/4' Digitized by Microsoft® GAYLORD PRINTEDIN U S.A. This book was digitized by Microsoft Corporation in cooperation with Corneii University Libraries, 2007. You may use and print this copy in iimited quantity for your personai purposes, but may not distribute or provide access to it (or modified or partiai versions of it) for revenue-generating or other commerciai purposes. Digitized by Microsoft® DIAGNOSIS BY THE URINE MEMMINGER Digitized by Microsoft® The original of tliis 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/cu31924000906200 Digitized by Microsoft® DIAGNOSIS BY THE URINE OR THE PRACTICAL EXAMINATION OF URINE WITH SPECIAL REFERENCE TO DIAGNOSIS. BY ALLARD MEMMINGER, M. D., PROFESSOR OP CHEMISTRY AND HYGIENE AND CLINICAL PROFESSOR OP URINARY DIAGNOSIS IN THE MEDICAL COLLEGE OP THE STATE OP SOUTH CAROLINA, ETC., ETC, THIRD EDITION, ENLARGED AND REVISED WITH 27 ILLUSTRATIONS. PHILADELPHIA: BLAKISTON'S SON & CO. 1012 WALNUT STREET. 1908 Digitized by Microsoft® S3 M5^ Mo. £■' ' ^ /9oe Copyright, 1908, , BY P. Blakiston's Son & Co, Printed by The Maple Press York Pa. Digitized by Microsoft® TO Students of Medicine and Practitioners at Large THIS LITTLE VOLUME IS DEDICATED. THE ATTEMPT AT SIMPLICITY OF ARRANGEMENT AND OF STYLE IT IS HOPED WILL COMMEND IT TO THEM, AND BE THE MEANS OF INCREASING THEIR KNOWLEDGE AND DIMINISHING THEIR LABOR IN THIS SPECIAL DEPARTMENT OF SCIENCE. Digitized by Microsoft® Digitized by Microsoft® PREFACE TO THIRD EDITION The author, in carefully revising this third edition, has added a little more matter, but has kept to the original idea of not making the book too bulky. Tests have been added here and there which seemed to him of service in his work, a reliable and practically useful method for the quantitative estimation of uric acid, a quantitative method for chlorids, a general outline of the anatomy of the kidneys and a short method for estimating the permeability of the kidneys. He has seen, too, nothing since the publishing of the second edition to change his views in regard to the chapter on the absolutes and relative absolutes of solids and urea in urine; far from it, in this edition he calls forth caution to those who pass urine under the name of renal insufficiency, which is constantly free of albumin, but in which the solids and urea are as stated in that chapter. He too feels that the views Digitized byMprosoft® via PREFACE TO THIRD EDITION. expressed by him in that edition as to the significance of tube-casts have been but verified by his work since. He hopes, then, this edition will meet with the same favor from his critics as previous editions, and that the little volume may continue to be a help to students and a safe guide to the busy general practi- tioner. The Author. 34 Montague Street, Charleston, South Carolina. June, igo8. Digitized by Microsoft® CONTENTS Page. Introdtjciion, I CHAPTER I. Physical Characteristic of Urine in Health, 4 Amount, 4 Specific Gravity, 5 Consistence, 8 Color, . 8 Transparency and Odor, -9 Reaction, 9 CHAPTER II. Deviations in the Physical Characteristic or Urine in Disease, . . .10 Amount, 10 Specific Gravity, . . 10 Color, 12 Transparency and Odor, 4 13 Reaction, 14 CHAPTER III. Deviations in the Normal Chemic Composition of Urine in Disease, 17 Urea, .... 17 Estimation of Urea, 18 Uric Acid, 22 Estimation of Uric Acid, 25 Chlorids 26 Phosphoric Acid, 30 Digitized byWicrosoft® X CONTENTS. CHAPTER IV. Page. Morbid Products in the Urine in Disease, . 33 Albumin, . . • ■ -33 Sugar, . . • . . .38 Composition of Fehling Solution, 43 CHAPTER V. Coloring-matters, ■ ■ -44 Bile, 44 Blood, 46 Pus SI CHAPTER VI. Morbid Products which are Properly Classified as Urinary Sediments and Urinary Calculi, ... 56 Urinary Sediments, 56 CHAPTER VII. Differential Diagnosis of Chronic Bright's Disease, Based on a Classification of the Normal Abso- lute, THE Absolute, and the Relative Absolute OF Solids and Urea found in Urine with Albumin AND WITH OR WITHOUT TUBE-CASTS, . . 6o Rules for Life Insurance Examiners . . 85 CHAPTER VIIT. Resume, ... 89 Diagnosis of Diseases of the Kidney and Urinary Organs, . 89 Parenchymatous Nephritis 92 Chronic Parenchymatous Nephritis, . . 93 Interstitial Nephritis, . . . . 94 Pyelitis and Cystitis, 104 Table for Calculating the Absolute Solid in Urine of Specific Gravities Ranging from 1.004 to 1.030, 109 Statements of the Results of a Complete Analysis of Urine, ... .... . .110 Index . 113 Digitized by Microsoft® LIST OF ILLUSTRATIONS. Page. 1. Urinometer, 6 2. Ureometer of Dr. Doremus, 19 3. Forms of Uric-acid Crystals, . . 23 4. Ruhemann's Uriccmeter . 25 5. Graduated Burette ... . 28 6. Esbach's Albuminometer 36 7. Graduated Burette, . . ... 42 8. Leucin Balls, Tyrosin Sheaves, Double Balls of Ammonium Urate, 45 9. Colored and Colorless Blood-corpuscles of Various Forms, . 47 10. Shriveled Blood-corpuscles in Urine (Catarrh of the Bladder) with Numerous Lymph-corpuscles and Crystals of Triple Phosphate, .48 11. Hemin Crystals, . . . ... .... 49 12. Deposit in Ammoniacal Urine (Alkaline Fermentation), . 50 13. Acid Ammonium Urate Crystals, S7 14. Crystals of Cystin, Oxalate of Lime Crystals 58 15. Oxalate of Lime Crystals, 59 16. Coarsely Granular Casts, . . 61 17. Acid Sodic Urate in Cylinders, 61 18. Leukocyte Cast 61 19. Blood-cast, . . . 61 20. Hyaline Casts, . 62 21. Epithelial Cast, . . 62 22. Finely Granular Cast, 62 23. Peculiar Changes of the Red Blood-corpuscles in Hematuria, 62 24. Crenated Red Blood-corpuscles in Renal Hematuria, . 63 25. Deposits in Acid Fermentation of Urine, , . .... 64 26. Apparatus for Determining Freezing Point or Urine .... 98 27. Epithelial Cells, 99 Digitized by Mcrosoft® Digitized by Microsoft® INTRODUCTION The urine is the secretion of the kidneys, and, nor- mally considered, is a solution of tissue which has undergone retrograde metamorphosis. The proc- ess by which this is brought about is a double one: filtration, which occurs chiefly in the Malpighian capsules of the kidney, and excretion, which is brought about by means of the epithelial lining of the tubules of the kidney. Although this is true for all practical purposes, still the lines are not so accurately defined as this, a certain though small proportion of the ex- cretion taking place through the Malpighian tufts, and, conversely, a certain percentage of water being excreted along with the solids by means of the epithe- lium of the tubules. The average composition of this fluid is as follows: Total solids, 60 to 65 gm. Urea 30 " 35 Uric acid, 0.5 " 0.8 Chlorids 10 " 12 Phosphoric acid, 2.5 " 3 Earthy phosphates r " 1.3 Sulphuric acid 1.5 " 2.5 Hippuric acid, 0.25 " 0.5 Creatinin, 0.5 " i Digitized by Microsoft® 2 INTRODUCTION. In disease the' urine, besides showing deviations in the normal constituents and physical characteristics, contains albumin, sugar, biliary coloring-matter, acids and fats, uroerythrin (red coloring-matter), ammonium sulphid, blood, leucin and tyrosin, car- bonate and oxalate of calcium, carbonate of ammon- ium, cystin, xanthin, pus, epithelium, spermatozoa, and fungi. Kidneys. — The kidneys are two large glandular organs located in the upper and posterior walls of the abdominal cavity on either side of the spine — the left kidney is ordinarily longer than the right and slightly narrower than the right. Each kidney is about four inches long, two inches wide and one inch thick ; they weigh about four to five ounces each, the male kidney being about two and a half drams heavier than that of the female, the left kidney, too, is about six and one- half grams more in weight than the right. The kidney in form represents the haricot or kidney bean; they are situated deep in the loins. The inner border at its upper part is about one inch from the middle line of the body, the outer border at its lowest part three and three-fourths inches from the same line. The upper border corresponds with the space between the eleventh and twelfth ribs, and the lower with that of middle of the third lumbar vertebra. A horizontal line then passed through the umbilicus would lie just Iselow the lower borders of both kidneys, and a vertical Digitized by Microsoft® INTRODUCTION. 3 line drawn perpendicularly upward through Poupart's ligament to the costal arch would pierce through the length of each kidney. The kidneys then rest on the crura of the diaphragm on the anterior lamella of the posterior aponeurosis of the transversalis muscle as also on the psoas muscle. The right kidney is slightly lower than the left, due to the location of the liver, to which it touches by its suprarenal capsule. The kidneys are surrounded by a thick layer of adi- pose tissue, held in the meshes of a loose areolar tissue and which constitutes the tunic adiposa. • The capsule of the kidney is a smooth, closely fitting membrane which covers the organs and is attached to it by elastic fibers, and adheres by means of connect- ive tissue and capillary blood-vessels ; it can be separated in the healthy kidney, but in diseased states of the organs it brings with it when torn off, small particles of kidney substance. The kidney is most liberally sup- plied with blood; the renal artery is of large size and arises from the aorta slightly below the origin of the superior mesenteric artery, the right usually a little lower than the left, and both break up then into small capillaries each of which abruptly terminate in a glomerulus of short capillaries, inclosed in the cap- sule of Bowman. The renal vein is short and wide and the nerves of the kidney consist of filaments from the sympathetic and cerebro-spinal systems. Digitized by Microsoft® Diagnosis by the Urine CHAPTER I. PHYSICAL CHARACTERISTICS OF URINE IN HEALTH. AMOUNT. The quantity of urine passed in twenty-four hours by one in health is dependent upon so many cir- cumstances, at times controlled by mental, emotional, and physical causes, that it is hard to give an accurate norm. After most careful observations, however, extending over years, the author has arrived at the following estimate of quantities as fairly representing, in a vast number of cases, a condition of health in the adult : 1. A winter average of 1500 c.c. 2. A winter occasional average of 2000 c.c, de- pending almost entirely on sudden cold changes, ac- companied frequently by moist, easterly winds. 4 Digitized by Microsoft® PHYSICAL CHARACTERISTICS IN HEALTH. 5 3. A winter minimum of 1200 c.c. 4. A summer average of iioo c.c. 5. A summer occasional average of 1500 c.c, depending much upon the same conditions as in winter. 6. A summer minimum of 900 c.c. The average quantity, then, of urine passed by one in health in the twenty-four hours in winter is 1500 c.c, or 50 fiuidounces. Most is passed in the afternoon, less in the morning, and least at night. Of course, the amount passed will be much influenced by the causes already mentioned, as also by the quantity of fluid taken into the system; but the above is the general average for winter in health, and a variation of 500 c.c. less than the maximum, or 500 c.c. more than the mini- mum, must be allowed, not constituting in this varia- tion a condition of disease. SPECIFIC GRAVITY. The specific gravity of normal urine for the twenty- four hours has quite an extensive range ; and, as in the case of quantity, so have our observations shown us that quite a different range is to be observed between the specific gravity of urine passed in winter and that passed in hot weather. Winter urine has a general average of 1.018, and varies, according to the quantity of water passed, from 1. 013 to 1.022. Digitized by Microsoft® 6 DIAGNOSIS BY THE URINE. Summer urine has a general average of 1.023, and varies, according to the quantity of water passed, from 1. 01 7 to 1.030. The urine, too, of children shows very different Fig. I. — Urinometer. specific gravities in health and disease from that of the adult; and, in the experience of the writer, has a normal specific gravity in winter varying from 1.008 to 1. 012, and in summer, from 1.012 to 1.017. The water solids and urea will be found one-third Digitized by Microsoft® PHYSICAL CHARACTERISTICS IN HEALTH. 7 less than in the adult; therefore calculations made as to the normal and relative absolutes of solids and urea, as indicating a state of health or disease, must ■be made with this understanding. In my experience, also, the urine of old men and old women shows a corresponding similarity to that of very young persons. The specific gravity is most easily obtained by means of the urinometer, as follows: Fill a small standing glass cylinder four-fifths full of the urine, remove all froth by means of filter-paper, and place in cylinder the urine float (hydrometer) — do not allow the float to touch sides — and read depth to which hydrometer sinks; the number so found, if the urine has temperature of 60° to 62° F., represents the specific gravity. If the temperature is above or below, wait until it becomes 60° or 62°, and then make your observations.* From the specific gravity we can approximately, and for all usual clinical purposes, calculate the solids excreted in the twenty-four hours. The rule is as follows: Multiply the decimal of the specific gravity by 2.33 and the result will represent the weight of solids contained in 1000 c.c. of urine; hence we can, if we have the quantity of urine passed in twenty-four hours, estimate the weight of solids contained in the ♦Hydrometers carrying temperature-chart on them can be pro- cured of Messrs. Eimer & Amend, of New York. Digitized by Microsoft® 8 DIAGNOSIS BY THE URINE. whole. For example, patient passed 3000 c.c. of urine of specific gravity 1.015; therefore 15 X 2.33 = 34.95 grams of solids contained in 1000 c.c. Conse- quently, to arrive at amount in 3000 c.c. we say: - 1000 : 3000 : : 34.95 : x X = 104.85 gm. If a more accurate determination of the solid matter is desired, the same is readily attained by evaporating a definite quantity of urine on the water-bath, drying at 212° F. the residue thus obtained, and then, by means of the chemic balance, ascertaining its weight. CONSISTENCE. Normal urine is a thin and easily dropping fluid, and only becomes viscid when it has undergone or is under- going some pathologic change. It foams on being shaken, but the same subsides and vanishes very soon after; if, however, it contains sugar or albumin, the foam remains for a long time. COLOR. The color of normal urine is a bright amber or sherry- wine yellow if the entire quantity for the twenty- four hours (1500 c.c.) is taken; if not, the color varies in consequence to the time of day taken — on rising in the morning it is darker, and during the day, and particularly after dinner, the tint is less strong. Digitized by Microsoft® PHYSICIAL CHARACTERISTICS IN HEALTH. 9 TRANSPARENCY AND ODOR. Normal urine is always clear and transparent, and shows, on standing, a cloud of mucus; this mucus is only mechanically suspended in the urine, and not in any wise dissolved; the odor is sharp and slightly aromatic, and its cause is at present unknown. REACTION. The reaction of normal urine for the twenty-four hours is slightly acid, the same being caused by the presence of acid phosphates of the alkalies. To deter- mine whether or not urine is acid, moisten a slip of blue litmus-paper with the secretion, and if it changes from blue to red, the urine is acid; should the urine show an excessive degree of acidity, it is a sign that the urine is passing from a normal state to an ab- normal one. Having now considered the general physical characteristics of normal urine, let us pass on to consider a deviation from these and note those points which mark the beginning of disease in the urinary organs. Digitized by Microsoft® CHAPTER II. DEVIATIONS IN THE PHYSICAL CHARACTERISTICS OF URINE IN DISEASE. AMOUNT. As has been previously said, the amount of urine passed in health in the twenty-four hours is about 1500 c.c, or say 50 fluidounces. If the quantity is much increased, and habitually so, we have a con- dition of things known as polyuria; if, on the other hand, it is much diminished, a condition known as oliguria ; and if entirely suppressed, anuria. Polyuria may be either physiologic or pathologic; in the first instance it is called urina potus (from excessive taking-in of fluids) , and in the second hydru- ria or diabetes. To make a differential diagnosis in these cases, the total quantity of solids passed in the twenty-four hours is requisite, so this brings me at once to the consideration of the deviations in specific gravity which constitute disease. SPECIFIC GRAVITY. The specific gravity of normal urine, as has been said, varies much, being in winter at times 1.013, 10 Digitized by Microsoft® PHYSICAL CHARACTERISTICS IN DISEASE. II and again 1.022, but averaging about 1.018. As in case, however, of the total quantity of urine passed in the twenty-four hours it was shown that an allow- ance, excessive or the reverse, to the amount of 500 c.c. must be made, so in the specific gravity a variation of a few degrees either way by itself indicates nothing; when, however, a urine habitually falls below the winter minimum, or goes above its maximum, it is an evidence in the first instance of a pathologic hydruria, and in the second of a condition known as polyuria. This latter condition is commonly called diabetes, and is of two kinds: Diabetes insipidus, where the solids are all increased, but no sugar is present; when sugar is found it is called diabetes mellitus. As examples of these different kinds of urine, I will say that in the first class of urines — the true pathologic hydrurias — we have a urine of low specific gravity, 1.002 or so, and large quantities of water, 4000 to 6000 c.c. On calculating the total solids, it will be found that they are much diminished, whereas the water is in a corresponding degree increased above the normal. In the second class of urines the hydrom- eter shows a specific gravity of 1.025 ^o i-030) ^i^d the quantity of water is also considerably increased, being 1500 c.c. to 2500 c.c. in the twenty-four hours. In these urines, if no sugar is found, the increase in solids is most surely due to excessive quantity of urea Digitized by Microsoft® 12 DIAGNOSIS BY THE URINE. or else to phosphoric acid. If the increase of solids is due to an increase of phosphates, it is called phos- phaturia; when, however, sugar is the cause of the increased specific gravity, it is called diabetes mellitus.* COLOR. Deviations in color mark the beginning of pathologic changes going on in the urinary organs. Colorless urines of low specific gravity and excessive increase of water — 4000 c.c. to 6000 c.c. — evidence a neurotic affection. Colorless urines, again, with habitual low specific gravity — i.oio to 1.005 — but not necessarily an increase of water, point to atrophy of the kidney as the probable cause; as the disease advances, how- ever, the water increases beyond the normal. Urines also appear dark yellow-red, bright garnet-red, dark brown, and greenish yellow. The color in dark yellow-red urines is due either to blood or else to a coloring-matter called uroerythrin. As the con- sideration of the morbid constituents found in urine is taken up separately, together with the consideration of the other colors named, I will defer this until later on, and will consider urines colored garnet-red, as * A condition known as chyluria, and simulating phosphatic dia- betes, sometimes occurs; the urine here is thick and heavy, and ap- pears as a milky white hquid. It coagulates readily on being heated, as it contains much fibrin, and the coagulum does not dissolve on the addition of acetic acid, as would the phosphates; this reaction, there- fore, together with the presence of fat, renders the differential diag- nosis in these cases easy. Digitized by Microsoft® PHYSICAL CHARACTERISTICS IN DISEASE. 13 this color is generally due to foreign vegetable coloring- matters. Take three drains of clear urine (filter, if not clear) ; add to the same in a test-tube ten drops of nitric acid (strong), and boil for a minute; if the red is not due to pathologic changes in the urine the color will disappear, and on the addition of an alkali it will return, to be again dissolved when the urine is once more acidified by nitric acid and heated. TRANSPARENCY AND ODOR. Normal urine being clear and transparent, with only floating particles of mucus, a urine deviating much from this is an indication of disease in the uri- nary organs. To determine this, take a portion of the twenty-four hours' urine, place in a glass cylinder, and stand same on piece of white paper; by this we can determine not only the amount of floating matter in the urine, but also, from the same specimen, the color, specific gravity, odor, and reaction. If the urine by this procedure appears thick and cloudy, it may be due simply to an insufficiency of water, or else to morbid changes. To differentiate these con- ditions,, heat the urine in a test-tube, and if all dissolves, the turbidity was due to urates; if, on heating, instead of clearing up it becomes more turbid, add a few drops of acetic acid, and if it now clears up, it is an evi- dence that the urine was too concentrated, and there- fore the solids precipitated out. , Digitized by Microsoft® 14 DIAGNOSIS BY THE URINE. If, finally, the urine appears with the addition of acid and heat as it does without them, the turbidity is surely due to bladder or kidney detritus, and may therefrom be taken as an indication of disease. REACTION. Normal human urine shows in the twenty-four hours' urine a slightly acid reaction; if, however, the urine is taken at different periods of the day, it will be found that the acidity varies. Shortly after a meal the urine is slightly alkaline, but after a while it again rights itself. If the urine shows too decided an acid reaction it is abnormal, and marks either an excessive quantity of uric acid present or else an acid condition of the urine caused by free acid. This latter condition is easily determined by taking three drams of the twenty-four hours' urine (clear; and, if not, filtered so as to make it so), placing it in a test-tube, and pouring into it one-half the quantity of a strong solution of the hyposulphite of sodium. If free acid be present, a turbidity immediately forms whose density is in proportion to the quantity of acid present. This reaction is caused by the precipitation of sulphur, the free acid having united with the sodium of the salt. The reaction, again, of urine may deviate in the opposite direction, constituting an alkaline urine, and therefore indicating disease. There are two Digitized by Microsoft® PHYSICAL CHARACTERISTICS IN DISEASE. 1 5 ways in which the urine may become alkaline, and it is very important, from a clinical standpoint, to name and understand them. The first is from fixed alkali and the second from volatile (carbonate of ammonia). Both forms of alkaline urine change red litmus- paper to blue on being moistened; but in the case of fixed alkali, litmus-paper, on being dried, does not regain its red color, whereas in the case of urine rendered alkaline from volatile alkali, the red litmus- paper regains its color on being dried. Urine showing the presence of volatile alkali is always an evidence of disease (inflammation) of some part of the genito- urinary apparatus. If there be both fixed and volatile alkali present in the urine, the above test will give a negative result; so important, however, is it for us to know whether or not volatile alkali is present, and therefore if in- flammation is to be excluded, that we proceed as follows: Place loo c.c. of the urine in a glass flask, to which is fitted a cork; on inserting the cork, allow a slip of moistened red litmus-paper to be placed against its side and extending down into the flask, but not reaching into the urine; heat the flask gently (do not boil), and if any carbonate of ammonia is present, the red litmus-paper will immediately turn blue. I suppose it is needless for me to caution that this test must always be applied to fresh urine. Digitized by Microsoft® 1 6 DIAGNOSIS BY THE URINE. Urines alkaline from fixed alkali generally effer- vesce on the addition of an acid, and though not indicating any particular derangement of the kidneys, are usually met with in enfeebled conditions of the body in which the respiratory act is performed with difficulty, and thus carbonic acid is allowed to accu- mulate in the system; also whenever the bile is dimin- ished, or when there is a tendency to fermentative changes in the stomach or intestines. The dyspepsia which accompanies this kind of urine is attended with great depression of spirit; flatulence is marked, the bowels confined, and the skin dark and sallow, showing evident derangement of the liver. Digitized by Microsoft® CHAPTER III. DEVIATIONS IN THE NORMAL CHEMIC COMPO- SITION OF URINE IN DISEASE. UREA. From a clinical standpoint, of all the normal con- stituents found in human urine we need only consider urea, uric acid, chlorids, and phosphates of the alkalies and alkaline earths. Urea is the main solid which is passed in the urine, and averages from thirty to thirty-five grams (460 to 540 grs.) in the twenty-four hours. It is a diureid, and has the formula C0N,H4. The quantity of urea excreted from the body in the twenty-four hours is much influenced by: (i) The amount of nitrogenous food supplied the system; (2) amount of active exercise taken during the day; and (3) the quantity of water drunk. If the three indications are all met, then urea increases very much in the urine. If, however, the amount increases and the three conditions mentioned are not given, why then the increase is an approximate evidence of the waste of the system. This takes place in all fevers and wasting diseases, and as long as the liver and Digitized by Microsoft® 1 8 DIAGNOSIS BY THE URINE. kidneys remain intact, the former to manufacture and the latter to convey away retrograde tissue prod- ucts, why then the estimate from day to day of the urea in the urine will be a pretty fair approximate estimate of the wearing away of tissue, and conse- quently of the loss of vital force. When urea under the before mentioned conditions instead of being increased, is found to have decreased, it is then an evidence of either a diseased condition of the liver or kidneys. It is surprising to see, however, how low the urea finally runs in some cases before the fatal hour arrives. I have notes of a case treated for two months, and on no occasion during this time was there more passed than 13.52 grams in the twenty- four hours. We can safely say, therefore, that when urea in the urine of the twenty-four hours habitually falls below twenty grams in the case of an adult of active pursuits and well-nourished body, we should suspect disease of the liver or else of the kidneys. ESTIMATION OF UREA. The manner in which the estimation of urea is made is very simple and sufficiently accurate for cHnical purposes. It is founded on the decom- position of urea by the action of such an agent as the hypobromite of soda: H4CON2 + sNaBrO = Nj -|- CO2 -|- 2H2O -|- 3NaBr. The results would be a little low if urine contained Digitized by Microsoft® ABNORMAL CHEMIC COMPOSITION IN DISEASE. 19 urea alone, but since we find in it also uric acid, urates, and kreatinin, these, in giving up their nitrogen, make up for the loss, and thus nicely counterbalance this source of error. The manipulatibn of the process is as follows: We advise for use the most excellent Fig. 2. — Ureometer of Dr. Doremus. ureometer designed by Dr. Charles Doremus, of New York, to whom, allow me to say, the profession owes a debt of gratitude for making so simple a proc- ess which has heretofore been so the reverse. These ureo meters are graduated according to the French and English systems, respectively: the manipulation ° ■' Digitiied b/MicrosoM ^ 20 DIAGNOSIS BY THE URINE. with either is the same, but the calculations being different, I deem it best to describe the procedure with each. 1. Make a solution of sodium hydrate, loo grams to 250 c.c. of distilled water. Keep this in bottle with rubber stopper. 2. Make solution of hypobromite by adding one c.c. of bromin to ten c.c. of sodium hydrate solution and diluting with ten c.c. of distilled water. It is convenient, instead of making this solution previously (which does not keep long), to pour directly into the ureometer the sodium hydrate solu- tion until the liquid rises to the mark " =," which is on each ureometer; by means, now, of a little nipple pipette, which goes with each set, measure out one c.c. of bromin, add this to the hydrate solution, and, after the bromin has all gone into solution, dilute by pouring in water so as to fill the long arm and bend of the ureometer; see, now, that the instrument is full, and thoroughly luted at the bend in the arm — ^which is easily attained by tilting and then raising again until all air has been expelled — and you have a thorough and complete mixture. The instrument is now in condition for your test, and the remarks made are true for the English as well as for the French instrument I am describing. Draw up by means of the pipette one c.c. of urine to be tested; if the urine contains much albumin, Digitized by Microsoft® ABNORMAL CHEMIC COMPOSITION IN DISEASE. 21 free it of the same by heating, but not boiling; if the quantity, however, is small, disregard it, and pass the pipette into the ureometer as far as the bend, and compress the rubber on end of pipette, thereby causing urine to ascend in hypobromite slowly; on so doing, there is great disengagement of gas (carbonic acid and nitrogen), and after the disturbance is over and several minutes are allowed to elapse, the volume of nitrogen may be read, as the column of liquid in the ureometer will be depressed just in proportion to the quantity of evolved gas, the carbonic acid gas being all absorbed by the hydrate of sodium. Each division mark on the ureometer indicates o.ooi gram of urea in one c.c. of urine. The quantity, therefore, of urea voided in the twenty-four hours is ascertained by multiplying the result of the test by the number of cubic centimeters of urine passed during that period. When the English ureometer is used — divided, as it is, into grains — ^the solutions are prepared and calculation made as follows: 1. Make a solution of sodium hydrate, six ounces to the pint of distilled water; keep this in a bottle with rubber stopper. 2. Make solution of hypobromite of sodium as previously described, and proceed exactly in the same way with the urine, etc. Each division on this ureometer indicates one grain of urea in one fluidounce of urine; the quantity. Digitized by Microsoft® 22 DIAGNOSIS BY THE URINE. therefore, of urea voided, in the twenty-four hours is ascertained by multiplying the result of the test by the number of ounces of urine passed during that period. URIC ACID. Uric acid is found only in small quantity in human urine, and when occurring in excessive amounts, its great insolubility in water causes it at once to crystal- lize out. This, unfortunately, frequently takes place in the kidneys, and thus concretions are lodged there which form foci of irritation, and finally, if allowed to continue, eventuate in one or other of the chronic forms of nephritis. Uric acid, also in union with sodium, potassium, and calcium, is often found in large quantities in urine, principally, we may say, in the beginning of fevers and in all conditions in which the system is subjected either to a higher temperature for a short time, or else to a lower temperature for a longer period. Along with these urates is precipitated a coloring- matter, called uroerythrin; this coloring-matter is red, and gives to uric acid and urate deposits a rosy- red tint — the so-called brick-dust deposit, so often observed in the pot de chamhre in the morning. If this deposit habitually occurs in the urine of persons not suffering from fever, it is a sign that the liver is . at fault, and that the gouty or rheumatic gout Digitized by Microsoft® ABNORMAL CHEMIC COMPOSITION IN DISEASE. 23 diathesis is being established. The presence of uroerythrin, uric acid, and urates is most easily ascer- tained. If these are present, the urine will be turbid, the Fig. 3. — Forms of Uric-acid Crystals. J.. Rhombic plates, ij. Whetstone forms. 3. Quadrate forms. 4,5, Prolonged into points. 6, 8. Rosettes. 7. Pointed bundles. 9. Barrel forms precipitated by added hydrochloric acid to urates will clear up on being heated, and the uric acid will be dissolved if to the sediment is added an alkali. To determine the presence of uroerythrin, take three drams of urine, place in a test-tube, add Digitized by Microsoft® 24 DIAGNOSIS BY THE URINE. one to three drops of a solution of the acetate of lead, and if it is present, a precipitate of a rosy pink (flesh colored) will immediately fall. When uric acid occurs in abnormal amounts, it will be found, if the case is one of true lithe mia, that all the other solids are diminished; this state of things points strongly to grave diseases of the liver, acute yellow atrophy, cirrhosis, and cancer. If the urine for the twenty- four hours is near the normal amount, and uric acid crystallizes out a short time after standing, it is in abnormal quantity. Its detection is readily made in the following manner: Filter, if the urine is not clear, loo c.c; acidify with ten c.c. of strong hydro- chloric acid, allow it to stand, and after twelve hours uric acid will be found crystallized, and can be verified by either the microscope or else by the murexid test, which is performed as follows: Take a few of the crystals; place on a watch-glass, add a few drops of nitric acid, and apply heat gently; after thus attain- ing solution of the uric acid, dry carefully over the flame, and to the dry and cool mass add a few drops of ammonia; if the crystals be uric acid, a most magnificent purple color will rapidly spread over the touched mass. Digitized by Microsoft® ABNORMAL CHEMIC COMPOSITION IN DISEASE. 25 ESTIMATION OF URIC ACID, BY RUHEMANN'S IODINE METHOD. This process has been somewhat criticized in regard to its absolute ac- curacy, but we may add, it gives at times absolutely accurate results and at all times quite near enough the truth when linked with the ease of execution, to make it, in our opinion, of great service to the clinician. Ruhemann's uricometer is to be recommended and his reagent solution consists of iodine 1.5 grams, potassium iodid 1.5 grams, and 15 grams of absolute alcohol in 185 c.c. of water. Carbon bisulphid is made to fill the instrument to the first line marked S, and on this is placed by means of a pipette the reagent solution until it stands on the next mark, I, on the instrument. The urine, now brought to the temperature of 65° Fahrenheit, is run in by pipette until it stands at the lower part of the graduated scale marked 2.45. The open end of the uricometer is now closed by the glass Digitized by Microsoft® Fig. 4. Ruhe- mann's Uricometer.