving symptoms sufficiently characteristic to suspect a nephritis. Causes. — Its causes are numerous, being partly the same as I those found in the catarrhal variety. Exposure to cold and ; moisture is a common cause, and it is not infrequently the con- ! sequence of irritant poisons acting upon the system, such as turpentine, bichloride of mercury, cantharides, arsenic, large doses of iodide of potash, and, occasionally, even chlorate of potash. As in catarrhal nephritis, it may be found in persons of a sedative habit and in those suffering from a lithaemia. The continued use of alcohol is an important causative factor. Among the most common causes in the production of the disease are the acute eruptive and inflammatory diseases, espe- cially scarlatina, diphtheria, and pneumonia ; less frequently typhoid fever and small-pox. It is occasionally seen during pregnancy, though it is not always easy to account for its DISEASES OF THE KIDNEY AND PELVIS 173 occurrence ; pressure produced by the gravid uterus may be partly responsible for it. In chronic aflfectious, such as heart diseases, tuberculosis, and syphilis it may also be seen, as well as in rarer cases of malarial poisoning. As a result of strictures of the urethra, prostatitis, and hypertrophy of the prostate gland, croupous nephritis is fre- quent. The original inflammation will cause a cystitis, and, from the bladder, ascend to the ureters, pelves, and kidneys, ending in a croupous nephritis. A peculiar occurrence is its ' appearance in strong, healthy athletes during active training, especially when they subsist upon a meat diet ; the same may be the case in fat people who desire to reduce their weight quickly by an exclusive meat diet. Clinical Symptoms. — The clinical symptoms vary with the intensity of the process, though anaemia, headache, loss of appetite, emaciation, nausea, and loss of strength are all gen- erally present. Severe acute cases may be ushered in by chills, followed by a rise in temperature. Very soon oedema will appear, first being localized, especially on the eyelids, but soon becoming general, involving the face, hands, feet, and cellular tissues generally. To these symptoms will be added dull, aching pains in the lumbar region, and, in the severe cases, urtemic symptoms.' Features Found in Urine. — Albumin is almost invariably present in comparatively large amount, and in some cases may be extremely abundant, reaching one-half of 1 per cent, or even more. It is claimed that occasionally croupous nephritis may exist without the presence of any albumin ; that it may exceptionally occur in small quantities only is undoubted ; but it will probably never be absent altogether, as careful tests for albumin will show. In acute croupous nephritis the amount of urine is usually decreased, sometimes to a great degree, and in the severer and fatal cases may sink to a few ounces in the twenty -four hours, or may even be practically suppressed. The specific gravity is in many cases higher than normal, often reaching 1.030 or more, and the color dark, being sometimes quite pronounced, since haemorrhages frequently occur. The amount of solids, especially urea, voided during the twenty-four hours is usually decreased to a greater or less degree. In chronic nephritis the amount of urine is also at first decreased, but later becomes 174 UBINABT ANALYSIS AND DIAGNOSIS more abundant, though never in as pronounced a degree as in chronic catarrhal inflammation. The specific gravity will grad- ually become lower, until in atrophy of the kidney it is never more than 1.012, or even less. The color varies, being pale in the later stages. The sediment found in the urine is always quite abundant, and when once separated does not readily mix with the watery portion. As in catarrhal nephritis, a positive diagnosis of croupous or parenchymatous nephritis is, in many cases, possible only from a microscopical examination of the urinary sediment. This will vary considerably in acute, subacute, and chronic cases. In this variety of nephritis the presence of casts in larger or smaller numbers is a constant feature, without which the diagnosis can never be made, and the greater the number of casts, the worse, as a rule, the inflammation. True casts will, however, never be found in urine without the presence at the same time of pus -corpuscles and kidney epithelia, the latter not only from the convoluted and narrow tubules, but frequently, also, from the straight collecting tubules, though these may be absent in mild cases. The varieties and sizes of the casts are of great importance for the diagnosis and prognosis. In strict^ acute cases we never expect to find either granular, fatty, or waxy casts, while hyaline and epithelial casts are always present in larger or smaller numbers, and blood easts in the severer, htemor- rhagic forms. Again, the severity of the process can easily be determined by the size of the casts — when the smallest casts from the narrow tubules alone are present in small numbers, the parenchymatous nephritis will be of a mild character, and recovery is the rule. Casts from the convoluted and narrow tubules together, the former being of medium size, denote a process of moderate severity ; but as soon as the largest casts, coming from the straight collecting tubules, are present with the other varieties, we know that the inflammatory process has affected the whole kidney, that is, both cortical and pyramidal substance, and is a severe one ; Iherefore a doubtful prognosis only can be given. Acute Croupous or Parenchymatous Nephritis (Fig. 84). — When we examine the urine from a case of acute croupous nephritis, the features are found to be numerous and character- istic. The most pronounced elements are undoubtedly the easts, Fig. 84. Acute Croupous or Parenchymatous Nephritis with Catarrhal Pyelitis and Cystitis {X 500). RB, red blood-eorpuscle ; PC, pus-corpuscles ; OE, epithelia from the convoluted tubules of the kidney ; UE, epithelia from the ureter ; PE, epithelia from the pelvis of the Mdney ; UB, epithelia from the upper layers of the bladder ; MB, epithelia from the middle layers of the bladder ; K, creatinine crystal ; HC, hyaline casts ; EC, epithelial cast ; MS, mucus- thread ; MC, mucus-casts ; CT, connective-tissue shred. (175) 176 UBINABY ANALYSIS AND DIAGNOSIS which are seen in varying numbers in every field of the micro- scope. In such cases, two varieties of casts are usually found — the hyaline and the epithelial, the latter studded with epithelia to a greater or less degree. The more numerous the casts, the severer the inflammation, and the more albumin the urine will usually contain. Besides the casts, pus -corpuscles, red blood -corpuscles, and epithelia from the convoluted tubules are always present. They are found in moderate or large numbers, the kidney epithelia being frequently seen massed together. Red blood -corpuscles are found in every field, though, unless a haemorrhage has taken place, they cannot be called very abundant. Epithelia from the straight collecting tubules may also be seen, and those from the ureter and pelvis of the kidney almost invariably accompany the other features. As a rule, there will also be an accompany- ing acute cystitis, shown by the presence of epithelia from the upper and middle layers of the bladder. In these acute cases, mucus is present in fairly large amount, the pale threads being sometimes of considerable size, irregular, and finely striated. Not infrequently mucus is found in the form of casts — the so-called cylindroids. The presence of these has no further significance than the presence of mucus in gen- eral, and they may be seen in inflammations of any one of the genito- urinary organs. When they exist in a pronounced form, they can hardly be mistaken, as they are always faintly striated; but not infrequently they are so faint that their striation becomes visible only upon sharp focusing, and caution is here necessary not to mistake them for hyaline casts, which is fre- quently done. In size and shape they may resemble hyaline casts, which latter, however, are never striated. When they assume an irregular, convoluted form, their diagnosis is easy. In the severer cases of acute croupous nephritis, small shreds of connective tissue will be present ; thej' are never large or numerous, and their higher refraction and pronounced fibrillary structure is sufficient to differentiate them from mucus. Besides these features, crystals of creatinine may be present in those cases in which uremic convulsions have made their appearance. The plate is taken from a case of severe nephritis, which devel- oped in the third week of scarlet fever, and caused the death of the patient. The urine contained large numbers of character- istic creatinine lozenges and plates. Fig. 85. Acute H.a;MOREHAGic Croupous or Parenchymatous Nephritis with Catarrhal Pyelitis and Cystitis (x 500). EB, red blood-oorpuseles ; PC, pus-corpuscles ; CE, epitbelia from the convoluted tubules of the kidney ; SE, epithella from the straight collecting tubules of the kidney ; UE, epithelium from the ureter ; PE, epithelium from the pelvis of the kidney ; MB, epithelium from the mid- dle layers of the bladder ; HC, hyaline casts ; EC, epithelial east ; BC, blood casts ; CT, con- nective-tissue shred. (177) 178 URINARY ANALYSIS AND DIAGNOSIS Besides the cases just described, severe cases with pronounced hsBraorrhages are often seen, and will give somewhat different features (Fig. 85). The urinary sediment contains a large number of red blood- corpuscles in every field, together with many blood casts. The blood casts are partly filled with red blood -corpuscles, which have retained their normal appearance, and partly with disinte- grated blood -globules, in the form of irregular brown masses, giving to the whole cast a rust -brown appearance; blood casts assume this character when they have been retained in the tub- ules for some time. Sometimes the larger portion of the cast contains fully formed red blood -corpuscles, while the disintegra- tion has commenced in a small portion. Besides these casts, hyaline and epithelial casts are found in large numbers, and in these cases we almost invariably find -large casts from the straight collecting tubules. Epithelia from the straight collecting tubules are usually quite abundant, and connective -tissue shreds are larger and more numerous than in the preceding. In an active haemorrhage such connective -tissue shreds are cast off in fair numbers and found in the urine. Sometimes masses of fibrin are also found. The other features are the same, there being in most eases an accom- panying inflammation of the pelves, the ureters, and the bladder. Subacute Croupous Nephritis (Fig. 86). — After a croupous or parenchymatous nephritis has lasted for some time, the casts, or rather some of the casts, commence to change. Such a change is r'arely noticed until four or six weeks after the commencement of the inflammation, but occasionally, especially in nephritis after scarlet fever in children, may take place in two or three weeks. The first change will be seen in the epithelial casts, some of the epithelia breaking down into granules, giving us an epithelial- granular cast. Very soon, however, perfect granular casts, with- out any trace of epithelia, are also found in small or moderate numbers, and these, in exceptional cases in children, can be seen as early as two weeks after the inflammation has started, being then scanty. The next change which takes place is the transition of the granules into glistening, refractive fat-granules and -globules, at first only two or three being noticeable in a granular cast, and later on a larger number. Traces of the original epithelia may still be seen in the cast, while the largest portion has become Fia. 86. Subacute Croupous or Parenchymatous Nephritis with Catarrhal Pyelitis and Cystitis (X 500). RB, red blood-corpuscle ; PC, pxis-corpuscles ;