CORNELL UNIVERSITY 
 
 THE 
 
 ?ffIomcr iletmnaty Sltbtrarg 
 
 FOUNDED BY 
 
 ROSWELL P. FLOWER 
 
 for the use of the 
 Y. STATE VETERINARY COLLEGE 
 
 1897 
 
 1897 "'" " ^"'-'~'- 
 
Ji *Myj3J 
 
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 http://www.archive.org/details/cu31924104224963 
 
CORNELL UNIVERSITY LIBIWRY 
 
 3 f924^'"'T04'''224''963 
 
SCALE OF URINARY COLORS, ACCORDING TO VOGEL. 
 
 Pale Yellow. 
 
 Light Yellow. 
 
 III. 
 Yellow. 
 
 IV. 
 
 Reddish Yellow. 
 
 V. 
 
 Yellowish Red. 
 
 VI. 
 
 Red 
 
 VII. 
 
 Brownish Red. 
 
 vni. 
 Re.'dish Brown. 
 
 IX. 
 
 Brownish Black. 
 
 CI IC; GO f HOIO-Er.G. CO., 
 
MANUAL 
 
 OP 
 
 URINARY ANALYSIS 
 
 CONTAINING 
 
 A SYSTEMATIC COURSE IN DIDACTIC AND 
 
 LABORATORY INSTRUCTION 
 
 FOR STUDENTS 
 
 TOGETHER "WITH 
 
 REFERENCE TABLES AND CLINICAL DATA 
 FOR PRACTITIONERS 
 
 BY 
 
 CLIFFORD MITCHELL, A.B., M. D. 
 
 PROFESSOR OF RENAL DISEASES IN THE CHICAGO 
 HOMCEOPATHIC MEDICAL COLLEGE 
 
 THIRD EDITION 
 II<I,USTRATED 
 
 PHILADELPHIA 
 
 BOERICKE & TAFEL 
 1902 
 
 T 
 
J 5 
 
 Ko-i-\<^ 
 
 X 
 
 COPYRIGHTED 
 BY 
 
 BOERICKE & TAFBL, 
 1902. 
 
MANUAL 
 
 OF 
 
 URINARY ANALYSIS 
 
 MITCHELL 
 
PREFACE. 
 
 THE object of this book is to provide the medical student and 
 the practitioner with a practical, accurate, and reliable 
 method for examination of the urine. The chemical and micro- 
 scopical operations described have been repeatedly verified by the 
 author, and nothing of this kind is commended which has not 
 stood the test of personal investigation and demonstration. The 
 book is original in the sense that unverified quotations from the 
 writings of others have been made but to a very limited extent, 
 and the clinical matter it contains is, for the most part, based on 
 the result of some three thousand examinations, made by the 
 author, of the twenty-four hours' urine. 
 
 Complete analyses of the twenty-four hours' urine are given in 
 many cases in which death, post-mortem examination, or surgical 
 operation during life, confirmed the diagnosis and prognosis pre- 
 viously made, based upon the urinary analysis. Results, also, of 
 a large number of analyses of the urine in various nervous dis- 
 eases are given, together with tables of differential diagnosis in 
 Bright's disease, hematuria, pyuria, diabetes, and other maladies 
 
 At the request of a number of physicians in the West, and in 
 accordance with my own desire, I have included in this volume 
 the notes on diagnosis by the microscope which I took, not long 
 since, in my course with Dr. Charles Heitzmann, of New York 
 Cuts of the slides which I obtained from him are also shown. 
 
 CM. 
 
 70 State Street, Chicaoo, 
 
 June, 1897, 
 
TABLE OF CONTENTS. 
 
 CHAPTER I. PAGE 
 Collection of the Twenty-four hours' Urine 21 
 
 CHAPTER II. 
 Significance of the Various Physical Cnaracteristics of Urine. 88 
 
 CHAPTER III. 
 The Reaction, Appearance, Consistency and Odor of Urine, 
 and their Significance 37 
 
 CHAPTER IV. 
 Clinical Significance of the Color of Urine 43 
 
 CHAPTER V. 
 Exercises in Physical Characteristics 48 
 
 CHAPTER VI. 
 Normal Constituents o£ Urine; Urea 54 
 
 CHAPTER VII. 
 Properties and Reactions of Urea 59 
 
 CHAPTER VIII. 
 The Determination of Urea 64 
 
 CHAPTER IX. 
 Urea: Physiology, Pathology, and Clinical Significance 71 
 
 CHAPTER X. 
 Pathology and Clinical Significance of Urea 78 
 
 CHAPTER XI. 
 Chemistry of Uric Acid 85 
 
 CHAPTER XII. 
 Physiology of Uric Acid 98 
 
 CHAPTER XIII. 
 Pathology of Uric Acid 98 
 
 CHAPTER XIV. 
 Substances Related to Uric Acid, Xantliins 104 
 
 CHAPTER XV. 
 Aromatic Compounds in the Urine, Ethereal Sulphates 109 
 
TABLE OF CONTENTS. 
 
 CHAPTER XVI. PAGE 
 
 The Aromatic Compounds (concluded) ..... 116 
 
 CHAPTER XVII. 
 Normal Urinary Coloring Matters and Cliromogens 122 
 
 CHAPTER XVIII. 
 The Non- nitrogenous Organic Acids of Normal Urine 126 
 
 CHAPTER XIX. 
 Carbohydrates Normally Present in Urine 128 
 
 CHAPTEK XX. 
 Inorganic Normal Constituents of Urine 131 
 
 CHAPTER XXI. 
 Phosphates in Urine, Pathology and Clinical Significance 140 
 
 CHAPTER XXII, 
 Chlorides in the Urine _ 151 
 
 CHAPTER XXIII. 
 Inorganic jSulphates in the Urine.— 157 
 
 CHAPTER XXIV. 
 Proteids: Abnormal Constituents of Urine 162 
 
 CHAPTER XXV. 
 Clinical Test for Serum-albumin 164 
 
 CHAPTER XXVI. 
 Life-insurance Tests for Albumin 168 
 
 CHAPTER XXVII. 
 Life-insurance Tests (continued) 174 
 
 CHAPTER XXVIII. 
 Life-insurance Tests (continued) 178 
 
 CHAPTER XXIX. 
 Miscellaneous Tests for Albumin 181 
 
 CHAPTER XXX. 
 Quantitative Determination of Albumin in the Urine 184 
 
 CHAPTER XXXL 
 Clinical SigDificance of Albuminuria 189 
 
 CHAPTER XXXII. 
 Proteids (continued) _ 193 
 
 CHAPTER XXXIII. 
 Sugar in the Urine gQ^^ 
 
 CHAPTER XXXiy. 
 Life insurance Tests for Sugar n^n 
 
TABLE OF CONTENT.-i. 
 
 CHAPTER XXXV. page 
 Delicate Tests for Sugar 317 
 
 CHAPTER XXXVI. 
 Quantitative Determination of Sugar 220 
 
 CHAPTER XXXVn. 
 Clinical Significance of GlycdsuriH 228 
 
 CHAPTER XXXVIII. 
 Acetone and Allied Substances 232 
 
 CHAPTER XXXIX. 
 Abnormal Coloring Matters in Urini^. Bile 236 
 
 CHAPTER XL. 
 Animal Bases in Urine. Toxicity of Urine 245 
 
 CHAPTER XLI. 
 Urinary Sediments, Chemical Examination . 253 
 
 CHAPTER XLII. 
 Microscopical Examination of Urine, Acid Urine 257 
 
 CHAPTER XLIII. 
 Sediments Found in Alkaline Urine 273 
 
 CHAPTER XLIV. 
 Sediments of Infrequent Occurrence 285 
 
 CHAPTER XLV. 
 Anatomical Sediments, Blood Corpuscles 289 
 
 CHAPTER XL VI. 
 Pus Corpuscles in the Urine 294 
 
 CHAPTER XL VII. 
 Epithelium in Urine 299 
 
 CHAPTER XLVIH. 
 Tube-casts in the Urine 303 
 
 CHAPTER XLIX. 
 Spermatozoa, Connective-tissue, Micro-organisms, Parasites.. 314 
 
 CHAPTER L. 
 The Urinf and Characteristic Symptoms of Diseases of the 
 Kidneys 818 
 
URINARY ANALYSIS. 
 
 CHAPTEE I. 
 
 COLLECTION OF THE TWENTY-FOUR HOURS' URINE. 
 
 Modern examination of urine requires the whole 
 quantity for twenty-four hours, which should be col- 
 lected day and night separately. By night urine is 
 meant only the urine voided after going to bed, and 
 including what is voided on rising in the morning. 
 All other urine is day urine. Patients should void 
 urine hefore going to stool to avoid loss. It is best to 
 begin the collection of the twenty-four hours' urine 
 just after breakfast. Clean, wide-mouthed bottles or 
 glass pitchers should be used for receiving purposes. 
 (Figs. 1 and 2). After the urine is collected, the vol- 
 ume of the day and that of the night should be meas- 
 ured separately in a graduate (Fig. 3), and the quan- 
 tity of each noted down, the two figures added, and 
 the urine mixed. 
 
 Fig. 1. Wide- Fio. 3. Neckless Pig. 3. Gradu- 
 
 mouthed quart glass pitcher for ate for measur- 
 
 bottle for re- receiving urine. ing quantity of 
 
 ceiving urine. urine. 
 
 Quantity of urine normal for twenty-four hours:— 
 
 For liealthy men, 40 to 50 fluidounces, at most; 30 to 40 for 
 women; 10 for children under 3 years of age; 10 to 30 when from 
 3 to 6 or 8 years; 30 to 80 between 8 and 13. (Sixteen fluidounces 
 make one pint, and 39.53 cubic centimeters, or approximately 30, 
 one fluidounce). 
 
33 URINARY ANALYSIS. 
 
 The normal ratio of day urine to night: — 
 
 The healthy person voids three times as much day 
 urine as night. If, however, he drinks freely before 
 going to bed the quantity of night urine wiil be greater ; 
 so also if the sleeping hours are long. JBui, as a rule, 
 when the quantity of night urine persistently equals or 
 exceeds the day, cardiac or renal disease is present 
 The writer has noticed this equality of day urine and 
 night in chronic myelitis also. 
 
 The object of collecting 
 
 The twenty-four hours' urine is to compare day with 
 night, to compare the total with normal average 
 standards, to observe the physical characteristics, and 
 to make quantitative estimates of the solids, as urea, 
 phosphoric acid, uric acid, together with albumin and 
 sugar, if either of the latter is present. In addition 
 to the twenty-four hours' urine we must have a sample 
 of wc'me freshly voided, passed, if possible, in presence 
 of the physician, for purposes of microscopical exam- 
 ination. Women should take cleansing vaginal injec- 
 tion or tampon the vagina before passing, urine for 
 such microscopical examination. The reason of the 
 latter precaution is that otherwise vaginal fluids may 
 be mixed with urine, and the sediment of the urine be 
 largely composed of matters from the vagina. 
 
 In order to preserve the specimen of freshly voided 
 urine, add at once ten grains of chloral hydrate, or a 
 few drops of a solution of chromic acid, strength one- 
 half of one per cent. Then set it aside for at least six 
 hours, until the sediment has settled, or settle, it in the 
 centrifuge. 
 
 Moreover, in cases where albumin in small quanti- 
 ties is for any reason suspected, but not found in the 
 twenty-four hours' mixed urine, the patient's urine 
 should be examined four times, viz. : (1) that passed 
 on rising, (2) at noon, (3) at six o'clock p. m., and 
 (4) as late as possible at night before going to bed. 
 If sugar is suspected, but not found in the twenty- 
 four hours' mixed urine, be sure to test the urine 
 
TWENTY-FOUR HOURS' URINE. 23 
 
 voided at different times in the day, and especially in 
 the afternoon. 
 
 The apparatus required for the collection and 
 measurement of the twenty-four hours' urine is as 
 follows : 
 
 Two clean "wide-mouthed" quart bottles with 
 labels and clean corks. 
 
 One small, clean, say eight-ounce, wide-mouthed 
 bottle and clean cork. 
 
 If wide-mouthed bottles are cot to be had, get 
 ordinary clean bottles, and a glass funnel. Let the 
 patient urinate either directly into the funnel resting 
 in the neck of the bottle, or else use a quart glass 
 pitcher (suitable ones may be had at an expense of 25 
 to 50 cents) for receiving the voided urine. 
 
 One graduated jar, holding thirty -two fluid ounces, 
 graduated also in pints and cubic centimeters. These 
 can be had of the dealers in chemical apparatus at a 
 cost of $2.25 or thereabouts. 
 
 For comparisons witb normal averages see tables in 
 Appendix. 
 
 [For microscopical examination of the sediment it is 
 always well to have as concentrated a sample of urine 
 as possible. Dark-colored urine is likely to have more 
 sediment in it than pale, watery urine.] 
 
 REFERENCE TABLE l.» 
 Qnantity of Urine per 24 Hours. 
 
 A. Quantity somewliat less than 48 ounces.— 1. Not uncom- 
 mon no- mally, and esppcially in women. 2. Noi-mal in children 
 under fifteen. 3. Mav I le due to (a) vigorous perspiration; (6) hot 
 weather; (c) rest; (d) abstention from fluids; (e) copious passages 
 from the bowels. 
 
 B. Quantity considerably less than 48 ounces.— 1. In all dis- 
 eases except tlie six or seven mentioned below. 2. In acute dis- 
 eases, daily diminution of the urine means increase in the inten- 
 sity of the disease. 8. As dropsy increases, urine may diminish. 
 4. May be due to ingestion of mineral salts, as those of iron and 
 copper; poisoning from external use of pyrogallic acid or aniline 
 compounds; from atropine as a collyrium. 5. May be due to 
 copious vomiting, or abundant watery stools. 
 
 C. Urine scanty or suppressed.— 1. In all types of violent 
 
 * The Reference Tables are for advanced students and prac- 
 titioners. 
 
24 URINARY ANALYSIS. 
 
 fever and inflammation, as scarlatinal nephritis, yellow fever, 
 collapse of cholera. 3. In late stages of chronic nephritis. 8. 
 Shock or collapse from internal injuries; reflex shock from 
 catheterization; administration of chloroform and ether. 4. 
 Poisoning by potassium chlorate, phosphorus, cantharides, 
 arsenic, carbolic acid, ergot, iodine, mercury, opium. 6. In cir- 
 rhosis ot the liver and in scurvy. 
 
 D. Qnantity more than three pints.— 1. Ingestion of 
 large quantities of food or drink, especially beer. 2. In cold 
 weather. 3. Due to diuretic drugs, as acetate of potassium, 
 lithium benzoate and citrate, diuretin, spirit of nitrous ether. 
 4. Due to inhalation of oxygen. 5. In diabetes, interstitial 
 nephritis, lardaceous disease of the kidneys, pure cardiac hyper- 
 trophy, some cases of ch'ronic pyelitis; temporarily, in hysteria, 
 and convulsions. 6. In convalescence from severe Ulness in 
 which the urine has been decreased. 7. In typhus at the height 
 of the disease, sometimes; in cerebro-spinal fever, sometimes; in 
 some cases of rheumatism. 8. In cases of neurasthenia. 
 
 BEPEBENCE TABLE 2. 
 The Quantity of Urine in Bri^ht's Disease. 
 
 A. Diminished: — In acute nephritis, in chronic (diffuse) ne- 
 phritis, in chronic congestions, in acute intercurrent attacks of 
 chronic nephritis, in last stages of all forms. 
 
 B. Increased: — In chronic interstitial nephritis, in lardaceous 
 diseases of the kidneys, after reduction of dropsy in chronic dif- 
 fuse nephritis, in convalescence from acute scarlatinal nephritis. 
 
 CLINICAL NOTES. 
 
 1. Polyuria in neurasthenia has been observed by 
 the author in a number of cases. Ohas. L. Dana says : 
 "Neurasthenics of middle age often pass enormous 
 amounts of urine of low specific gravity." 
 
 2. I am of the opinion that 60 (1,500 c.c.) ounces 
 is above the normal average voided by Americans. 
 In 1,300 specimens of the twenty-four hours' urine, 
 records of which I have recently gone over, more than 
 1,000 were less than 60 ounces (1,500 c.c.) in 
 volume. 
 
 3. Vimination in the quantity of urine during or 
 after an attack of urinary fever (called, also, urethral 
 fever) is a bad sign and means suppression of urine 
 and death. 
 
 4. After surgical operations, in general, on the 
 urinary tract, if the volume of urine is good the great- 
 
TWENTY-FOUR HOURS' URINE. 85 
 
 est danger is averted, but when not a drop is secreted 
 for a considerable period the case is usually fatal. 
 
 5. It is said that the time of maximum secretion of 
 urine is from 2 to 4 p. m., and the minimum from 2 
 
 to 4 A. M. 
 
 6. Dr. Howard A. Kelly, after numerous ureteral 
 catheterizations, calculates that each kidney secretes 
 about half a c.c. per minute, a total of 60 o.c. per 
 hour. The urine flows into the bladder in gushes at 
 intervals of 10 or 15 or 30 seconds. 
 
 CHEMICAL EXERCISE 1. 
 
 1. The student should collect his twenty-four hours' 
 urine, according to directions given, day and night 
 sejjarately, bring it to the laboratory, and measure it 
 in the graduates. He should be required to express 
 the results in both French and American measures, 
 consulting Table 1 in Appendix. 
 
 For Example: 
 
 Day urine, 900 cubic centimeters, or 30 fluidounces. 
 
 Nitrht urine, 300 cubic centimeters, or 10 fluidounces. 
 
 By use of Table 1, Appendix, the conver-sion of cubic centime- 
 ters into fluidounces is easily acooinplii-hed, the fluidounces be- 
 ing in the first column of figures to the left, and the cubic centi- 
 meters corresponding in the second column. Take the nearest 
 figure. For example, if it be required to convert 900 cubic centi- 
 meters into fluidounces, run the eye down columns 3 and 5, and 
 pick out the nearest figure to 900. It is found in column 3, 
 namely, 885. The number of fluidounces corresponding is found 
 in the same line in column 1, namely, 39.5, or 30 in round num- 
 bers. To convert 300 c.c. pick out 375 in column 5. and find 9.16 
 fluidounces corresponding, or in round numbers 10, since 375 ia 
 considerably less tlian 300. 
 
 [The division into separate sets of figures for male and for 
 female patients is entirely for comparison vrith normal averages, 
 and either set may be used for conversion, since 39.53 o.c. equals 
 one fluidounce, regardless of sex.] 
 
 2. Having measured the quantity of day urine and 
 of wip'A^ urine, and expressed each in cubic centimeters 
 and in fluidounces, next find the relation of the quan- 
 tity of day urine to that of night, by dividing the fig- 
 ure representing the quantity of day urine by that of 
 the night. In the case above 900 divided by 300 
 equals 3. In other words, the day urine in this case 
 is three times the night urine. In scientific language 
 this is expressed as follows : the ratio of the quantity 
 
26 URINARY ANALYSIS. 
 
 of day urine to night is as 3 to 1 ; or, briefly, day 
 urine : night urine=3 : 1. 
 
 Next consult Table 8, Appendix, and ascertain 
 whether this ratio of 3 : 1 is normal or not, and if not, 
 in how much it differs from normal. In this table a 
 ratio of 3 or more to 1 is taken as normal, so in the 
 case above the day urine bears a normal ratio to the 
 night urine. Suppose, however, the daj'^ urine were 
 500 0. and the night urine 1,000 c.o. : — in this 
 case 500 divided by 1,000 equals 0.5. The ratio of 
 day urine to night is here as 0.5:1. Consulting 
 Table S, Appendix, and finding the nearest figure, find 
 0.45 to 1, which is said to be 15 per cent, of normal. 
 That is, assuming 3 or more to 1 as the normal ratio, 
 which we may indicate by the figure 100 (^. e. 100 
 percent, of normal equals normal itself), 0.5 to 1 would 
 bear the same relation to 3 : 1 as 15 to 100, hence we 
 say 0.5 to 1 is 15 per cent, of the normal. From this 
 we establish the following : — 
 
 Rule 1. Divide the quantity of day urine by tJie 
 quantity of night urine. Make a proportion thus: 
 Day urine : night equals quotient of day divided by 
 night :1. Find in Table ^, Appendix, the nearest 
 proportion to this, and set down the per cent, figure as 
 indicating the relation to normal in your case. 
 
 Next add the figure representing the quantity of 
 day urine to that representing the quantity of night 
 to get the total volume of urine passed in twenty-four 
 hours. In the case above 900 c.o. plus 300 c.c. 
 equals 1,200 c.c. or 40 fluid ounces. Now ascertain 
 by use of Table 1, Appendix, what relation to the 
 average normal quantity this total bears, keeping in 
 mind now for the first time the sex of the person. If 
 the person is a man, find the nearest figure to 1,200 
 in column 2, of Table 1. It is 1,225. Now find on 
 the same line in column 3, the figure 90. This means 
 that calling normal 100, the total urine in this case 
 may be represented by 90, or is, in other words, yO 
 per cent, of normal. Do not write 90 per cent, thus, 
 .90 per cent. Prefixing a decimal makes it 9-10 of 1 
 
TWENTY-FOUR HOURS' URINE. 37 
 
 per cent., a fact seemingly unknown to many students. 
 Suppose now the person is a female, who passes 1,200 
 CO. in 24 hours: — Looking in column 5, at the top 
 we find the highest figure 1,100 cc, but going down 
 to the ascending scale in column 5, we find 1,200 
 there, and to the right in the same line the figure 100, 
 or normal. 
 
 The reason of division into two scales, descending 
 and ascending, is that normal averages vary according 
 to nationality. The French observers, Tvon and 
 Berlioz, think 1,100 c.o. the average normal for 
 women, while the English make it 1,200. In other 
 words, women void 1,100-1,200 o.c. (37 to 40 ounces), 
 according to nationality. 
 
 My own statistics show that the French figures are 
 nearer right in case of Americans than are the English 
 figures. Out of 1,300 different persons where the 24 
 hours' urine was measured by the author, nearly 80 
 per cent, voided less than 48 fluidounces of urine. 
 
 4. Finally make out a report on work done as fol- 
 lows. 
 
 1. Name of person; 3. Sex; 3. Age; 4. Weight. 
 
 5. Day urine c.c fl. oz. 
 
 6. Night urine --- c.c fl. oz. 
 
 7. Ratio of day urine to night 
 
 8. What per cent, this ratio is of the normal ratio per cent. .... 
 
 9. Total volume of urine in 34 hours c.c fl. oz. 
 
 10. What per cent, of the normal average per sex this volume 
 is - per cent. 
 
 Mix the two samples of urine, day and night, pour- 
 ing to and fro, from one graduate to the other, down 
 the side of the glass, thus avoiding foam, and set the 
 whole aside for the next exercise. 
 
28 URINARY ANALYSIS. 
 
 CHAPTEE 11. 
 
 SIGNIFICANCE OF THE VARIOUS PHYSICAL 
 CHARACTERISTICS OF URINE. 
 
 The physical characteristics of urine, in addition to 
 the twenty-four hours' quantity, include the color, 
 odor, specific gravity, from which the total solids may 
 be computed when the quantity of urine is known, 
 reaction, appearance, co7isistency, and condition of 
 frothiness. 
 
 The color of the healthy filtered urine of twenty -four 
 hours is straw yellow. The color is due chiefly to col- 
 oring matters called urochrome and urobilin, the latter 
 a derivative of heraatin. See No. 3 on Vogel's Scale, 
 Frontispiece. 
 
 The odor of freshly voided urine, contrary to the 
 prevailing impression, is decidedly agreeable, and 
 called aromatic. The odor of the twenty-four hours' 
 urine is usually not unpleasant, though in the case of 
 women nearly always slightly pungent from decomposi- 
 tion of the mucus present in that part of the urine 
 which is oldest. The twenty-four hours' urine of men 
 is, in health, often of an aromatic odor, though some- 
 times this odor is lost, and a slight indescribable 
 pungency noticed. The taste is slightly alkaline or 
 bitter. 
 
 The specific gravity of the twenty-four hours' urine 
 is not, as formerly stated, 1015 to 1025, but, more 
 commonly, 1020 to 1025 in the healthy adult. 
 
 What do we mean by the figures 1015, 1020, etc.? 
 Urine is heavier than water, since it contains certain 
 salt-like solid matters, derived from the blood, dis- 
 solved in it. Every one knows that a pint of water 
 in which several ounces of salt are dissolved will 
 weigh more than another pint in which no salt is dis- 
 solved. Now, urine contains enough salt-like matters 
 
PEYSIOAL CHARACTERISTICS. 
 
 29 
 
 l9l 
 
 I 
 
 dissolved in it to make one pint of it weigh 1.020 to 
 1.025 times more than one pint of water of the same 
 temperature. In other words, a pint of urine will 
 weigh one and two-hundredths more than a pint of 
 pure water. "When this is the case we say the specifio 
 gravity of the urine is 1020, the decimal point being 
 omitted by general consent. 
 
 In order to find the specifio 
 gravity of a given sample of 
 urine we pour it into a tall 
 glass, and let a urinometer float 
 in it. Fresh urine should be 
 cooled to 77° F. before the spe- 
 cifio gravity is taken. The 
 cooling is best accomplished by 
 setting the fluted jar in cold 
 water. A urinometer is com- 
 posed of a graduated stem, a 
 central cylinder-like portion, 
 and a bulb at the bottom 
 weighted with mercury, the 
 whole so constructed that it 
 floats upright in water or other 
 liquids. In pure water it sinks 
 to the very top of its graduation, and this point where 
 it sinks in water is marked by the zero sign (0), in some 
 instruments, and 1000 in others. It is worth while to 
 know whether your instrument is graduated for use in 
 liquids of a temperature of 60° or those of 77° F. The 
 more modern American urinometers are standardized, 
 as it is called, at 77°, sinking to the zero of graduation 
 in distiUed water of 77° Fahrenheit temperature. The 
 urinometers commonly sold, while they may all sink 
 to the zero point in pure water, nevertheless will vary 
 among themselves considerably in liquids of a high 
 specific gravity, 1030 or upwards. 
 
 By the term total solids in urine is meant the 
 weight of all the normal solids dissolved in it. Ab- 
 normal constituents, as albumin, sugar, bile, blood, 
 etc., are not included in this category. 
 
 The most important normal solids are urea, com- 
 
 FiG 4.— Urinometer, 
 fluted jar, chemical ther- 
 mometer; for ascertaining 
 specific gravity of urine. 
 
30 URINARY ANALYSIS. 
 
 mon salt, the sulphates, phosphates, urates, kreatinine, 
 and hippuric acid, the average quantity of which per 
 twenty-four hours is shown in the following table: 
 
 Table I. 
 
 Constituent. Averaf?^ amount In 2t hours. 
 
 "Water, 40 to 50 fluid ounces. 1.200 to 1,500 c.c. 
 
 Urea, 310 to G15 grains, 20.0 to 40.0gramti 
 
 Urati-s, 6 '~ 
 
 Hippuric acid, 8 
 
 Kreatinine, - 8 
 
 Chlorides, ...155 
 
 Earthy phosphates, 15 
 
 Alkaline " 30 
 
 Sulphates, 45 
 
 The sum total of these various solids in the iirine of 
 a healthy adult male, weighing about 150 pounds, on 
 ordinary mixed diet, and taking ordinary exercise, 
 may be expressed as follows : 
 
 Urea,... ..- 500 grains. 
 
 Common salt, 250 " 
 
 Other solids, 250 " 
 
 12 
 
 0.4 " 
 
 0.8 
 
 15 
 
 0.5 " 
 
 1.0 
 
 20 
 
 0.5 " 
 
 1.3 
 
 245 
 
 ' 10.0 " 
 
 16.0 
 
 23 
 
 1.0 " 
 
 1.5 
 
 fiO 
 
 3.0 " 
 
 4.0 
 
 60 
 
 3.0 " 
 
 4.0 
 
 Total solids, 1,000 " 
 
 That is, urea represents about half the total solids 
 and common salt about one-quarter. 
 
 In my opinion these figures are maximum ones, and 
 much lower results may be obtained by analysis in the 
 case of perfectly healthy persons under certain circum- 
 stances of age, diet and exercise, as will be shown 
 further on. 
 
 The weight of tho total solids in urine, which 
 chemists obtain by evaporating the liquid to dryness 
 and weighing the solid residue, may, for clinical pur- 
 poses, be computed mathematically as follows : 
 
 1. Take the specific gravity of the twenty-four 
 hours' mixed urine; 
 
 2. Multiply the last two figures of the specific 
 grjivity by 2.33 (Haeser's coefficient); 
 
 3. Divide the product by 1,U00; 
 
 4. Multiply quotient by number of c. c. of urine voided 
 in 24 hours. Result is grammes of solid matter in the 
 24 hours' urine. 
 
PHYSICAL CHARACTERISTICS. 31 
 
 Now, in taking the specific gravity of the urine two 
 precautions must be observed : First the urinometer* 
 must be fairly accurate: second, the specific gravity 
 must be taken at the temperature at which the urin- 
 ometer is standardized. 
 
 Pour a sample of the twenty-four hours' urine into 
 the fluted jar ; set the latter in a glass of warm or 
 cold water; take the temperature of the urine with 
 the thermometer ; when it is 77° F. , remove the fluted 
 jar from the water and take the specific gravity at once. 
 
 I have not been able to draw any deductions what- 
 ever from our former method of comparing the total 
 solids estimated, as above, with some arbitrary normal 
 average, as 58 grammes. When nothing is known 
 about the patient, as is sometimes the case, we may 
 indeed guess at the amount of " renal insufficiency " 
 bv comparing the solids computed as above with 58 
 grammes (900 grains). But when the age, weight, 
 diet, and exercise of the patient are known, our ideas 
 of the relation of solids excreted by him compared to 
 the work his kidneys ought to do, are much better. 
 
 For example, take the following : twenty-four hours' 
 urine, 900 cubic centimeters (30 fluid-ounces) ; specific 
 gravity 1015. Total solids, 15 times 2^ times 900, 
 divided by 1000, equals 31^ grammes, or 488 grains. 
 Suppose the patient's condition be unknown. We 
 would say, in a general way, that his kidneys were 
 doing only half the work they ought to, since 488 is 
 about half of 900 to 1000 grains, which we assume 
 the normal excretion to be. But suppose the patient 
 was above 70 years of age, or, if between 20 and 40, 
 
 * There are two kinds of urinometers, fairly accurate ones, and 
 decidedly inaccurate ones. Those made by Squibb are recom- 
 mended as being accurate. I know from experience that if thirty 
 or forty urinometers are successively floated in tlie same urine at 
 the same temperature, the readings will vary very considerably. 
 I have known these variations in urines of high specific gravity, 
 1030 or upwards, to be as great as 8 or 10°. Urinometers are 
 standardized from chemical solutions, but solutions o( the same 
 strength of different chemicals give different readings with the 
 same urinometer. For example, 2 per c-nt. solutions of urea, 
 sodium carbonate, and potassium sulphate gave the writer specific 
 gravities of 1009, 1013, and 1017 respectively. Potassium sulphate 
 has no water of crystallization in its formula. 
 
83 UBINARY ANALYSIS. 
 
 weighed only 100 pounds, and was in bed on restricted 
 diet? It is evident that in either of these ca,ses we 
 might be seriously at fault in assuming renal insuffi- 
 ciency. In order to make deductions of any definite 
 value from the actual quantity of solids found, says 
 Dr. Purdy, careful regard must be paid to certain con- 
 ditions and features connected with each individual 
 case, the most prominent of which are the weight, 
 age, diet, and amount of exercise taken. Purdy's 
 rules for making reduction or addition for weight, age, 
 diet and exercise involve considerable figuring ; so I 
 have constructed a table, based on his rules, giving 
 reductions or additions for weight and age at a glance. 
 The normal average excretion of solids for a person 
 between 20 and 40 years of age, weighing 145 pounds, 
 on ordinary mixed diet and taking ordinary exercise, 
 is assumed to be 945 grains (61.14 grammes). On 
 this assumption the following table is constructed : 
 Table II. 
 
 
 
 VoxiulV EXCREnOHi 
 
 
 Weight. 
 
 
 
 
 Age 20 to 40. 
 
 Age 40 to 60. 
 
 Age 60 to 60. 
 
 Ae& 60 to 70. 
 
 Age above 70, 
 
 145 pounds.. 
 140 "^ '• . 
 
 6Xgnis.,945gre. 
 912 •• 
 
 55 gms., 880 grs. 
 820 " 
 
 i8gaa.,756gK. 
 
 42 gms., 660 grs. 
 CM " 
 
 30 gms., 473 grs. 
 466 " 
 
 135 '• , 
 
 878 " 
 
 790 " 
 
 702 " 
 
 608 " 
 
 439 " 
 
 130 " , 
 
 815 " 
 
 760 • 
 
 675 " 
 
 682 " 
 
 428 " 
 
 125 " , 
 
 812 " 
 
 730 " 
 
 649 " 
 
 556 " 
 
 •406 " 
 
 120 " I 
 
 780 " 
 
 702 " 
 
 624 " 
 
 530 " 
 
 890 " 
 
 115 " . 
 
 748 " 
 
 673 " 
 
 898 " 
 
 604 " 
 
 374 " 
 
 no " _ 
 
 715 " 
 
 644 " 
 
 672 " 
 
 478 " 
 
 8J7 " 
 
 105 " , 
 
 682 » 
 
 614 " 
 
 645 '• 
 
 4.52 " 
 
 841 " 
 
 100 " - 
 
 650 " 
 
 685 " 
 
 620 " 
 
 426 " 
 
 326 " 
 
 9.5 " : 
 
 618 '• 
 
 656 " 
 
 494 " 
 
 400 " 
 
 809 " 
 
 90 " . 
 
 685 " 
 
 526 '• 
 
 468 " 
 
 374 " 
 
 293 " 
 
 85 " , 
 
 652 " 
 
 497 " 
 
 442 " 
 
 848 " 
 
 276 " 
 
 80 ' , 
 
 620 " 
 
 468 " 
 
 416 " 
 
 822 " 
 
 260 " 
 
 76 •' » 
 
 488 " 
 
 439 " 
 
 390 " 
 
 296 " 
 
 244 " 
 
 TO • , 
 
 456 " 
 
 410 " 
 
 865 - 
 
 270 " 
 
 228 " 
 
 
 
 For weights al»ve.l45 pounds (aeMograms). 
 
 
 150 " . 
 
 97B " 
 
 880 " 
 
 782 " 
 
 685 " 
 
 489 " 
 
 I.i5 " . 
 
 1010 " 
 
 910 » 
 
 808 " 
 
 707 " 
 
 605 " 
 
 MO " _ 
 
 1012 " 
 
 938 " 
 
 8S3 " 
 
 ■729 " 
 
 621 " 
 
 165 " . 
 
 1074 " 
 
 967 " 
 
 859 " 
 
 761 " 
 
 586 " 
 
 no " . 
 
 1106 " 
 
 998 " 
 
 SSo " 
 
 773 ** 
 
 553 " 
 
 1-5 » . 
 
 1138 '• 
 
 1024 " 
 
 910 •■ 
 
 795 " 
 
 569 " 
 
 180 • . 
 
 1170 " 
 
 1063 " 
 
 9.% « 
 
 817 " 
 
 585 •• 
 
 185 " . 
 
 1202 " 
 
 1082 " 
 
 962 " 
 
 840 " 
 
 601 " 
 
 190 " . 
 
 1234 " 
 
 1110 " 
 
 988 "- 
 
 862 " 
 
 617 " 
 
 Ifti " . 
 
 1266 " 
 
 1140 ■• 
 
 1014 " 
 
 884 " 
 
 683 ' 
 
 200 .'• - 
 
 1298 " 
 
 1168 " 
 
 1040 " 
 
 907 ■' 
 
 649 " 
 
 205 '• . 
 
 1330 " 
 
 1197 " 
 
 3066 " 
 
 930 * 
 
 665 " 
 
 210 •• . 
 
 1362 " 
 
 1226 " 
 
 1092 " 
 
 952 " 
 
 681 " 
 
 215 '• . 
 
 1394 " 
 
 .1255 " 
 
 1118 " 
 
 973 " 
 
 697 " 
 
 220 '• . 
 
 1426 " 
 
 1284 " 
 
 1144 " 
 
 996 -■ 
 
 713 " 
 
 225 " 
 
 1168 " 
 
 1312 " 
 
 ll70 " 
 
 1020 <• 
 
 7-29 " 
 
PHYSICAL CHARACTERISTICS. 88 
 
 The preceding table, page 32, gives the normal 
 averages of total solids in the urine of persons on 
 ordinary diet, taking ordinary exercise. It represents 
 the mean of the combined observations of eight 
 writers. 
 
 The table gives corrections for age and weight only. 
 From these figures deduct 33 per cent, for fasting two 
 or more days, as in some fevers, or 12 to 16 per cent, 
 for a sparing diet, or 10 per cent, when the person is 
 not eating as freely as when in health. 
 
 Furthermore, deduct 10 per cent, if the person is in 
 bed, or 5 per cent, if confined merely to the house. 
 
 Examples illustrating the above : 
 
 1. Solids computed, 580 grains in the twenty-four 
 hours' urine. 
 
 Patient 35 years old; weight, 155 pounds; diet, 
 ordinary; exercise, ordinary. 
 
 Deduction. — A person 35 years old, weighing 155 
 pounds, should excrete (Table II.), on ordinary diet and 
 exercise, 1010 grains. The person in question excretes 
 530 grains. Therefore he or she is passing only about 
 half what should be excreted in twenty-four hours. 
 
 2. Solids computed, 530 grains in twenty-four 
 hours' urine. Patient 65 years old, weighs 140 
 pounds, eats sparingly, and is confined to the house. 
 
 Deduction. — A person 65 years old, weighing 140 
 pounds, should pass (Table II.) 634 grains of solids 
 when on ordinary diet and exercise. But as the diet 
 is sparing, dec; act from 12 to 16 per cent, of 684, say 
 90 grains ; 634 — 90 equals 544 grains. Still further, 
 deduct 5 per cent, from the figure last obtained since 
 the patient is confined to the house. Five per cent, of 
 544 is about 28 grains. Final figure, 544 — 28, or 
 about 515 grains. In other words, a person under 
 these circumstances should void about 515 grains of 
 solids in twenty-four hours. The amount computed is 
 530 grains. Therefore, he or she is passing just about 
 what would be expected under the conditions. 
 
 It goes without saying that a faulty urmometer will 
 cause considerable difference in results. 
 3 • 
 
84 URINARY ANALYSIS. 
 
 Example 3. — Urine in twenty-four hours, 1000 c.o. 
 (33 fl. ozs.); specific gravity by one urinometer, 
 1030; by another, 1022. 
 
 Patient weighs 175 pounds; age, 30; diet, hearty; 
 exercise, vigorous. By one urinometer, the first, he 
 is voiding 70 grammes (30 times 2^ times 1000, 
 divided by 1000), or 1085 grains. By the second 
 instrument he is voiding 51 grammes, or 890 grains. 
 A person of his age, weight, etc., should void at least 
 11.38 grains (Table II.). If the first urinometer is 
 correct, he is voiding only about 50 grains short of 
 what we should expect. If the second urinometer is 
 correct, he is voiding 250 grains less than he ought; 
 890 grains would represent the excretion of a person 
 weighing 40 pounds less than the person in question. 
 
 The whole calculation, with the table and reduc- 
 tions, depends greatly on the accuracy of the urin- 
 ometer used. 
 
 Lastly, if the urine contains any sugar or albumin 
 in abundance the method of computing solids is not 
 trustworthy, since the specific gravity of the urine is 
 changed by the abnormal constituent present. Also 
 in cases where there is considerable polyuria an inac- 
 Gurate urinometer will give rise to a considerable error 
 in results. For example, suppose the total quantity 
 of urine in twenty-four hours be 2,800 c.c, or 93 fluid- 
 ounces. Suppose the true specific gravity at 77° F. 
 be 1006. In this case the total solids are 6 times 
 2.33 times 2,800, divided by 1,000, equals 39 gram- 
 mes, or 600 grains. But a urinometer giving a read- 
 ing of 1008 would indicate total solids amountino- to 
 52 grammes, or 800 grains, the error amounting to 
 200 grains. 
 
 When there is no great polyuria the total solids may 
 be computed from saccharine urine by first ferment- 
 ing with yeast, then filtering, and "taking specific 
 gravity at 77° F. 
 
 PEACTIOAL APPLICATIONS TO DIAGNOSIS AND TREATMENT. 
 
 1 . In gynecological cases and nervous diseases Dr. 
 N. B. Delamater has shown for fifteen years past that 
 
PHYSICAL CHARACTERISTICS. 35 
 
 deficiency in solids, with accompanying symptoms, 
 often yields to eliminative treatment. 
 
 2. Dr. J. H. Etheridge has, independently, con- 
 firmed the statements so often made by Dr. Delamater, 
 showing that amenorrhoeas, neuralgias, pelvic perito- 
 nitis, dyspepsias, bronchitis, cutaneous eruptions, 
 headaches, backaches, leucorrhceas, nervousness, and 
 insomnias accompany deficient excretion of urinary 
 solids. "Women passing not to exceed 400 grains of 
 solids daily present various degrees of nervous irrita- 
 bility. When less than 300 grains are passed the con- 
 dition of nervousness becomes serious; bronchitis, 
 neuralgia, perimetritis or pleurisy may then result 
 from taking cold. A very close relation exists 
 between renal insufiiciency and pelvic disorders. 
 Many disorders of this character are relieved by 
 including in the treatment remedies that increase the 
 urinary solids. 
 
 3. Deficiency in solids in the urine of men I have 
 found, to indicate unrecognized interstitial nephritis in 
 some cases; in others, serious nervous disorders. 
 Purdy says the same thing so far as the renal condi- 
 tion is concerned. In such cases collect -the twenty- 
 four hours' urine, day and night separately, deter- 
 mine urea and phosphoric acid, look for casts, and 
 examine the patient's chest for cardiac lesions. 
 
 4. The differential diagnosis between diabetes in- 
 sipidus and simple hydruria may be made by deter- 
 mining the total solids, which in the former disease 
 are largely in excess of the normal average. 
 
 5. In fevers and acute diseases, as pneumonia and 
 typhoid fever, the severity of the disease is indicated 
 by increased quantity of solids in the urine ; if, on the 
 other hand, the temperature is high, but the excretion 
 of solids in the urine is deficient, eliminative treat- 
 ment should be employed, since elimination is evi- 
 dently defective. 
 
 6. In diseases in which there is exudation, marked 
 increase in the quantity of solidg in the urine is a good 
 sign, and indicates that eliminative treatment is not 
 needed. 
 
86 URINARY ANALYSIS. 
 
 7. By subtracting the total urea determined in the 
 twenty-four hours' urine from the total solids computed, 
 an idea may be had as to the general composition of the 
 urine in question. In cases in which the total urea is 
 greater than three times the total salts (difference be- 
 tween total solids and total urea) I have observed 
 great mortality. 
 
^ rl 
 
 REACTION OF THE URINE. 87 
 
 CHAPTEE III. 
 
 THE REACTION. APPEARANCE. CONSTSTENGT AND ODOR 
 OF URINE, AND THEIR SIGNIFICANCE. 
 
 The next physical characteristic to be con- 
 sidered is the reaction of the urine, whether 
 acid, neutral or alkaline. 
 
 The reaction of the normal twenty-four 
 hours' mixed urine is slightly acid, made so 
 by the presence of sodmm acid phosphate. 
 Blue litmus paper is turned slightly reddish 
 when held immersed in it some little time. 
 
 If the urine when boiled turns cloudy, and 
 the cloudiness is dispelled by adding a few 
 drops of 20 per cent, acetic acid, and shaking, 
 the reaction is not sufficiently acid. JSTormal 
 urine should be as clear after it is boiled as 
 before, when not over twenty-four hours' old. 
 
 Litmus paper is sensitive to light and air, 
 and should be kept in small salt-mouthed bot- 
 tles, tightly corked, and covered with paper to 
 keep out the light. I prefer soft litmus paper 
 to stiff, for the reason that the latter in small 
 pieces has a way of curling up and floating on 
 the surface of urine, instead of sinking quickly, 
 when dipped into it, hence it is less economical 
 for use. In larger pieces the stiff paper is easily 
 managed. Different Articles of litmus paper 
 vary in the tint of red obtained bj'' dipping into 
 the same sample of urine. This is because 
 some paper is impregnated with more coloring- 
 matter than others. Some blue litmus paper 
 will give a fairly bright red tint with urine W 
 which when boiled becomes cloudy, the cloud- 
 iness being dissipated by addition of acid, so ^Jtoius 
 that deficiency in acidity should be tested for pencil. 
 
 ^. 
 
38 URINARY ANALYSIS. 
 
 by this means as well as by use of litmus. Litmus 
 pencils {Fig. 5) may be used instead of litmus paper and 
 are preferable in that they do not lose their color as 
 does litmus paper. One end of the pencil is blue the 
 other red. Rub the sharpened ends on paper and get 
 ready-made litmus paper of either color. 
 
 The appearance of normal urine when freshly 
 voided is invariably clear. The twenty-four hours' 
 urine is almost always slightly hazy, when looked at 
 in a glass held lelow the window sill. Urine voided 
 in a cold room, 40° to 35° F., may soon, though 
 normal, become turbid. The urine of even healthy 
 women almost always, on standing, deposits a more 
 or less abundant whitish sediment, derived chiefly 
 from vaginal fluids mixed with it. 
 
 The consistency of normal urine is that of water — 
 easily dropping. Normal urine foams when shaken, 
 but the foam disappears in time, not remaining per- 
 manently on top of the liquid. 
 
 Now, the chief clinical points of value to be derived 
 from study of the physical characteristics are these : 
 
 Decrease in the twenty-four hours' urine is usually 
 accompanied by increase in the color, odor, acidity, 
 and specific gravity. If a patient passes a pint in 
 twenty -four hours, the color, will be darker, the odor 
 more noticeable, the acidity greater, and the specific 
 gravity highe% than when he passes three pints. Ex- 
 ceptions may be found in nephritis, and especially in 
 ati-uphy of the kidney, when the specific gravity is low. 
 
 Asa rule the urine voided at 10 : 30 a. m. should not 
 be strongly acid. Keyes thinks this an important 
 point in the diagnosis of the cause of pain in the back, 
 which he thinks renal in origin, no other cause being 
 apparent, provided the urine voided at 10 :30 a. m. is 
 noticeably acid. Physiologically the urine at this 
 hour should be less acid than at other times, that is it 
 should be neutral or only slightly alkaline. 
 
 In general, the urine of digestion (two hours, say, 
 after a meal) is less acid, unless acid foods or drinks be 
 taken. This urine is called urina cibi, the urine of 
 food. 
 
REACTION OF THE URINE. 89 
 
 CTrine voided on rising in the morning is called 
 urina sanguinis, urine of the blood, because it is voided 
 when the stomach is empty. It is deeper in color, 
 higher in gravity, etc. , than at other times of the day ; 
 in other words, its characteristics are increased in 
 intensity. 
 
 Urine voided after copious draughts of fluids is 
 called urina potus, the urine of drinking. Its charac- 
 teristics are diminished, *. e., it has less color, less 
 acidity, etc. Its specific gravity may be very low, 1005 
 even. 
 
 We find, as a general rule, that polyuria, or voiding 
 of increased urine in twenty-four hours, is attended by 
 diminution in the intensity of the physical characteris- 
 tics, except in diabetes mellitas, in which one charac- 
 teristic, specific gravity, is greatly increased. 
 
 Unusual shade of color, as greenish, deep yellow, 
 or deep red, may be seen when bile is in the urine, or 
 when certain drugs containing coloring-matters have 
 been taken, as santonin, rhubarb, etc. 
 
 In cardiac or renal diseases when a patient who has 
 beea in the habit of passing light-colored urine sud- 
 denly and without any apparent cause, begins to void 
 urine of a bright red tint, death is apparently inevit- 
 able. I have noticed this change but twelve times, 
 and all the patients concerned died in a few weeks or 
 months, only one surviving as long as a year after the 
 color changed. The particular color I have been able, 
 after much trouble, to imitate by diluting a solution of 
 the oxychloride of iron {not per-chloride). The 
 appearance of the urine in these twelve fatal cases 
 was like that of a diluted solution of oxychloride of 
 iron, in that it was clear, or nearly so, when looked at 
 through the sides of the glass, but inky when looked 
 at from above, in this respect differmg from bichro- 
 mate solutions, with which I first tried to imitate the 
 color. Such urine is usually more or less turbid from 
 mucus or urates, seldom contains much albumiu and, 
 usually, but a few casts, yet it is one of the worst 
 prognostic signs I have yet observed. 
 
40 URINARY ANALYSIS 
 
 The chief points in regard to the odor of urine are as 
 
 follows : 
 
 Urine which smells like ammonia when freshly 
 voided is found in inflammations of the bladder, espe- 
 cially in the cases of old men with enlarged prostates, 
 and with pus in their urine. Such urine is irritating 
 to raucous surfaces. Iformal urine, when old enough, 
 i. e., "stale," takes on this ammonia-like odor, but 
 should not do so when only twenty-four hours old. 
 
 Urine which soon acquires dt^iitrid oAov, something 
 like that of decayed meat, has decomposing mucus, 
 pus, or blood in it. The urine of healthy women may 
 become putrid from decomposing mucus soon after the 
 twenty-four hours have passed, especially in warm 
 weather. 
 
 Urine which is turbid, when freshly voided, is found 
 chiefly in inflammations of the bladder and contains 
 pus, usually with micro-organisms, and suspended 
 phosphates. Sometimes, however, the turbidity of 
 freshly voided urine is due wholly to suspended simple 
 phosphates ; if it clears up on addition of a few drops 
 of acid, and shaking, this latter is the case, and usu- 
 ally nothing serious is indicated. But urine turbid 
 when freshly voided, which does not clear on addition 
 of a,oid, and especially if it have an ammonia- like odor, 
 is indicative of disease, usually of the bladder. It is 
 al'^hline, turning the red paper blue, and called alka- 
 line from volatile alkali, *. e. , ammonia. 
 
 Urine which turns the red paper blue, but has not 
 rne ammonia-like odor, and which, if turbid, clears on 
 addition of acid, is said to be alkaline from fixed alka- 
 li, i. e., the carbonates of sodium and potassium. 
 Such urine, if clear when freshly voided, becomes tur- 
 bid vp-hen boiled, but clear again vsrhen acid is further 
 added. This does not signify presence of albumin, as 
 supposed by some, but is due to a precipitate of simple 
 phosphates, caused probably by increase in the alka- 
 linity produced by the boiling, which drives off car- 
 bonic acid. 
 
 Urine which, on standing, soon deposits a pinkish 
 sediment {uraten) atlherin^^ closely to the sides of a 
 
REACTION OF THE URINE. 41 
 
 chamber-vessel or streaking the sides of a glass vessel, 
 is too acid in reaction {hyper-acid). Such urine we 
 see in what is rather vaguely called Uthcemia or uric- 
 cemia, a condition in which uric acid formed in the 
 body is not sufficiently excreted or else not excreted 
 with regularity. In such urines we often see little 
 reddish or brownish specks, which are very heavy, 
 and settle quickly to the bottom. These are uric acid 
 crystals. 
 
 Urine which, on standing for a time, becomes 
 cloudy, and then when heated becomes clear again, 
 contains a sediment which is composed of urates (com- 
 pounds of uric acid) especially noticeable in cold 
 weather. 
 
 As to the character of the foam in urine, it may be 
 said that even slightly albuminous urines foam abund- 
 antly, and the foam is persistent. Albuminous urines 
 give rise to much foam in the urea instruments, as we 
 shall learn further on. Urine containing sugar foams 
 readily, and the foam is persistent. I have seen some 
 cases of persistent foam in which I could find nothing 
 unusual in the urine, except a sediment of uric acid 
 and urates. 
 
 When the urine is of some unusual color and the 
 foam has a faint or marked color, held in the right light, 
 bile is present, and a slight or marked odor of ox-gall 
 may be noticed. This is, on the whole, the easiest and 
 simplest test for bile that we have. 
 
 Urine having a sediment which sticks to the glass 
 contains pus, more or less mixed with mucus, and 
 altered by the ammoniacal alkali present in such con- 
 ditions. This is the easiest and quickest way of recog- 
 nizing pus, since mucus alone does not stick to the 
 glass. But all urine containing pus does not have this 
 sticky sediment. In acid urine pus shows large flocks 
 which rapidly settle, but do not stick to the glass. Set 
 the bottle aside in a warm place, and in a day or two 
 the sediment, if pus, will stick to the glass. 
 
 Patients sometimes pass urine containing gases, 
 which are, probably, carbonic acid gas and nitrogen. 
 The gases escape in large bubbles, and the unusual 
 
43 URINARY ANALYSIS. 
 
 occurrence generally causes much alarm. These gases 
 form especially in eases when urine containing sugar 
 is for any reason retained in the bladder where bac- 
 terial fermentation sets in, thus forming the various 
 gases. The condition is known as pneumaturia. 
 Keyes says that pneumaturia may exist without sugar 
 being in the urine. The gases are usually odorless, 
 but I have heard of one case in which an odor like 
 sulphuretted hydrogen was claimed. Pneumaturia 
 may exist without vesico-intestinal fistula. Keyes has 
 seen it only in patients who used the catheter. 
 
 In certain cases it may be worth while to take the 
 temperature of the freshly voided urine. For this pur- 
 pose a clinical thermometer is useful. 
 
REFERENCE TABLES. 43 
 
 CHAPTER IT. 
 
 CLINICAL SIGNIFICANCE OF THE COLOR OF URINE. 
 REFERENCE TABLES FOR THE PRACTITIONER. 
 
 The following pages give in tabular form the clin- 
 ical significance of the various physical characteristics 
 of the urine, as set forth in the preceding chapters. 
 
 REFERENCE TABLE 3. 
 
 Synopsis for Color. 
 
 I. Pale urines. — Either (A) physiological, after drinking, or (B) 
 pathological; the latter in (a) polyuria, as in neurasthenia, hys- 
 teria; (b) in diabetes insipidus; (c) in interstitial nephritis; (d) in 
 lardaceous disease of the kidneys; (e) in convalescence from many 
 acutt' diseases; (/) poisoning by duboisin; (gr) anaemia; (h) diabetes 
 insipidus. 
 
 II. Urines lighter than straw-yellow but not pale.— (a) That 
 of nnurotic persons; (&) of most women; (c) normally in children; 
 (d) sometimes in diseases of the prostate; (e) in cases of sexual de- 
 bility: light, phosphatic sediment in the urine; (/) diabetes insipi- 
 dus (milder cases). 
 
 III. Lemon-yellow. — ^Diabetes mellitus, when much sugar is 
 present. Said to occur in cholera and in spioal disease. 
 
 IT. Peculiar bright-yellow tints. — Due to taking internally 
 of gamboge, senna, logwood, picrotoxin. santonin, rhubarb. 
 
 V. Darker than straw-yellow.— Approaching red. — Diminu- 
 tion in volume of urine; physiologically, after perspiration, or 
 when but little liquid is taken in the diet. 
 
 TI. Reddish urine. — In fevers and inflammations. Sometimes 
 due to sediment of urates colored red by uroerythrine, a patho- 
 logical coloring matter; in such case filter the urine, and the 
 tinf '"ly be yellowish rather than reddish. 
 
 Vli. Peculiar bright-red tints.— Due (a) to presence of bile, 
 blood, or (6) to coloring matters from such substances taken 
 internally as logwood, madder, bilberries, fuchsin, aloes, alizai'in. 
 
 VIII. Orange-red.— Ingestion of santonin, chrysophanic acid. 
 
 IX. Dark-red. — (a) In severe acute febrile diseases; (6) blood in 
 the uriue; (ci external use of aniline chlorhydrate. 
 
 X. Brownish tints.— Brown-red, in acute febrile disorders or 
 inflammations; brown-yellow or red-brown, due to ingestion of sen- 
 na,rhubarb,chelidonium ; greenish-brown, due to bile in urine; dark 
 brown, (a) due to bile or blood in urine; (b) found in long continued 
 intermittent fever; (c) due to external use of pyrogallic acid; 
 brown to brown-black, in so-called metheemoglobinuria; in melan- 
 otic sarcoma; in wasting diseases; in this case the color is due to 
 the presence in the urine of a black pigment called melanin; the 
 urine, if not dark when voided, darkens on standing; this is not 
 
44 URINARY ANALYSIS. 
 
 the same coloring matter found in the urine in carbolicacid 
 poisoning:. In carbolic-acid poisoning. _ 
 
 XI. Black urine. — Brownish-black, see preceding; (a) m 
 poisoning by sulphuric acid, creosote, arseniuretted hydrogen, 
 potassium chlorate; (6) ingestion of naphthalin, hydrochinon, 
 resorcin, pyrocateohin; (c) inunction of tar; {d) melanuria (on 
 standing). Urine containing melanin darkens on standing, and 
 becomes intensely black when oxidized by ferric chloride or other 
 oxidizing: agents. 
 
 XII. Oreen tints.— (a) Greenish-yellow, greenish-brown, see 
 above; (6) dirty-green or blue in cholera and typhus, when urine 
 putrefies; (e) dark-green in carbolic-acid poisoning. Greenish to 
 grns--green is said to have- been seen in cystitis and in Bright's, 
 in alkaline decomposed urine. 
 
 XIII Blue* tints.— (a) See above; (6) In typhoid fever, 
 oh ionic affections of the spinal cord; (c) Presence of indigo. (See 
 Sedi'iients.) 
 
 Pale urines are deficient in urohematin, the nor- 
 mal coloring matter of urine. Lemon-yellow urine 
 contains uroxanthin. The pinkish or rosy tints of 
 urates in the sediment are due to urserythrin. The 
 blue pigments are oyanurin (uroglancin) and indigo. 
 The greenish may be due to mixtures of uroxanthin 
 with the blue pigments. (Thudichum.) 
 
 REFERENCE TABLE 4. 
 Odor. 
 
 Odor slightly aromatic— Health. 
 
 Pronounced aromatic odor, not offensiTC— Decrease in quan- 
 tity of urine, as after psrspiration, m fevers, etc. 
 
 Slightly pungent odor.— Norma,! after twenty-four hours in 
 mfn. 
 
 Pungent odor.— Common after twenty-four hours in urine of 
 women containing much mucus. 
 
 Putrid odor,— Due to decomposing mucus, pus, blood. 
 
 Odor of ammonia.— Alkaline urine either stale or, if fresh, 
 due to diseases of the prostate, bladder, or kidneys; usually cys- 
 titis. 
 
 Odor of sulphuretted hydrogen.— Decomposing mucus; com- 
 mon in the stale urine of diseases of the bladder and prostate, 
 and in that of women containing leucorrhoeal fluid. Also in urine 
 containing cystin. 
 
 Sweetish odor.- Sugar in the urine. 
 
 Sour milk or yeasty odor.— Stale urine containing sugar. 
 
 Odor of tainted meat.— Stale urine containing albumin, pus 
 or blood. ' ' 
 
 * Dr. Wesley A. Dunn tells me that that the urine mav be col- 
 ored blue as a result of applic.ition of methyl blue locally to the 
 throat, as also wheu takeu intt-niall\ . 
 
REFERENCE TABLES. 45 
 
 Odor of ehloroform-acetie acid.— Acetone in the urine, as in 
 diabetes with acetonuria. 
 
 Odor of violets. — Ingestion of oil of turpentine. 
 
 Odor of sweet-briar.— Fresh urine containing cystin. 
 
 Odor of ox-g'all. — Bile in the urine. 
 
 Sabstances which more or less communicate their own odors 
 to urine are: 
 
 Asafoetida, Castor Oil, Cubebs, Onions, 
 
 Asparagus, Coffee, Garlic, Sandal wood, 
 
 Beef extract, Copaiba, Oil of tola, Valerian. 
 Cauliflower, 
 
 REFERENCE TABLE 5. 
 
 Specific GraTity. 
 
 1020 to 1035. — Usual normal range. 
 
 1013 to 1060. — Possible ransre when sugar is in the urine. 
 
 1003 to 1035. — Possible range when albumin is in the urine. 
 
 Above 1040. — Abnost invariably diabetes melUtus; invariably, if 
 polyuria. 
 
 1035 to 1030. — May be normal in those leading sedentary lives. 
 
 1025 to 1040. — Possibility of diabetes mpllitus. acute nephriti-s, 
 cong stion of kidnwys. oxaluria. some ojis"s of neu- 
 rasthenia, uric aciii sedimerits. acute diseases gen- 
 erally. Functional albuminuria. 
 
 1020 to 1015. — May be normal in tho^e who drink copiou-ly. Pos- 
 sibility of neurasthenia, anaemia in women, chronic 
 nephritis. 
 
 Below 1015. — Diabetes insipidus; neurasthenia; chronic nephritis; 
 lardaceous disease of kidneys; hysteria; anaemia. 
 
 REFERENCE TABLE 6. 
 Cliemical Reaction. 
 
 Slightly acid. — Usual normal reaction of the twenty-four 
 hours' urine. 
 
 Plainly acid. — Urine diminished in twenty-four hours' quan- 
 tity: in those who drink but little water; due to muscular exer- 
 tion, meat diet, ingestion of saocharn: stale urine which has 
 undergone acid fermentation. Milk diet sometimes increases 
 acidity of urine. 
 
 Strongly acid. — Due to ingestion of acids, as boracio. benzoic 
 or acid salts, as perchloride of iron. Horsford's acid phosphates, in 
 febrile disorders; in the uric acid diathesis; in certain diseases of 
 the liver. 
 
 Neutral. — Copious drinking; usual after meals. 
 
 Alkaline. — Three or four hours a*'ter meals; after perspiring co- 
 piously; after hot baths; due to > egetable diet; after copinus vomit- 
 ing; from ingestion of alkaline carbonates or salts i if vegetable 
 acids, as in mineral waters containing the above; lithia waters and 
 tablets, lithium beozoate, citrate, etc., from fixed alkali in debil- 
 ity, nervous exhaustion, ansemia and chlorosis, pulmonary dis- 
 orders, some acute diseases (pneumonia, typhus, enteritis, flatu- 
 
46 URINARY ANALYSIS. 
 
 lent dyspepsia; from volatile alkali in stale urine, or, when in 
 freshly voided urine, cystitis or pyelitis). 
 
 CLINICAL NOTES ON EEACTION. 
 
 1. Urine of highly acid reaction is irritating to the 
 mucous membrane of the urinary tract and aggravates 
 any existing disease, especially in women. 
 
 2. Alkaline urine (fixed alkali) is somewhat ir- 
 ritating. 
 
 3. Ammoniacal urine causes the greatest distress of 
 all. The agony of a patient with prostatic abscess, 
 who voids strongly ammoniacal urine, is extreme. 
 
 REFERENCE TABLE 7. 
 
 The Quantity, Specific Gravity, and Color of Urine in 
 Pathological Conditions. 
 
 A. Quantity small, specific gravity low, color pale. — Suspect 
 chronic nephritis; uraemia. 
 
 B. Quantity large, specific gravity high, color paler than 
 
 normal.— Suspect diabetes mellitus. 
 
 C. Quantity large, specific gravity not ahove normal, color 
 pale. — Suspect diabetes insipidus, neurasthenia, intprstitial 
 nephritis, lardaceous disease of kidneys, reduction of dropsy, con- 
 valescence from, acute diseases. 
 
 D. Quantity small, specific gravity high, color high.— (a) 
 acute febrile diseases; (b) dropsy; (c) to a less degree, in cerebral 
 and gastric neurasthenias, and in oxaluria: (3) in acute and 
 chronic renal hyperaemia; (e) in certain hepatic disorders. 
 
 CLINICAL NOTE. 
 
 Urine as described in D has been observed by the 
 author in {a) cases of gall-stone colic ; (5) just preceding 
 ursemic convulsions ; (c) commonly in oxaluria (500-6(K) 
 c.c. of urine in 24 hours); (d) in obscure mental 
 diseases (insanity?) soon terminating fatally, with 
 marked relative excess of uric acid in solution. 
 
 REFERENCE TABLE 8. 
 
 Consistency and Frothiness. 
 
 A. Increased consistency. — Presence of mucus and pus 
 especially in alkaline urine; chyle in the urine; fibrin in the urine.' 
 
REFERENCE TABLES. 47 
 
 B. Diminished consistency, sliown by increase in the froth- 
 
 iness. — Albumin or sugar in the urine. 
 
 Frothiness is Increased sometimes in urine of highspeciflc grav- 
 ity; in urine feebly acid or alkaline; in urine containing excess 
 of mucus. 
 
 REFERENCE TABLE 9. 
 Appearance of the Urine. 
 
 A. The nrine looks millty.^Ia childrea, perhaps due to sed- 
 iment of urates, cleared by heacing; due to presence of pus, or 
 chyle. 
 
 is. The urine has a greenish-red "smoky" hue. — Suspect 
 pi esence of blood in it. 
 
 C. The urine has a dusky hue. — See remarks on brown and 
 black color. 
 
 D. The urine is turbid when freshly voided.— Suspect pres- 
 ence of blood, bile, mucus, pus, phosphates. If light color, the 
 last three; phosphates cleared by shaking with 50 per cent, acetic 
 acid. Pus, blood, and mucus are not cleared by the acetic acid. 
 
 E. The nrine is clear when freshly voided, but becomes 
 turbid on cooling. — A sediment of urates has deposited and may 
 be cleared by heat (150° F.) 
 
 F. The urine is tnrbid, and, when shaken, the cloudiness 
 has a wave-like motion. — Presence of bacteria in the urine. 
 Not affected by acetic acid. The urine never clears completely 
 on standing. 
 
 G. The uriue filters slowly.— Excess of mucus; presence of 
 pus, blood. 
 
48 
 
 URINARY ANALYSIS. 
 
 CHAPTEE V. 
 
 EXERCISES IN PHYSICAL CHARACTERISTICS. 
 
 The student having collected his twenty-four hoars' 
 urine, day and night separately, measured it, and 
 mixed it, should determine the physical characteris- 
 tics as follows : 
 
 CHEMICAL EXERCISE IL 
 
 A. Filter the urine: — Obtain glass 
 funnels {Fig. 6), filter paper, of the 
 size represented in Fig. 7, filter rings 
 and stand {Figs. 8, 9, 10 show dif- 
 fei-ent kinds) and collecting vessels, as 
 wide mouthed bottles or beakers. 
 
 Fig. 11 shows a convenient appara- 
 tus for managing filtration. The 
 receiving vessels in Fig. 11 are beak- 
 ers, which are sold in " nests " {Fig. 
 12) of different sizes. 
 
 Funnels should be of two sizes {a) those 3 or 4 inches 
 in diameter across the top, and {b) those about two 
 inches. The smaller ones may be set directly into 
 test-tubes. The larger ones require either a support 
 or a wide-mouthed bottle to rest in. 
 
 Fig. 6. G ass fun- 
 nel used in fil- 
 tering urine. 
 
 Fig. 11. Apparatus for filtration. 
 
CHEMICAL EXERCISES. 
 
 49 
 
 Fia.8. Support 
 for f annel. 
 
 Fig. 9. Filter 
 rings and stand. 
 
 FiQ. 10 suppurt 
 for two f nnnels. 
 
 Fig. 7. This circle represents the exact size (4 inches diameter) of 
 filter paper most convenient for use in these exercises. 
 
 Filter-paper should be bought already out in pack- 
 ages of 100. For the larger funnels get paper about 
 7i inches in diameter. For the smaller funnels use 
 the size shown in M,g. 7. The larger funnels and pa- 
 per are useful for various quantitative filtrations, as in 
 uric acid determinations ; the smaller ones for qualita- 
 tive work, especially clinical. 
 
 For the larger funnels buy what is known as rapid 
 filtering paper^ which is especially serviceable when 
 it is desired to collect sediments on a filter. 
 
 For filtering urine clear do not use rapid filtering 
 paper, but fold several of the smaller papers together. 
 4 
 
50 
 
 URINARY ANALYSIS. 
 
 In order to fold filter-paper, first fold it in two, 
 then fold again in two, but this time at right angles 
 to the first folding. A funnel shape is thus given to 
 it, and it may be fitted into a funnel and is ready for 
 
 use. 
 
 Fig. 12. " Nest " of beakers. 
 
 Filter the urine into a thin glass jar or beaker at 
 least 3 or 4 inches in diameter, and for observing color 
 always use the same beaker. Observe whether the 
 urine filters slowly or rapidly. If it filters slowly, it 
 indicates the presence of mucus in excess. 
 
 Note whether the color is normal (straw-yellow), 
 pale, or high. More precisely, compare the shade 
 with Vogel's Color Scale, and report the color as No. 
 1, 2, or 3, etc., on this scale. Note any unusual color 
 as red, green, brown, or black. 
 
 Vogel's Color Scale divides the urinary colors into 
 the following : — (see J^ro7itisjnece). 
 
 1. Pale-yellow; — 2. Light-yellow;-^ 3. Straw-yel- 
 low; — 4. Red-yellow; — 5. Yellow-red; — 6. Red; — 
 7. Brown-red; — 8. Eed-brown; — 9. Brownish-black. 
 
 These colors, as given us, seldom match closely with 
 the color of the filtered urine. Between yellow-red 
 and red, as pictured in the books, a number of urine 
 shades occur. Moreover the colors in the color-scale 
 
CHEMICAL EXEBCISES. 51 
 
 fade on exposure, so as to show in time but little dif- 
 ference in the first three shades. As yet, however, 
 nothing superior to this scale has been devised. The 
 author has been able to imitate closety several of the 
 urine tints by solutions of certain chemicals, as, for 
 example, a peculiar dark inky-red by diluting oxychlo- 
 ride of iron solution. 
 
 B. Smell of the urine and note whether the odor is 
 slightly (a) aromatic, not at all unpleasant, sometimes 
 agreeable; (5) strongly aromatic, still not disagreeable, 
 as in fevers ; (o) pungent, slightly disagreeable, as in 
 case of urine twenty-four to forty-eight hours old ; {d) 
 
 fetid, decidedly unpleasant, suggesting decomposition ; 
 or (e) ammoniacal, having distinct odor of ammonia. 
 (Students are usually at fault regarding the odor of 
 urine.) 
 
 Ifote whether there is any odor of ox-gall (bile), or 
 of any drug, such as cubebs, sandalwood, creasote, etc. 
 
 C. Take the specific gravity of filtered urine in the 
 beaker, pouring it carefully, to avoid foam, into the 
 fluted Jar which comes with Squibb's urinometer, 
 removing foam with filter paper. When the urinom- 
 eter is floating in the liquid, touch the top of the stem 
 lightly so that it sinks and rises a few seconds, then 
 wait until it settles down to quietude. Read off the 
 scale when on a level with the eye, and note the figure 
 on the level of the liquid. For accurate work use a 
 chemical thermometer, and warm or cool the urine to 
 77° F. (25° C), by setting the jar in hot or cold 
 water. 
 
 D. Compute the total solids by multiplying the 
 number of cubic centimeters of urine in twenty-four 
 hours by the last two figures of the specific gravity, 
 that product by 2.33, and divide last product by 1,000. 
 The result is grammes of total solids for twenty-four 
 hours. Convert to grains by Table 3, Appendix. 
 Compare the number of grains found with what the 
 student ought to excrete for his age and weight, using 
 7\ible 3 in Appendix. 
 
 E. Work out the following problems in total solids : 
 
52 URINARY ANALYSIS. 
 
 (a) Urine in twenty-four hours. 850 c.c; speciflo gravity, 1013; 
 age 55, weight 160, fasting, in bed. How do»s the excretion com- 
 puted compare with the theoretical excretion based on 945 grains 
 (61 grammes) minus the deductions for age. etc. 
 
 (6) Urine in twenty-four hours. 400 c.c; specific gravity, 1030; 
 age. 70; weight. 155; appetite and diet normal; exercise, normal. 
 
 (c) Urine in twenty-four hours, 1500 o.c; specific gravity, 1025; 
 age, 30; weight, 140; otherwise normal. 
 
 F. Take the reaction of the urine with litmus 
 paper, holding two slips, red and blue, in the urine 
 until saturated, or placing a drop of urine in the 
 center of each of the slips. If the blue paper is turned 
 red and no change has taken place in the red paper, 
 the urine is acid. Notice whether the reddened lit- 
 mus is only slightly red, or a bright brick- red, i. e., 
 feebly acid or strongly acid. If neither paper is 
 affected in color, the uriue is neutral. If the red 
 paper is turned blue and no change takes place in the 
 blue paper, the urine is alkaline. Let the paper, 
 which has been turned blue, dry ; notice whether it 
 remains blue (fixed alkali) or turns red again (volatile 
 alkali). 
 
 If both the blue paper is turned red and the red 
 paper blue, the urine is what is called amphoteric in 
 reaction, which is without known significance. 
 
 Acid urine on standing sometimes becomes more 
 acid than normal, due to action of mucus as a ferment 
 producing' a lactic fermentation, darkens in color, and 
 deposits a sediment (uric acid and urates), calcium oxal- 
 ate, penicillium glaucum (fungi) and bacteria, so that the 
 reaction should be taken as soon as possible after the 
 twenty-four hours are up. Again, in the course of 
 three or four days, usually, or sooner in hot weather, 
 the urine grows turbid from the presence of micro- 
 organisms, becomes alkaline from decomposition of 
 the urea, which is converted into ammonium carbonate 
 by action of the micro-organisms, and a whitish phos- 
 phatic sediment is deposited. 
 
 Note. — Despite the assertions of some authors it is possible to 
 have a sediment of uric acid and triple phosphate in the same 
 sample of stale urine. The writer has seen it Occur several times. 
 As the urine becomes hyper-acid uric acid crystals are deposited, 
 and these may not be entirely dissolved after the alkaline change 
 has caused deposit of triple phosphate. 
 
CHEMICAL EXERCISES. 53 
 
 G. Note the appearance of the unflltered urine, 
 whether clear or turbid. If turbid, set a few ounces 
 aside and, after a time, a sediment or deposit will be 
 noticed. Students sometimes incorrectly report " no 
 sediment" in urine which they have previously 
 described as " turbid ". Note whether the turbidity 
 is slight, slowly settling, as in case of ahnost all normal 
 urine twenty-four hours old, or whether the urine is so 
 turbid as to deposit an abundant sediment within half 
 an hour or so. 
 
 When the urine of women is examined, a whitish 
 sediment of mucus is almost always noticed. 
 
 H. Note the consistency of the urine, whether it 
 flows easily, or is thick and ropy from presence of 
 muco-pus; or creamy, forming a jelly-like mass on 
 standing, due to chyle or fibrin. 
 
 I. Shake some of the urine in a bottle, and notice 
 whether the foam subsides quickly, or whether it is 
 wholly permanent. 
 
 J. Make out a report fiUing in the following blanks : 
 
 I. The urine filters (Specify whether slowly 
 
 or rapidly.) 
 
 3. Color of the filtered urine 
 
 3. Odor - , suggesting 
 
 4. Specific gravity at 77° F. (35° C.) 
 
 5. Total solids by HsBser's coefficient grammes; 
 
 grains. 
 
 6. Corrections for age, weight, diet, and exercise leave a total 
 of grammes; - grains of solids. 
 
 7. The patient should void by Table S, Appendix, and correc- 
 tions grammes; --. grains of solids. 
 
 8. Therefore this patient is voiding compared 
 
 with what he or she ought to void. 
 
 9. Reaction 
 
 10. Appearance — . 
 
 II. Consistency 
 
 18. Frothiness 
 
 Apparatus used in Chemical Exercise 2. 
 1. Glass fuimels, some 2 inches, others 3 or 4 inches in diameter 
 across the top. 3. Slips of blue and of red litmus paper or litmus 
 pencils. 3. A filter ring and stand. 4. Filter papers, ordinary 
 and for rapid filtering. 5. Glass beakers. 6. Vogel's color scale, 
 7. Squibb's urinometer and fluted jar. 8. A chemical thermome- 
 ter. 
 
54 UBINABY ANALYSIS. 
 
 CHAPTEK YI. 
 
 NORMAL CONSTITUENTS OF URINE : UREA. 
 
 The normal constituents of urine of clinical interest 
 are the following : 
 
 A. Organic, j urfc ^cid and urates. 
 
 i Phosphates; 
 
 B. Inorganic, -< Chlorides; 
 
 ( Sulphates. 
 
 In addition to these there are numerous other sub- 
 stances of less clinical importance which will be de- 
 scribed with less detail than in case of the above. 
 
 UREA. 
 
 Pronunciation: U'rea. 
 
 Synonyms: German, Hamstof; Feench, TJrie., 
 
 Chemical constitution: CH.N.O, or 00 | ^^' 
 
 carbamide, an amide of carbonic acid ; an organic sub- 
 stance, containing over 45 per cent, of nitrogen. 
 
 Occurrence: Always in solution in urine of any 
 reaction. Never in the sediment of urine. Urine is 
 a solution of urea in strength about 2 per cent. 
 
 Form: Crystalline ; quadratic prisms. 
 
 Color and appearance: Pure urea occurs in com- 
 merce in colorless crystals, of taste like saltpetre. 
 
 Solubility: 1. Eeadily soluble in water and alco- 
 hol. 2. Insoluble in ether and chloroform. 
 
 Reaction: Solutions of urea are neutral in reaction. 
 
 Preparation: {a) From the urine by evaporating 
 the latter to syrupy consistence, adding gradually and 
 with constant stirring pure nitric acid in excess ; ni- 
 trate of urea crystallizes out, from which, when sepa- 
 rated, urea may be obtained by decomposition with 
 
NORMAL CONSTITUENTS OF URINE: UREA. 
 
 55 
 
 barium carbonate. (5) Synthetically by heating am- 
 monium cyanate to 100° C. (212° F), (Wohler, 1828); 
 (c) By the action of ammonia on carbonyl chloride. 
 Note: The equations in the two processes in (b) are as follows: 
 
 1. CNONH4 = CO j jjjj^ by molecular rearrangement. 
 
 2. C0CIa+4NH,=C0 (NH,)j+3NHiCl. 
 
 Miscellaneous properties: The crystals of urea 
 contain no water of crystallization ; they are perma- 
 nent in the air. The commercial article in time gives 
 off an odor of ammonia, due to change into ammonium 
 carbonate, which occurs by taking up water, as under 
 the influence of a ferment, as follows : 
 
 CHiN40+2H,0=(NH4)2COs. 
 (Urea.) (Water.) (Ammonium carbonate,) 
 
 This change may take place in the bladder under 
 the influence of bacteria, the mic7'ocoGcus ureae, to be 
 explained further on. 
 
 The ammoniacal odor of decomposed urine is due to 
 this change into ammonium carbonate. 
 
 Combinations: (a) With nitric acid, forming urea 
 nitrate; (5) with oxalic acid, forming urea oxalate 
 — 2.CO(NH,)5.H^C,0^. Also, combinations with 
 mercuric nitrate in variable proportions, one of which 
 
 Fig. 13. Crystals of urea. {Purdy.") 
 serves as a basis for Liebig's titration method, and 
 with various salts, as sodium chloride, and chlorides 
 
66 
 
 URINARY ANALYSIS. 
 
 of the heavy metals, forming combinations, for the 
 most part crystallizable. 
 
 Microscopical appearances: Urea itself: Silky, 
 four-sided prisms with oblique ends, or (rapidly" crys- 
 tallized) in delicate white needles (^«'^. 13). Nil/rate of 
 urea : Thin rhombic or hexagonal crystals, overlap- 
 ping tiles, colorless plates, whose point has an angle 
 of 82° {Mg. llf). Larger and thicker rhombic pillars 
 
 Fia. 14. Crystals of urea-nitrate, 
 {JS-rukenherg.) 
 
 or plates are obtained on slowly crystallizing. Oxal- 
 ate of urea : Ehombic or six-sided prisms or plates 
 more regular than the nitrate, {Mg. 15.) 
 
 Fia. 15. Crystals of urea-oxalate. 
 {Krukmiberg .) 
 
NORMAL CONSTITUENTS OF URINE: UREA. 57 
 MIOEO-CHEMICAL TESTS. 
 
 1. To a drop of urine, preferably of high specific 
 gravity, on a glass slide, add a drop of nitric acid ; 
 warm it gently and cautiously over an alcohol lamp 
 until it is slowly evaporated. Characteristic crystals 
 of urea nitrate may be seen under the microscope even 
 with a low power, 150 diameters. {-Fig- i4-) 
 
 2. Again, place a drop of urine, preferably of a 
 high specific gravity, on the slide, add a thread 
 and cover-glass, and allow a drop of nitric acid 
 to enter by capillarity. Crystals of the nitrate 
 of urea will form along the thread. 
 
 CHEMICAL TESTS. 
 
 A. Qualitative. 
 
 1. The biuret reaction: Heat crystals of urea in 
 a test tube; the crystals melt, decompose, give off an 
 odor of ammonia, leave a whitish residue which, dis- 
 solved in water, to which a couple of drops of sodium 
 hydroxide solution (caustic soda) and a drop of a dilute 
 solution of copper sulphate being added, a violet or 
 rose-red color is produced. 
 
 2. The furfurol test: Treat a crystal of urea with 
 a drop of a nearly saturated solution of furfurol in 
 water, and immediately with a drop of hydrochloric 
 acid (sp. gr. 1.1); a color-change occurs, passing from 
 yellow through green, blue, and violet to purple-red. 
 
 3. Decomposition with solutions of alkaline hypo- 
 bromites or hypochlorites. 
 
 B. Quantitative. 
 
 Determination of urea (theoretical). The prin- 
 ciple on which our clinical* quantitative determina- 
 tions are founded is that urea is decomposed by hypo- 
 bromites, with formation of carbon dioxide and nitro- 
 gen. In practice we use an alkaline hypobroraite, as 
 sodium hypobroraite, since carbon dioxide (carbonic 
 acid gas) is soluble in alkalies, while nitrogen is insolu- 
 ble. The urine is introduced into a graduated tube, 
 filled with the chemical solutions, and the nitrogen 
 
 *The Liebig method is described in the Appendix. 
 
58 URINARY ANALYSIS. 
 
 gas evolved collects at the top of the tube and dis- 
 places the solution. 
 
 The equation is as follows : 
 
 CH4NsO+3NaBrO.=Nj+C02+2HsO+3NaBr. 
 
 In other words, urea plus sodic hypobromite, equals 
 nitrogen plus carbonic dioxide, plus water, plus sodic 
 bromide. From this it may be calculated that 60 
 parts of urea by weight (the sum of the atomic weights 
 of the atoms in the molecule CH^lSTjO) yield 28 parts 
 of nitrogen by weight. One gramme of urea, then, 
 would yield 28-60 gramme of nitrogen, which is known 
 to occupy a volume of about 37li cubic centimeters. 
 If, then, 371^ c.o. of nitrogen gas indicates the pres- 
 ence of one gramme of urea in a given quantity of 
 urine, then one o.c. of nitrogen gas would indicate the 
 presence of one divided by 371-| whicli equals 0.002ti9 
 gramme of urea. Every c.c, of nitrogen gas obtained 
 in the process at ordinary temperature and pressure 
 signifies that 0.00269 gramme of urea is present in the 
 amount of urine used, and on this principle the grad- 
 uation of the instruments is made. In some American 
 instruments the French measures are not used but 
 American grains per ounce instead. Grammes per 
 liter may be converted into grains per ounce by divid- 
 ing by 2^. 
 
 The clinical instruments for determination of urea 
 which are most commonly used are those of Eartley, 
 Doremus and Squibb. The method by which we de- 
 termine the quantity of urea in the urine is given in 
 full in the next Chemical Exerecisb, where the three 
 instruments are described. 
 
PROPERTIES AND REACTIONS OF UREA. 59 
 
 CHAPTER VII. 
 
 PROPERTIES AND REACTIONS OP UREA. 
 
 CHEMICAL EXERCISE III. 
 
 A. Properties and Reactions of Urea. 
 
 B. Quantitative Determination of Urea. 
 G. Calculation of Results. 
 
 Properties and Reactions of Urea. 
 
 1. Examine crystals of urea. Note col- 
 or, taste, solubility in water and alcohol ; ac- 
 tion of hot alcohol ; of ether, and of chloro- 
 form. 
 
 2. Take the chemical reaction with lit- 
 mus paper of an aqueous solution of urea. 
 
 What is it? 
 
 3. Perform the biuret test, as follows : — 
 Fuse about 0.3 gm. (5 grains) of urea in a 
 
 test-tube, shown in Fig. 16. Now boil the 
 liquefied crystals till a white residue appears ; 
 next add about 10 c.c. (2 to 3 fluidrachms) 
 of distilled water, shake thoroughly and add 
 several cubic centimeters (1 to 2 fluidrachms) 
 of a strong solution of sodium hydrate (10 
 gm. in 25 c.c. water, or 155 grains to the 
 
 fluidounce). '^'^Test ^ ^' 
 
 Set the tube aside for the present. Now Tubes, 
 make a solution of oupric sulphate in distilled water, 
 strength 0.5 gramme (3 grains) to 100 c.c. (3^ fluid- 
 ounces.) Add several drops of this copper solution, 
 drop by drop, to the alkaline solution above made, and 
 a beautiful red-violet color appears at the top. Too 
 much or too strong copper solution gives a blue color 
 with the alkali, which can be seen by adding a large 
 number of drops of the copper solution. 
 
60 
 
 URINARY ANALYSIS. 
 
 In this test urea is converted into biuret, or allo- 
 phanamide, a derivative of urea. 
 
 4. Perform the furfurol test as follov?-s : Shake up 
 one c.c. of furfurol with about 15 o.o. of water. To 
 a crystal or two of urea on a porcelain surface add a 
 drop of the furfurol solution and immediately a drop 
 of strong hydrochloric acid, and observe the color 
 change, in which a purplish tint is prominent. Fur- 
 furol is an expensive article, and waste should be 
 avoided. 
 Quantitative Determination of Urea (Practical). 
 
 1. The student having collected, mixed, 
 and measured his twenty-four hours' urine, 
 should proc-eed to determine the quantity of 
 urea by use of Bartley's ureometer, and Leslie 
 Beebe's clamp {Fig 17.) 
 
 Bartley's ureometer consists of a somewhat 
 long, graduated tube, called by chemists a 
 "gas tube," and a 1 c.c. pipette, about 
 twice the length of a medicine-dropper, with 
 a rubber nipple on one end of it. That is the 
 entire apparatus. To estimate urea with 
 this instrument it is only necessary to pro- 
 ceed as follows : 
 
 1. Fill the long graduated tube up to the 
 mark five with a twenty per cent, solution 
 of C.P. potassium bromide (bromide of pot- 
 ash). 
 
 2. Next, pour in a solution of Squibb's 
 chlorinated soda up to the eighteenth mark, 
 or anywhere between the eighteenth and 
 twentieth mark on the tube. [In buying the 
 chlorinated soda solution, get Squibb's 2 per 
 cent. U. S. P., put up in sealed bottles con- 
 taining 250 grammes. The solution does not 
 keep long after the bottle is opened, hence it 
 is better to get six 250 gramme bottles, 
 rather than one large one.] 
 
 3. Let water trickle slowly down the side of the tube 
 till the latter is filled to the twenty-fifth mark. 
 
 4. Now take up urine with the pipette exactly to the 
 
 Fig. 17. 
 Leslie 
 Beebe's 
 clamp. 
 
PROPERTIES AND REACTIONS OF UREA. 61 
 
 single mark on this little instrument. Some practice is 
 
 necessary in order to do this well. See that the rubber 
 
 nipple is not cracked. It is well to buy a few dozen 
 
 pure gum rubber nipples, but care must be taken that 
 
 they fit tightly to the large orifice of the pipette. 
 
 In order to take up urine in the pipette exactly to 
 
 the mark on the pipette, dip the latter below the level 
 
 of the urine, squeeze the rubber nipple, then gradually 
 
 relax pressure and the urine will rise iu the tube. 
 
 Keep the tip end of the pipette below the level of the 
 
 urine always so that no air bubbles shall rise, and 
 
 keep trying till finally you have the urine exactly to 
 
 the mark. Eelax all pressure on the nipple when this 
 
 has been obtained — but it is best to relax gradually so 
 
 that by the time all pressure is relaxed the urine has 
 
 risen to the mark. 
 
 Note. — By use of a soft rubber nipple 1 o.c. of urine can be 
 easily obtained as follows: Draw up more than one c.o. into the 
 pipette and then work the nipple down. The urine ilows out as 
 the nipple is worked downward, and no air-bubbles enter from be- 
 low. Work the nipple down until the level of the urine is exactly 
 t^at of the 1 CO. mark, then take the pipette by the glass por- 
 tion, avoiding pressure on the nipple, and introduce it into the 
 Hartley tube. 
 
 5. ISTow hold the long tube well inclined in the left 
 hand and with the right cause the urine in the pipette 
 to trickle slowly down into the liquids in the long tube, 
 squeezing the rubber very gently. When all the 
 urine has been squeezed out of the pipette, gradually 
 raise the inclined long tube to the perpendicular and 
 put Beebe's clamp over the mouth of the tube. In- 
 vert the long tube several times. Inside the tube the 
 urine mixes with the chemicals and a lively efferves- 
 cence takes place. Niti'ogen gas has been set free by 
 the action of the chemicals on the urea and is trying 
 to escape from the tube. Now bring the tube to the 
 perpendicular position, and wait for the effervescence 
 to cease. This may take several minutes. Eead what 
 mark on the tube is even with the level of the liquid 
 in the tube after the foam has settled. You will see 
 the figure 15 without diificulty somewhere near the 
 level of the liquid in the tube. The next long mark 
 not lettered is 16, the next 17, the short marks 
 
62 UBINABT ANALYSIS. 
 
 between the long ones representing quarters. 
 If, then, the level of the liquid is one long mark 
 plus two short ones helow 15, then the level is 
 at sixteen and a half. Having made the read- 
 ing accurately, carry the instrument to the 
 nearest jar {Fig. 18".) filled with water, and 
 plunge the instrument below the level of the 
 water. When once below the water's edge, 
 remove the clamp and notice that instantly 
 the level of the liquid in the tube sinks. This 
 is because the pressure of the clamp being re- 
 laxed the nitrogen gas is able to expand to its 
 proper bulk, which it does, driving out the 
 liquid as it does so. Now see that the level 
 of the liquid inside the tube is the same as the 
 water outside, raising or lowering the tube ^^^ ^^'^ 
 as necessary, but always keeping its mouth use in 
 under water. Wait three minutes for diffu- Bartley's 
 sion to take place. . Then take a second read- P"^*"^®^^- 
 ing. The level of the liquid will now be down any- 
 where from the twentieth to the twenty-fifth mark, in 
 exceptional cases from the nineteenth to the thirtieth. 
 Subtract the first reading before the clamp was removed 
 from the second reading, after the clamp was removed, 
 and the difference represents grains of urea in one fluid- 
 ounce of the urine under examination. For example, 
 if, after the efl'ervescence has ceased, and the clamp 
 is still over the mouth of the tube held perpendicularly, 
 mouth down, the level of the liquid inside is at the 
 sixteen-and-a-half mark, and if, after you have plunged 
 the instrument under water and taken away the clamp 
 the level of the liquid is now at the twenty-six-and-a- 
 half mark, then twenty-six-and-a-half minus sixteen- 
 and-a-half equals ten, that is, ten grains of urea in 
 every fluidounce of the urine. 
 
 If you are working with the twenty-four hours' 
 urine, as you ought to be, then multiply the ten, or 
 whatever figure you get, by the number of fluidounces 
 of the urine in twenty -four hours ; that is, if there are 
 fifty fluidounces of urine in twenty-four hours, and ten 
 grains in every fluidounce, then you have 500 grains 
 
PROPERTIES AND REACTIONS OF UREA. 63 
 
 of urea in twenty -four hours. If you have, say forty 
 fluidounces, and the diflferenoe in the readings is seven, 
 then seven times forty, or 280 grains, in twenty-four 
 hours. [To convert grains per ounce to grammes per 
 liter, see Tabled-, Appendix. Grains total to grammes, 
 TaUe 5.] 
 
 The whole operation is simple, and takes less time 
 to perform than to describe. I recently distributed 
 Bartley's ureometers to a class of fifty or sixty stud- 
 ents who had never before used them, and the results 
 of the first trial in ninety per cent, of the cases were 
 sufficiently near my own to be " clinically accurate. ' ' 
 After three or four trials there were but one or two 
 who did not obtain the correct results. The only pre- 
 cautions of importance are : — 
 
 1. To see that the urine is taken up exactly to the 
 mark on the pipette ; 
 
 3. That the clamp is not removed until the orifice 
 of the instrument is under water. 
 
 The advantages of Bartley's instrument when provided with 
 Leslie Beebe's clamp are the following: 
 
 1. Bromine is not used. 
 
 3. The instrument is not easily broken, and can be hung up on 
 a peg or nail. 
 
 3. The decomposition of the urea within the tube takes care of 
 itself, does not need to be watched nor helped. 
 
 4. The urine, if of high specific gravity, does not need to be di- 
 luted. 
 
 5. Rubber tubing is dispensed with. 
 
 The advantages of the Leslie Beebe clamp are: 
 
 1. The instrument, thus closed, may be hung up on a nail, and 
 the physician attend to other business while the decora position is 
 going on. 
 
 2. A tall narrow glass cylinder full of water may be used, and 
 the reading easily taken when the clamp is removed. 
 
64 
 
 URINARY ANALYSIS. 
 
 OHAPTEE VIII. 
 
 THE DETEEMINATION OF UREA BY OTHER CLINICAL 
 METH0D8. 
 
 ^1 
 
 
 
 One of the most popular clinical instruments for de- 
 termination of urea is that of Dr. Doremus, of New- 
 York. No modern book on clinical urinary analysis 
 is complete without a description of this apparatus. 
 
 Doremns' instrument. {Fig. 19.) One hundred grammes 
 (1,543 troy grains) of caustic soda dissolved in 
 250 c.c. (8.5 fluidounces) of distilled water. Of 
 this solution take 10 c.c. (3.7 fluidrachms) and 
 add 1 c.c. (16 minims) of bromine. Shake the 
 mixture well, until the bromine is dissolved 
 and the whole becomes yellow in color. Di- 
 lute with 10 c.c. of water. Pour the whole 
 into the cup of Doremus' ureometer and care- 
 fully fill the limb with it by tipping backward. 
 Then by means of the curved pipette introduce 
 1 c.c. of urine into the soda solution. Ef- 
 fervescence takes place and the soda solution is 
 displaced by the gas formed. 
 
 The instruments are graduated either in 
 grains per ounce or in grammes per liter. In 
 the latter case the figures 0.01, 0.02 and 0.03 sig- 
 nify 10 gm. , 20 gm. and 30 gm. per liter, respect- 
 ively. See Table 4, Appendix, for conversion 
 to grains per ounce. 
 
 Manipulation. 
 
 1. Get Larkin & Schefifer's bromine, as the 
 bottles are easier to open. Use great care in 
 opening the bottles. 
 
 2. Use the 1 c.c. pipette in adding bromine to ^^- ^^' Doremus' 
 the caustic soda solution. ureometer, etc., 
 
 3. Dilute all urines of specific gravity 1025 ^'^^'^ foot. 
 
 or upwards with equal parts of water and multiply result obtained 
 by 2. 
 
 CLINICAL NOTE. 
 
 _ The writer has made several thousand determina- 
 tions of urea with the Doremus instrument, and can 
 commend it for simplicity. It is not as durable as the 
 Bartley, but does not involve the use of rubber tubing. 
 
DETERMINATION OF UREA. 65 
 
 The principal objections to it are the use of bromine, 
 and the necessity for diluting the urine in cases where 
 the specific gravity is above 1025, since the gas, when 
 in excess, drives the hypobromite solution below the 
 graduation. Again, unless the instrument is provided 
 with a foot, it is without support and, when it is made 
 with a foot, it is easily broken. After the foot is 
 broken insert the broken end into paraffin, melted in 
 a tin box or other receptacle and allowed to solidify. 
 
 The great advantage of the Doremus instrument, to 
 the author's mind, consists in the use of hypobromite, 
 which may be freshly made for each determination. 
 But few will agree with him from a practical stand- 
 point, since use of bromine is exceedingly unpleasant 
 to the majority. An important practical point in the 
 use of bromine is the fact that Larkin & Scheffer put 
 up bromine in such a way that it is possible to get the 
 glass stopper out of the bottle with comparatively lit- 
 tle difficulty. Novices who break bottles of bromine 
 with dangerously unpleasant results will do well to 
 note the above. 
 
 Too large quantities of hypobromite should not be 
 made, as it deteriorates on keeping, though not in a 
 week's time, as I have often observed. How much 
 longer it will keep I do not know. Again, some 
 samples of bromine combine with the sodium hydrox- 
 ide solution with more energy than others. The 
 writer once shook up 10 c.o. of bromine with 100 c.c. 
 of caustic soda solution, with result that the bottle 
 burst and was broken to atoms, either from the heat 
 generated or for other reasons. It is safer in making 
 100 c.c. to make 10 lots of 10 c.c. caustic soda solu- 
 tion containing 1 c.c. of bromine each. 
 
 The Squibb apparatus (Mg. SO) consists of three bottles con- 
 nected during the determination by rubber tubing. Into one of 
 the bottles st?,nding upright a short test tube, F, containing a 
 measured volume of the urine is dropped by means of a small for- 
 ceps. A bent glass tube and a rubber tube connect this with the 
 other bottle, B, which, at the beginning of the test, is quite filled 
 with water. Another glass tube connects B with the bottle D, 
 empty at the beginning of the test 
 
 To make the test, pour into the first bottle 20 c.c, of strong hy- 
 
 5 
 
URINARY ANALYSIS 
 
 pobromite solution, or 40 c.c. of the hypochlorite. Measure accu- 
 rately 4 or 5 o.c. of urine into the tube, drop this into the bottle 
 and insert the stopper. Fill B quite full of water, and insert its 
 stopper which drives out a little water through the short tube 
 into D. Allow the whole apparatus to stand ten minutes to take 
 the temperature of the air, then empty D and replace it. Now 
 tip the first bottle so as to mix the contents of F with the reagent 
 and shake gently. Bubbles of gas escape and pa-=sing over into B 
 drive out a corresponding volume of water. Repeat the shaking 
 of the reagent bottle several times. In a few minutes the reaction 
 
 Fia. 20. 
 
 [iriiil|iiilJI.H|iii.|ll, l |l,..|injJi i i|| 
 
 Squibb's apparatus for determination 
 of urea. 
 
 is complete, but the apparatus must be allowed to stand to cool 
 down to the air temperature. A part • if the water in D may be 
 drawn back into B. Finally measure the volumt- of water left in 
 D, and take this as the volume of gas liberated. Make the calcula- 
 tion as before on the Assumption that each c.c. of gas corresponds 
 to .0037 Gm. of inpi. 
 
 The results obtained are said to be more accurate than those 
 where but 1 c.c. of urine is used. 
 
 OLINIOAL NOTE. 
 
 The Squibb apparatus is unpopular with most stud- 
 ents and ph^'sioians, who prefer a more ready method, 
 even if the results obtained are not so accurate. 
 
 The principal objection, in the writer's mind, to 
 Squibb's apparatus is the use of small rubber tubing 
 which, in time, wears out and must be replaced. The 
 instrument is, however, certainly to be commended to 
 those who have time and opportunity for more careful 
 clinical determinations. 
 Error of the clinical instruments: 
 
 It must not be assumed that the clinical instruments 
 are chemically accurate in the results shown. When 
 
DETERMINATION OF UREA. 67 
 
 the quantity of urea in the urine is small, two to four 
 grains per ounce (1 to 2 gm. per liter), the error is 
 small, but when the percentage of urea is high, 10 to 
 1 5 grains per ounce, the error is considerable. Drs. 
 Bader, Hollo way, Leslie Beebe, and the writer have 
 conducted numerous experiments for information on 
 this point. The results have been as follows : 
 Bartley gas tube: 
 
 Solution of urea 9f grains per ounce ; five determi- 
 nations with the Bartley instrument and Leslie Beebe 
 clamp gave 10 grains, 10^, lOJ, lOf, 10|- respec- 
 tively. Error, one-half grain to a grain per ounce, 
 too high. 
 
 Solution of urea 4:f grains per ounce : Bartley gave 
 5f grains. Error about two-thirds grain per ounce 
 too high. Another determination, 5 1-5 grains, about 
 a half grain too high. 
 
 Solution of urea 15|- grains per ounce : Bartley gave 
 1 4 grains per ounce, or one and two-thirds grains too 
 low. 
 Doremus' instrument: 
 
 Solution of urea 4.7 grains per ounce: Doremus' 
 instrument 4 grains per ounce, or about three-quar- 
 ters of a grain too low. 
 
 Solution of urea 1 of grains per ounce: Doremus' 
 instrument, 11^ grains per ounce, or about 4 grains 
 per ounce too low. 
 
 Now, while these errors, from a chemist's view- 
 point, are great, clinically we have not much cause to 
 complain, for the following reasons : 
 
 1. In cases in which urea is low in grains per ounce 
 the error is usually but a fraction of a grain. Suppose 
 it be a whole grain. If the patient passes 50 ounces 
 of urine, the total error is at most 50 grains in, say, 
 200 to 300 grains total of urea per 24 hours. In cases 
 where the patient voids 80 or 100 fluidounces of urine, 
 the total error is not correspondingly increased since 
 the quantity of urea in grains per ounce wiU be less, 
 and the error less per ounce. 
 
 2. In cases where the urine is concentrated and the 
 error 2 to 4 grains per ounce, the total error is likely 
 
68 URINARY ANALYSIS. 
 
 to be no greater, if as great as above, because the 
 quantity of urine per 24 hours will be small. More- 
 over, by diluting the urine in these cases with equal 
 parts water, as is of necessity done when the Doremus 
 instrument is used, the error is not as great. 
 
 I conclude, therefore, that the clinical methods en- 
 able us to determine the total quantity of urea present 
 within 25 or 50 grains at most, which in anything 
 above 100 grains is of no great importance. In gen- 
 eral, any quantity of urea below 200 grains in 24 hours 
 is small, and above 450, large, unless in the latter case 
 the patient be a large, heavy person. If the patient 
 is passing less than 300 grains, it should attract our 
 attention. The clinical instruments certainly enable 
 us to determine these points, and also to judge in a 
 general way whether the elimination of urea is increas- 
 ing or decreasing to a marked extent. 
 
 C. Calculation of results: 
 
 BAETLBY INSTEUMENT. 
 
 1. Subtract the reading made before immersing in 
 water from that made after the Beebe clamp is removed 
 under water. The difference is grains of urea in fluid- 
 ounces of urine. Convert into grammes per liter by 
 Taile 4-, Appenmx, and find out also by this table what 
 per cent, of the normal average it is. 
 
 2. Multiply the grains of urea per ounce by the num- 
 ber of fluidounces of urine in 24 hours. Product rep- 
 resents the total grains of urea in the 24 hours' urine. 
 Convert into grammes per 24 hours by Table 5, Appen- 
 dix, and find out also by this table what per cent, of 
 the normal average it is. 
 
 3. Determine what per cent, of the weight of the 
 twenty-four hours' urine the urea for twenty-four 
 hours is, (so-called percentage of urea in the urine; 
 carefully distinguish from per cent, of normal aver- 
 age.) To do this divide the grammes per liter found 
 in 1 by 10. The result is approximate only, since the 
 specific gravity of the urine is disregarded. 
 Examples: 
 
 1. Male patient passes 40 fluidounces of urine in 24 hours: 
 
DETERMINATION OF UREA. 69 
 
 Reading before immersion, 16; after, 35. (40 fl. oz. equals about 
 
 1200 CO.). 
 
 Answers: 
 
 (a) 25 minus 16 equals 9 grains per ounce; 
 
 (b) 9 grains per ounce by Table % equals 19.35 grammes per liter; 
 
 (c) 9 grains per ounce or 19.35 gm. per liter in a male {Table 4) 
 
 equals 90 per cent, of the normal average; 
 
 (d) 9 times 40 equals 360 grains urea in ^4 hours; 
 
 (e) 360 grains by Table S, Appendix, equals about 23 grammes; 
 (/) 860 scrains, or 23 gm. in a male equals by Table S, 90 per 
 
 cent, of the normal average; 
 (g) 19.85 gm. per liter (b) divided by 10 equals 1.93 per cent, of 
 
 urea in the S^ hours' urine. 
 3. Female patient voids 66 fluidounces of urine in twenty-four 
 hours: the reading before immersion is IDf, after immersion it is 19. 
 
 (a) 19 minus 15J^ equals 3 1-4 grains urea per ounce urine; 
 
 (b) By Table 4, Appendix, SJ grains per ounce equals about 6.4 
 gm. per liter; 
 
 (c) By Table 4, Appendix, SJ grains per ounce or 6.4 gm. per 
 liter, equals about 35 per cent, of the normal average in 
 ease of females; 
 
 (d) 3i times 66 equals SIS grains urea in 24 hours; 
 
 (e) By Table 5, 215 grains ^ quals about 14 grammes; 
 
 (/) By Table 5, 215 grains or 14 gm. in females equals 70 per 
 
 cent, of the normal average; 
 (g) 6.4 gm. per liter (b) divirled by 10 equals 0.64 per cent. 
 
 (sixty-four hundredths of one per cent.) of urea in the urine, 
 
 BEPOET. 
 
 Make out a report as follows : 
 
 Urine per 24 hours, c.c fl. oz 
 
 What per cent, of normal for sex 
 
 Urea, grains per ounce 
 
 grammes per liter 
 
 What per cent, of normal for sex 
 
 Urea, grains per 34 hours 
 
 grammes per 24 hours 
 
 What per cent, of normal for sex 
 
 Chemicals and Apparatus Used in Chemical Exercise III. 
 
 An ounce of urea crystals. 
 Distilled water.— Alcohol. — Ether.— Chloroform. 
 Litmus paper. 
 
 Solution of sodium hydroxide, 100 grammes in 250 c.c. of water. 
 Solution of cuprio sulphate, one-half of one per cent. 
 Solution of furfurol, nearly saturated. 
 Hydrochloric acid, c.p., U. S. P. 
 Nitric acid, c.p., U. S. P. 
 Strong solution of oxalic acid. 
 
 One dozen five-inch test-tubes, with test-tube, rack, CEHg. SI.) 
 Bartley's urea instruments. 
 Leslie Beebe's clamp.". 
 
 Tall narrow jars, preferably 10 or 13 inches high and 3 or 3 inches 
 in diameter; in default of these any container of this size or larger. 
 Test-tube cleaner. 
 
70 
 
 URINARY ANALYSIS. 
 
 ajiliiilf n 
 
 Fig. 31. Test-tube cleaner. Fig. aS.-Xest-tube rack. 
 
 Alcohol lamp {Fig. SS), or Bunsen burner. {Fig- H-) 
 
 Fig. 33, Alcohol Lamp. 
 
 Fig. 24. Bunsen Burner. 
 
 Glass slides. 
 
 Solution of potassium bromide, c.p., freshly made. 20 per cent. 
 
 Squibb's' solution of chlorinated soda, in auiber b.)Ldes, with 
 rubber stoppers, containing 250 grammes. 
 
 [Standard methods for determining urea, and total nitrogen, 
 are given in the Appendix.] 
 
 MICEOSCOPIOAL EXEECISE I. 
 
 1. (as) Dissolve some crystals of urea in water, warm 
 a few drops of the solution on a glass slide, and exam- 
 ine with a low power (150 diameters) and subsequently 
 with a high power (500). Make a drawing in a note- 
 book, of the crystals seen. (5) Dissolve some crystals in 
 alcohol, let it evaporate spontaneously, and e.xamine. 
 See Fig. 13. 
 
 2. Perform the micro-chemical tests in which urea 
 nitrate crystals are found, making a drawing of the 
 crystals obtained as above. See Fig. llf,. 
 
 3. Add a strong solution of oxalic acid to a solution 
 of urea, warm slowly, gently and cautiously a few 
 drops of the mixture on the slide, and compare the 
 crystals obtained with those of oxalic acid and of urea 
 respectively. See Fig. 15. 
 
 EEQ0IEEMENTS. 
 
 Microscope with half-inch and one-fifth-inch objectives. 
 (Bausch & Lomb's BB stand is recommended.) Glass slides, cov- 
 er-glasses, pipettes, alcohol lamp, nitric acid, oxalic acid, alcohol. 
 
PHYSIOLOGY OF UREA. 71 
 
 CHAPTER IX. 
 
 UEEA: PHYSIOLOGY, PATHOLOGY, AND CLINICAL 
 SIGNIFICANCE. 
 
 A. PHYSIOLOGY. 
 
 Eegularity of excretion. — Urea is the chief vehi- 
 cle by which the nitrogenous food leaves the body. 
 About ninety per cent, of the nitrogen taken in the 
 food is excreted as urea. Contrary to the statements 
 of various authors I find the total amount of urea 
 passed in a day not exceedingly variable. In the 
 urine of a person of regular habits the daily excretion 
 of urea is sometimes remarkably regular : one patient, 
 for example, whose urine I examined once a week for 
 seven weeks voided a total of 13, 12, 14|^, 13^, 13, 
 12, 13-|- grammes respectively. Moreover, the amount 
 of urea voided by the same person may not vary 
 greatly in a term of years. Thus in a case in which I 
 examined the urine eight times in five years the urea 
 ranged from 14 to 24 grammes, five of the analyses 
 showing quantities from 20 to 24 grammes inclusive. 
 
 It would seem that the quantity of urea passed by 
 an Individual fluctuates within a not very great range, 
 and that, if the average for any ten days be compared 
 with that of any other ten days, the diilerence is not 
 great. 
 
 In one case the average excretion for a period of ten 
 days was to a grain (0.6 gm.) the same as that for 
 another period of the same length. 
 
 Quantity per twenty-four hours The figures 
 
 given by English observers as the average in twenty- 
 four hours, 26 to 33 grammes (412 to 515 grains), I 
 regard as being too high. Out of 200 Americans 
 whose urine contained neither albumin nor sugar I 
 found only 11 to contain as much as 30 gm. 
 
72 URINARY ANALYSIS. 
 
 (465 grains) in twenty-four hours. Two-thirds 
 voided less than 20 gm. (310 grains) in twenty- 
 four hours. But inasmuch as nearly all these 
 persons were not typically healthy, and in 
 fact many were ill enough to consult a physician, I 
 can not take their average as the normal one. But 
 the urine of such healthy Americans as I have exam- 
 ined has scarcely ever contained as much as 500 grains 
 of urea. I would assume the quantity to be about 
 26J gm. (410 grains) in men, and 20|- gm., or 315 
 grains, in women. These are the figures of the French 
 observers, Tvon-Berlioz, and I regard them as approach- 
 ing more closely our American average than the Eng- 
 lish figures do. 
 
 The excretion of urea per hour is said to be 0.015 to 
 0.035 gramme for every kilogram of weight; that is, 
 0.231 to 0.54r of a grain for every 2^ pounds. For 
 adults I would regard the smaller figure rather than 
 the larger as correct. 
 
 Children are said to void 0.131 gm. a day for every 
 kilogram of weight when weighing from 18 to 36 kilo- 
 grammes (4|- grains for every pound when weighing 
 from 40 to 80 pounds), and 0.122 gm. when weighing 
 from 28 to 56 kilograms (4 grains per pound from 60 
 to 120 pounds.) At this rate we would expect a child 
 weighing 40 pounds to pass 180 grains of urea in 
 twenty-four hours. 
 
 I have examined the urine of a number of children. 
 The urea figures are given at the end of this chapter. 
 Men pass 17 to 21 grammes per liter (8 to 10 grains 
 per ounce), and women 16 to 19 (7^ to 9). 
 
 Formatioii in the body. — Part of the urea excreted 
 may possibly be formed in the liver from ammonium 
 carbonate. The reasoning that points to the liver as 
 the chief seat of urea formation is as follows : 
 
 1. In diabetes, where we know the metabolism of 
 hepatic cells is greatly increased, urea is increased 
 
 2. In degenerative changes in the liver, urea forma- 
 tion is decreased. 
 
 Unfortunately, however, the first of these premises 
 is vulnerable. Out of 45 typical diabetics, in whose 
 
PHYSIOLOGY OF UREA. 73 
 
 twenty-four hours' urine the author determined the 
 urea, half voided from 20 to 40 grammes, (310 to 620 
 grains) which is not an excessive amount considering 
 the polyuria, and 15 patients voided less than 465 
 grains (30 grammes), which is less than the normal 
 average of the English. A comparatively low ex- 
 cretion of urea is possible even in severe oases of 
 diabetes ; for example, one of the writer's patients 
 passed only 265 grains of urea in the twenty-four 
 hours' urine, containing five-and-a-half per cent, of 
 sugar, or nearly 1,250 grains. 
 
 Moreover, in diseases not attended by degenerative 
 changes in the liver a low excretion of urea may be 
 found: as, for example, in the case referred to the 
 writer by Dr. Thomas E. Eoberts, in which in 825 c.o. 
 (27 fl. oz.) of urine there was less than 1 gm. (15 
 grains) of urea. "Women often void as little as 6 
 grammes (93 grains) in a day and recover. 
 
 In view of such facts I am inclined to agree with 
 Dr. Long, who says, "how or where the conversion 
 of nitrogen into urea takes place is not known." 
 
 Effect of diet and exercise. — Urea is increased by 
 animal diet, and mental and physical activity ; decreased 
 by non-nitrogenous diet and quietude. Hence, more 
 urea is voided during the day than during the night. 
 In thirty-one instances in which the writer has examined 
 the day urine and night urine of twenty-three patients 
 separately the day urea was found to be greater than 
 the night urea in twenty-nine out of the thirty-one 
 samples examined. In only six of the twenty-nine 
 was the day urea as much as twice the night urea, and 
 in but two instances, three times. The amount by 
 which the day urea exceeded the night varied from 0.3 
 gm. (5 grains) to 1 5 gm. (225 grains) ; the average excess 
 of day over night was about 2.5 grammes (40 grains). 
 One of the two oases in which the night urea exceeded 
 the day was that of acute chorea following diphtheria ; 
 in the other the diagnosis is unknown. 
 
 Effect of mill( diet. — Milk is said to increase urea 
 in urine. One of my patients voided 46 gm. (715 
 grains) of urea on strict milk diet, but, unfortunately, 
 
74 URINARY ANALYSIS. 
 
 what his excretion was prio:' to the diet is not known. 
 In another case no increase at all was noticed in a con- 
 siderable period of time. Both were cases of slight 
 albuminuria without casts. 
 
 B. PATHOLOGY. 
 
 Relative urea and absolute urea — Much confu- 
 sion has been caused in the past by not distinguishing 
 a relative increase in urea from an absolute increase. 
 By relative increase in urea we mean an increase in 
 urea as compared with some other constituent of the 
 urine, notably water. In this book when speaking of 
 relative increase of urea I shall mean an increase com- 
 pared with the water of the urine, i. «., an increase of 
 urea in grains per ounoe (grammes per liter). 
 
 Thus, if the urine of a certain patient contain 15 
 grains of urea to the ounce of water, urea in this case 
 is relatively increased, since 8 to 10 grains per ounce 
 is normal. 
 
 By absolute increase in urea we mean increase in the 
 total urea for twenty -four hours as compared with the 
 normal average quantity for that period : thus, a 
 patient who passes 750 grains of urea in twenty-four 
 hours, voids urea which is absolutely increased in 
 quantity. 
 
 Relative increase and absolute deficiency. — Some- 
 thing which puzzles beginners is the fact that a patient 
 may pass urine in which urea is relatively increased 
 but absolutely deficient. Thus, suppose a patient 
 voids 10 ounces of urine in twenty-four hours contain- 
 ing 15 grains of urea to the ounce. Urea is increased 
 relatively., since 15 grains to the ounce is one-and-a- 
 half times the normal average of 10 grains to the 
 ounce ; but urea is decreased absolutely^ since the total 
 product is 10 times 15, or 150 grains total, about one- 
 third the normal quantity for twenty-four hours. 
 
 Relative deficiency and absolute increase. — Again, 
 in the same urine urea may be relatively deficient and 
 absolutely increased : thns, if a patient voids 1 00 
 ounces of urine containing 6 grains to the ounce, urea 
 is deficient relatively, since 6 grains per ounce is less 
 
PATHOLOGY OF UREA. 75 
 
 than 6 to 10, the normal range. On the other hand 
 urea is increased absolutely, since 600 grains the total 
 quantity, is in excess of the normal range, 400 to 500 
 grains at most. 
 
 DISEASES IN WHICH UREA IS DECREASED IN GRAINS PER 
 
 OUNCE (relative DEFICIENCY OF URBA). 
 
 Urea is decreased relatively from physiological causes, 
 after copious ingestion of fluids. Pathologically rel- 
 ative decrease takes place in the following diseases : 
 
 1. Chronic nephritis, except when dropsy is exces- 
 sive. 
 
 2. Diabetes insipidus. 
 
 3. Hysteria (after paroxysm). 
 
 4. Anaemia. 
 
 5. Some cases of neurasthenia. 
 
 EXAMPLES. 
 
 In eighteen cases of chronic nephritis in which the 
 twenty-four hours' urine contained large percentage of 
 albumin, urea was relatively deficient in all but four. 
 In one case but 2 gra. per liter of urea (1 grain per 
 ounce) was found. Nine grammes per liter (4 grains 
 per ounce) is quite commonly observed in chronic 
 interstitial nephritis. In one case of hysteria with 
 anaemia urea was as low as 1 gramme per liter (one- 
 half grain to the ounce.) The patient recovered and 
 afterwards voided normal urine. In some cases of 
 neurasthenia the writer has noticed urea 9 to 13 
 grammes per liter (4^ to 6 grains per ounce), but 
 this is not invariable. 
 
 DISEASES IN WHICH UREA IS INCREASED IN GRAINS PER 
 
 OUNCE (relative INCREASE). 
 
 Urea is relatively increased physiologically by 
 abstinence from liquids or other causes which diminish 
 the volume of urine. Pathologically it is increased 
 relatively in the following diseases : 
 
 1. Febrile- disorders, especially acute rheumatism. 
 
 2. Acute or chronic nephritis, where the urine is 
 concentrated and high-colored from dropsy. 
 
76 URINARY ANALYSIS. 
 
 3. Congestion of the kidneys. 
 
 4. Certain hepatic disorders. 
 
 5. Some cases of diabetes mellitus. 
 
 6. Certain nervous diseases. 
 
 7. Before the convulsions of pregnancy. 
 
 EXAMPLES FROM THE AUTHOR'S CASES. 
 
 In all these cases the twenty-four hours' urine is understood as 
 specified. 
 
 Chronic Nephritis. — In the case of a dropsical woman 31 gm. 
 grn. per liter (15 grains per ounce) and subsequently S5 gm. and 31 
 (12 grains and 10 grains). In the case of a -woman who passed 
 but 40 CO. (1 fl. oz.) of urine in twenty-four hours, urea was 49 gm. 
 per liter (23 grains per ounce). 
 
 G-all-Stonb Colic — la one case 41 gm. per liter, 30 grains per 
 ounce. 
 
 Diabetes Mellitus. — The greatest quantity of urea 
 ever found by the writer in diabetes was 35 grammes 
 per liter (16 grains per ounce). The lowest, 5 gm. per 
 liter (2^ grains per ounce). In the majority of oases 
 10 to 21 gm. per liter (5 to 10 grains per ounce). 
 Nervous Diseases : 
 
 Epilepsy, in a boy of twelve years. 
 
 Chronic meningitis. 
 
 Oxaluria. 
 
 Canoke. — In one case of cancer of the intestines 
 the writer noticed relative increase of urea in the 
 urine. Absolutely it was diminished. 
 
 Convulsions of Pregnancy. — In two cases of 
 puerperal nephritis the writer has observed a high per- 
 centage of urea, 12 and 16 grains per ounce (25 and 
 33 gm. per liter), respectively. In one case the 
 patient died of convulsions in less than a day ; in the 
 other there was vomiting, diarrhoea, and urine loaded 
 with albumin. 
 
 The second case was that of a woman who had a 
 history of puerperal convulsions at the same date in a 
 previous pregnancy. Her urine was carefully and 
 fully examined by me from time to time during the 
 early months of pregnancy and found to be abundant, 
 pale, of poor quality, urea about 4 grains per ounce 
 (9 gm. per liter), albumin small, two per cent. hulk. 
 Suddenly, without warning, the urine became scanty, 
 concentrated, highly acid, urea increased to 16 grains 
 
PATHOLOGY OF UREA. 77 
 
 per ounce, and albumin to the enormous figure of 60 
 per cent, bulk, or about one per cent, weight. At the 
 same time she was seized with violent vomiting and 
 purging. 
 
 It is evident that in these cases urea is not decreased 
 relatively, as in the uraemia of interstitial nephritis, 
 but is decidedly increased, 
 
 CHEMICAL EXERCISE IV. 
 
 Repeat the determination of urea, this time compar- 
 ing the Bartley clinical instrument with the Doremus 
 in various ways. 
 
78 URINARY ANALYSIS. 
 
 CHAPTEK X. 
 
 PATHOLOGY AND CLINICAL SIGNIFICANCE OF UREA, 
 (CONTINUED.) 
 
 Diseases in which urea is decreased in total 
 quantity for the twenty-four hours. 
 
 Urea is decreased in total quantity per twenty-four 
 hours (absolute decrease) in the following : 
 
 1. Cheonio Diseases. Especially many nervous 
 ones; in chlorosis, paralysis, ovarian tumor, uterine 
 cancer, chronic nephritis', 
 
 2. In diseases of the liver, notably acute yellow- 
 atrophy ; 
 
 3. Preceding and during uroemic attachs. 
 
 4. Before paroxysms of gout and asthma. 
 
 5. In yellow-fever and in cholera. 
 
 EXAMPLES FROM THE AUTHOR'S CASES. 
 
 Internal Cancer. — In two cases the urea was absolutely dimin- 
 ished. In one of these two relatively and absolutely dlmiaished. 
 Eleven grammes (170 grains) total in each case. The diagnosis 
 was verified. 
 
 Uterine Fibroid. — In two cases 15 and 14 gm. (325 and 210 
 grains) total. 
 
 Chronic Cystitis in an Anemic Woman.— Eight analyses gave 
 an average of only 8.5 gm. (130 grains). The patient had an 
 ureemic attack, but recovered and is alive today. 
 
 Chronic N.phritis. — In one case a dropsical woman averaged 
 10.5 gm. (165 grains) in nine analyses made during the last month 
 of life. 
 
 In twenty-eight fatal cases of chronic nephritis in which dur- 
 ing life albumin together with granular, fatty or waxy casts 
 were found the average total urea excretion was 14 gm. (210 
 grains). When albumin was very abundant urea was below the 
 normal in fourteen out of 18 cases, and never above normal. 
 
 In one case a female patient several days before death voided 
 only 1.5 gm. (22 grains of urea) in twenty- four hours. 
 
 Occasionally urea is not greatly diminished until shortly before 
 death. One patient, male, aged 55, dropsical from head to foot, 
 passing urine loaded with albumin, several weeks before death, 
 voided 20 gm. of urea (300 grains). A few days before death 
 urea decreased materially. 
 
 Acute Chorea.— In one case, a child, urea was relatively and 
 
CLINICAL SIGNIFICANCE OF UREA. 79 
 
 absolutely decreased, 10.5 gm. (160 grains) total, and night urea 
 exceeded day. 
 
 Chronic Rheumatism. — Patient, male, unable to move, 
 averaged 13 grammes (200 grains) in seven analyses covering a 
 period of seven weeks, and lived several years afterward. 
 
 Chronic Albuminuria. — A man, aged 45, averaged 21 grammes 
 (325 grains) during scattered analyses extending over a period of 
 five years. There was absence of other symptoms. 
 
 Chronic Prostatitis. — A man. aged 70, averaged 19 grammes 
 (800 grains) in ten analyses made one each week for ten consecu 
 tive weeks. He was invariably worse whenever urea fell below 
 20 sframmes daily; better when it was higher. 
 
 Psoas Abscess. — A child of 12 years; urea 7 grammes (110 
 grains). The case resulted fatally. 
 
 Nervous Diseases. — In the case of one hundred patients with 
 various nervous diseases the urea per twenty-four hours in the 
 majority of cases was from 14 to 30 grammes (210 to 465 grains). 
 In about one-quarter of the cases it was less than 14 grammes, 
 but in only about 5 per cent, of the cases above 30 grammes. 
 The diseases in which urea was greatly decreased, below 14 gm. 
 (210 grains), were as follows: 
 
 Great relative and absolute decrease. — Epilepsy; neurasthenia; 
 reflex nervous headaches from uterine diseases; acute chorea fol- 
 lowing diphtheria; locomotor-ataxia. 
 
 Ch-eat absolute decrease only — Irregular cerebral development; 
 spinal irritation, witli chronic meningitis; epilepsy; cerebral 
 hemorrhage and hemiplegia; aphasia, with paralysis. In the last 
 two cases, 11.5 gtn. (178 grains) and 7 gm. (110 grains) respectively. 
 
 Moderate decrease. — Diseases in which the deficiency of 
 urea was moderate, 14 to 17 grammes (220 to 265 grains) in 
 twenty-four hours were as follows: writer's cramp: oxaluria with 
 mental and nervous symptoms; epilepsy in a young girl; hysteria 
 in a neurotic woman; neuritis; cerebral tumor: insanity (reflex 
 from uterine disease); posterior spinal sclerosis; paralysis agi tans; 
 paralysis from softening of the brain; nervous symptoms reflex 
 from uterine disease (two cases); neurasthenia; neurasthenia wiili 
 tremor. 
 
 Urea nearly normal. — Diseases in which the excretion of 
 urea was nearly normal, 18 to 25 gm. (280 to 390 grains), were the 
 following: Chronic cerebral meningitis and facial paralysis; brain 
 symptoms following sun-stroke; neurasthenia (three cases); epi- 
 lepsy in a child of 11; nervous symptoms reflex from uterine dis- 
 order; epilepsy in a l3oy of 12; localized chorea; melancholia fol- 
 lowed by suicide; congenital neurasthenia; cephalalgia foUowiag 
 pneumonia; sexual neurasthenia; hypochondria; nervous symp- 
 toms reflex from disease of the eye; hysteria in several male 
 patients; chorea; reflex epilepsy; epilepsy; melancholia. 
 
 Urea normal. — Diseases in which urea was full normal were 
 the following: Nervous symptoms, from worry and abuse of 
 tobacco; epileptoid convulsions; melancholia; nervous symptoms 
 reflex from uterine disease, and from rectal diseases; torticollis 
 in a neuropath; epilepsy in a boy. 
 
80 URINARY ANALYSIS. 
 
 DISEASES IN WHICH UEEA IS INOEEASED IN TOTAL QUAN- 
 TITY FOE TWENTY-FOtTE HOUES (ABSOLUTE INCEEASE). 
 
 Urea is increased ia absolute quantity (total per 
 twenty- four hours) in — 
 
 1. Acute febrile diseases with emaciation, as typhoid 
 fever; pneumonia; the exanthematous diseases; ty- 
 phus ; to some extent in remittent fevers ; intermittents 
 iefore the chill ; 
 
 2. PvEemia; 
 
 3. Some cases of diabetes ; 
 
 4. Atrophy from dyspepsia in children (Parrot- 
 Kobin) ; 
 
 5. Phosphorus poisoning; 
 
 6. Some nervous diseases, as progressive muscular 
 atrophy ; 
 
 7. Sometimes in dififuse bronchial catarrh without 
 fever. 
 
 EXAMPLES PROM AUTHOR'S CASES. 
 
 Pneumonia. — In one case the patient, male, on the second day 
 and before the diagnosis was established with certainty passed 4^*1 
 gm. (750 grains) Convalescing passed but 30 gm. (465 grain-!.) 
 
 Diabetes. — In one case a male patient passed 81 grammes (IS-l't 
 grains). Six out of 43 patients voided more than 50 gm. (775 
 grains). 
 
 0. CLINICAL NOTES. 
 
 1. A high figure of relative urea (grammes per 
 liter, grains per ounce) is not necessarily a favorable 
 sign in acute or chronic nephritis, for it may mean 
 merely scanty urine, which is usually an unfavorable 
 sign. 
 
 2. A low figure of urea, relative and absolute, is 
 almost always observed in chronic nephritis. 
 
 3. Patients with chronic nephritis seldom show 
 increase in absolute urea (grammes per twenty-four 
 hours, grains per twenty-four hours) proportionately 
 to increase in urine voided. 
 
 4. In one case under the influence of diuretin the 
 amount of absolute urea was diminished one-half, 
 although the quantity of urine was increased six-fold. 
 
 5. A patient on the same diet may pass more urea 
 
CLINICAL SIGNIFICANCE OF UREA. 81 
 
 both absolutely and relatively in 1,000 c.c. of urine 
 (33 fl. oz.) than in 2,000 (66 fl. oz.) 
 
 6. In diabetes the safest excretion of absolute urea 
 appears to be from 20 to 30 grammes (310 to 465 
 grains) in twenty-four hours. The mortality in cases 
 where more than 60 grammes (930 grains) are voided 
 is high. 
 
 7. It is possible for a pregnant woman with a his- 
 tory of convulsions in a previous pregnancy to be con- 
 fined without convulsions when 20 days before confine- 
 ment urea is but 8 gm. per liter (4 grains per oz.) and 
 7 gm. per twenty-four hours (125 grains), albumin 
 and casts being absent. 
 
 8. It is possible for a pregnant woman with the 
 urine and urea of chronic nephritis to be delivered 
 safely and to have no convulsions after delivery. 
 
 9. On the other hand, it is possible for a pregnant 
 woman to die of urseraic convulsions when twenty -four 
 hours before death urea was 25 gm. per liter (12 grains 
 per ounce), albumin and casts, granular and waxy, 
 being present. 
 
 10. It is possible for a pregnant woman to die of 
 convulsions when a week before death urea is normal 
 both relatively and absolutely, albumin being a plain 
 trace, but no casts present. 
 
 11. It is possible for a pregnant woman to have 
 numerous convulsions at term and survive, who passed 
 20 gm. (310 grains) of urea in twenty-four hours a 
 few days before confinement, albumin being between 
 first and second mark on Esbaoh tube, casts, a few hy- 
 aline. 
 
 12. Drug's which are said to diminish urea are al- 
 cohol, digitalis, mercury, tea, valerian, lead, all drugs 
 which interfere with the functions of the liver ; phospho- 
 rus to increase urea temporarily ; quinine to diminish 
 urea at first ; potassium bromide to decrease urea while 
 the bromide is being eliminated ; arsenic to increase 
 it at first. 
 
82 URINARY ANALYSIS. 
 
 The author has noticed a diminution of urea in cer- 
 tain cases in which diuretin was given, but cannot say 
 positively that it is a characteristic of this drug. 
 
 13. The drugs which are said to increase urea are 
 the mineral acids, excess of alkaline chlorides, iron 
 "tonics," squill, juniper, potassium chlorate, pepsin, 
 maltin, euonymin, mercuric chloride, salicylic acid, 
 benzoic acid, lithium benzoate, colchicum, and drugs 
 which stimulate the liver. 
 
 The author has verified repeatedly this statement in 
 regard to lithium benzoate, which will often in- 
 crease both urine and urea per twenty-four hours, and 
 sometimes increase relative urea. 
 
 14. In certain cases where there are obscure ner- 
 vous symptoms, reasoning by exclusion leads us to 
 suppose that retention of urea in the body is the cause 
 of the trouble. Fifteen analyses made by the author 
 in the case of a chronic invalid, from the year 1891 
 to death in 1896, showed usually about 10 gm. (155 
 grains) or less of urea, never more than 13 gm. (200 
 grains), and once or twice less than 7 gm. (105 
 grains). To such cases Dr. Delamater has given the 
 name uroemia chronica. Less than 13 grammes 
 (200 grains) of urea occurred in other cases quite 
 frequently. 
 
 15. Of interest in confirming the writer's observations 
 is the following : Lucas-Championniere has found in 
 800 determinations that the quantity of urea on the 
 average does not, as is generally believed, vary 
 between 3Y5 and 450 grains, but really between 225 
 and 300 grains. Diminution of urea is most marked 
 in ovarian cancer where, before surgical interference, 
 effort should be made to increase the amount of urea 
 by rest, milk diet, and relief of pain (anodynes). In 
 mild ovarian disease urea may fall below 100 grains in 
 twenty-four hours, to rise rapidly above it on milk diet. 
 Pain reduces excretion of urea, and the patient's vital- 
 ity may be thus so lowered as to influence materially 
 the success of operation. Success of operation is in- 
 versely proportional to the quantity of urea before the 
 operation. The second or third day after major 
 
CLINICAL SIGNIFICANCE OF UREA. 83 
 
 operations the proportion of urea increases; thus, 
 after removal of the appendages of both sides urea may 
 rise from 60 or Y5 grains to 375 grains. 
 
 UREA IN THE URINE OF CHILDREN. 
 
 Girls. — Six analyses of the twenty-four hours' urine of a girl 
 five years of age, showed an average of 13 to 13 gm. per liter (6 
 grains per ounce), and an average total of 8 grammes (183 
 grains). Albumin in small quantity was constantly present, but 
 no oasts. 
 
 In a girl of six years, urea was 8J gm. per liter (4 grains per 
 ounce); total 11 gm. (170 grains). 
 
 A girl of eight years voided 13 gm. per liter (5} grains per 
 ounce); total lOi grammes or 160 grains. 
 
 A girl of ten years voided 31 gm. per liter (10 grains per ounce); 
 total 14| grammes (230 grains). 
 
 A girl of twelve years voided 21 gm. per liter (10 grains per 
 ounce) and 19 gm. total (300 grains). 
 
 Two other girls, ages unknown, voided 10 gm. (155 grains) and 
 11 grammes (175 grains), respectively in twenty-four hours. 
 
 From these cases it appears that female children between 5 and 
 15 years old void from 8 to 19 grammes, 130 to 300 grains. 
 
 Boys. — A boy of twelve years, weight 83 pouads, voided on an 
 average 18 gm. per liter, 8 grains per ounce; total 11 gm., 175 
 grains. 
 
 A boy of twelve years, weighing 84 pounds, voided 17 gm. per 
 liter, 8 grains per ounce; 13 gm. total or 200 grains. 
 
 A feeble-minded boy of ten years voided 19 gm. per liter (9 
 grains per ounce); total 8 grammes, 135 grams. 
 
 A boy of twelve years, with subacute diffuse nephritis, voided 
 200 grains total of urea on ten separate occasions (13 grammes 
 per twenty-four hours). 
 
 An infant barely one year old, male, slowly dying of an obscure 
 dis-order in which the urine contained albumin and at times traces 
 of blood, but no casts, voided but 3gm. urea per liter (1 grain per 
 ounce), and never over 3 grammes total or 30 grains during six 
 weeks of fatal illness. 
 
 A diabetic boy of ten years, averaged 18 gm. per liter (8 1-3 
 grains per ounce); total averaged 24 grammes, about 400 grains. 
 Case terminated fatally in a few years. 
 
 A diabetic girl of twelve years, passed 33 gm. per liter (11 grains 
 per ounce) and 43 grammes total or 665 grains. This case soon 
 terminated fatally. 
 
 Epileptic Children. — A girl of eight years (epileptoid) voided 
 34}^ gm. per liter (11 grains per ounce); total 13| gm. (2 1 grains). 
 
 A boy of ten years voided 36 gm. per liter. 13^ grains per 
 ounce; total 19 gm. or 195 grains. 
 
 A boy of eleven years voided 13 gm. per liter, 5J grains per 
 ounce; total 18i gm. (285 grains). 
 
 Another epileptic boy, C. T , age unknown, voided on an 
 average 83 gm. per liter, 16 grains per ounce; total averaged 27 
 gm or 425 grains. 
 
 In other words, there seems to be a tendency in the majority of 
 epileptic cases in children toward relative increase in the excre- 
 tion of urea, and in some cases absolute as well. 
 
84 URINARY ANALYSIS. 
 
 CHEMICAL EXERCISE IV. 
 
 Compare the three clinical instruments, Bartley, 
 
 Doremus, and Squibb, using — (a) a known solution of 
 
 urea, and (5) the same sample of urine. 
 
 For the Liebig process for urea and the Kjeldahl luethod of 
 determining total nitrogen, see Appendix. 
 
CHEMISTRY OF URIC ACID. 85 
 
 OHAPTEE XI. 
 
 THE CHEMISTRY OF URIC ACID. 
 
 TTeio acid occurs uncombined in normal urine in but 
 minute quantity. Combined it forms salts called urates, 
 which occur in solution in the urine in considerable 
 quantity. It is the custom among physicians, how- 
 ever, to use the term "uric acid" rather than urates, 
 in referring to various clinical conditions in which these 
 substances are thought to play a part. It must be dis- 
 tinctly understood that the urates may be found both 
 dissolved in the urine, and undissolved in the sediment 
 of urine. The following table will make the matter 
 clear : 
 
 tmiO ACID AND URATES. 
 
 Uric acid. — In solution, normally, in small quantity. In the 
 sediment, abnormally in comparative abundance. 
 
 Urates. — Normally in solution in comparative abundance. Ab- 
 normally in sediment in comparative abundance. 
 
 The most convenient method to determine the 
 quantity of urates in urine is to convert them into uric 
 acid ; or, more scientifically stated, to set free the uric 
 acid which they contain, and determine the quantity 
 of that. Hence the chemist speaks of the amount of 
 uric acid the urine contains, rather than the amount 
 of urates. It should be understood also, before pro- 
 ceeding further, that uric acid is a weak acid, and 
 but loosely combined with the various bases, so that on 
 addition of stronger acids, as hydrochloric, to urates, 
 the stronger acid drives away the uric acid from its 
 combination, or "sets it free," as chemists say. More- 
 over, uric acid differs from the familiar mineral acids, 
 nitric, sulphuric, and the like, in being a crystalline 
 solid, instead of a liquid, and in being difficultly soluble 
 in water. 
 
 Normal urine, then, contains in solution uric acid 
 combined with sodium, potassium, etc. , forming urates 
 
86 URINARY ANALYSIS. 
 
 of sodium, potassium, etc. Under abnormal 
 circumstances, to be described later, these urates 
 may be thrown out of solution and appear as a sedi- 
 ment; and, still further, uric acid, itself, may be set 
 free, and appear, itself, in the sediment. All normal 
 urine contains urates dissolved in it. Some abnormal 
 urine may contain urates as a sediment, some abnor- 
 mal urine may contain uric acid as a sediment, some 
 abnormal urine may contain both urates and ui'ic acid 
 as a sediment. In the author's experience as a 
 teacher much confusion results in the minds of students 
 unless, these facts just stated are thoroughly under- 
 stood. 
 
 UEIO AOID (FOEMINa TJEATES) IN SOLUTION. 
 
 Synonyms: 
 
 Uric acid. Gbeman, Harnsaiire, French, Acide 
 Urique. 
 
 Urates. Geeman, SamsaUre Salzen, JJraten; 
 Feench, Us urates. 
 
 Chemical constitution — JJrio acid: — C^HiN^Oj 
 an organic substance containing 33 per cent, of 
 nitrogen; a dibasic acid, H3(Cs,n2TSr,03), that is con- 
 tains two atoms of hydrogen replaceable by two of 
 a monad metal. 
 
 NH.C.NH~.^Pf. . „„„„ 
 
 The structural formula is saidto be C0<;; CNH^^ 
 
 NH.CO 
 
 a derivate of acrylic acid or acrylic acid diureid. The diureids are 
 compounds formed from two molecules of urea. Acrylic acrid is 
 CiHaO,. 
 
 Urates. — Compounds of uric acid in which one or 
 two atoms of hydrogen of the acid have been replaced 
 by an equivalent of a metal, thus, sodium urate, 
 ]S'a,(C,HjlN'jOj). Two kinds of urates are recognized, 
 namely, acid urates and neutral urates. Acid urates 
 (biurates) are those in which but one atom of hydro- 
 gen has been replaced by the metal, as ]Sra(CBH5]Sr,03), 
 acid sodiuni urate. Neutral (normal) urates are those 
 in which both replaceable hydrogen atoms have been 
 set free, as in the case of sodium urate above. 
 
 The formation of the two different kinds of urates is shown by 
 
CHEMISTRY OF URIC ACID. 87 
 
 the following equations, accordinp; as uric acid combines with 
 potassium, sodium, or ammonium carbonate or hydrate: 
 
 C6H4N403+3NaOH=Na2(C6H,N403)+3HsO. 
 
 C6H4N403+NajC08=NaH(CiHjN403)+NaHC03. 
 
 The following table shows the different urates, let- 
 ting U represent the unchangeable bracket C^ H, N, 
 O. : 
 
 Urates.* Formula. Solubility in water. 
 
 Acid ammonium NHiHZJ 1 in 1600 
 
 Acid sodium NaHCJ 1 in 1200 
 
 Acid potassium KHU" 1 in 800 
 
 Acid calcium CaH.^Z7( 1 in 600 
 
 Neutral sodium Na^D" 1 in 77 
 
 Neutral potassium Kj Z7 1 in 44 
 
 Neutral calcium Caf7 1 in 1500 
 
 Occurrence. Uric acid: — In solution in all normal 
 urine of human beings in the form of urates. In the 
 sediment under abnormal conditions as free uric acid 
 or as urates. More abundantly in the urine of birds 
 and scaly amphibians ; in large quantities in ' 'chalk- 
 stones," calculi, and in guano. 
 
 Form. Uric acid in sediments is crystalline. Urates 
 in sediments may be either crystalline or amorphous. 
 (See Sediments.) 
 
 Solubility: 
 
 A. Ujtio Acid : 
 
 1. Soluble with difficulty in water: 1 in 16000 cold 
 
 water; 1 in 1900 boiling water. 
 
 2. Insoluble in alcohol and ether ; soluble in boiling 
 
 glycerine. 
 3.. Soluble in sulphuric acid without decomposition. 
 
 4. Soluble in nitric acid with decomposition. 
 
 5. Soluble in solutions of caustic alkalies, as caustic 
 
 soda and caustic potash, less so in ammonia. 
 
 6. Soluble in alkaline solutions of the lactates, 
 
 phosphates, as sodium phosphate; carbonates, 
 as lithium carbonate; acetates and borates, 
 forming neutral salts. According to Haig 
 salicylate of sodium is a powerful solvent. 
 
 ♦According to Bence Jones the salts of uric acid are really 
 gwadrMrafes, composed of a molecule of acid urate and a molecule 
 uric acid, thus potassium quadrurate C6HsKN40s.' tH4NOj or K 
 HJ7HaJ7. The "'Hterof the urine brealis these up into tree uric 
 acid and acid urates. 
 
88 VniNARY ANALYSIS. 
 
 7. In solutions of piperazine, lycetol, lysidin, tartar- 
 
 lithine, tetra ethyl-ammonium hydroxide.* 
 
 8. According to Klemperer, solutions of pure urea 
 
 exercise solvent action on uric acid ; according 
 to Eudel, a liter of a 2 per cent, solution 
 of urea dissolves 0. 529 gm. of uric acid. 
 
 9. In the body, sodium chloride by forming sodium 
 
 carbonate, contributes to the solubility of uric 
 acid in the blood. 
 
 10. According to Posner urine best dissolves uric 
 acid when of low specific gravity, and not in- 
 tense reaction of either kind. 
 
 B. Neuteal Urates : 
 
 1. Lithium urate most soluble in water ; potassium 
 
 and sodium next, calcium least. 
 
 2. Eeadily soluble in hot water. 
 
 (See Sediments for individual solubilities.) 
 
 C. -Acid Urates : 
 
 1. Sparingly soluble in cold water, especially am- 
 
 monium urate. 
 
 2. Eeadily soluble in hot water. 
 
 (See Sediments for individual solubilities.) 
 
 Note: — Hence most urinary sediments of urates are acid urates. 
 Owing to the feeble solubility of the acid urates in cold water, these 
 substances are deposited as the urine cools. On the other hand 
 urine highly charged with neutral urates may remain clear but, 
 on addition of a strong mineral acid, as nirric acid, a whitish 
 opacity is occasioned owing to formation and separation of acid 
 urates, which, however, may be dissolved by heat. 
 
 State : Pure uric acid is a white, odorless, tasteless 
 
 powder consisting of very small rhombic prisms or 
 
 plates. As obtained from urine it is colored pinkish 
 
 by urinary pigments. 
 
 Preparation: 
 
 A. Synthetically in several ways: 
 
 1. By fusing urea and glycocoU (amido-acetlo acid) the latter 
 in one-tenth the weight of the former (hydantoin and biuret are 
 intermediate products), thus; 
 
 C,H,N05+3CH,N50=CsH.N40,+3NH,+HjO. 
 
 GlycocoU, Urea, Uric acid. 
 
 3. By heating trichlor-lactic acid-amide (oyanuric acid, carbon- 
 dioxide, and other by-products not considered) with excess of 
 urea: CsCl.H.OaN+SCHiNjO—CBHiNiOs+HjO+NHiCl+aHCl. 
 
 *See author's Chemistry, 4th ed. , p. 338. 
 
CHEMISTRY OF URIC ACID. 89 
 
 3. From isobarbiturio acid, a ureide of oxypyruvic aoid. 
 B. From the excrement of serpents, guano, or urine as follows: 
 
 1. From serpont excrement by boiling; with dilute solution of 
 caustic potash aad filtering hot; the hot filtrate contains the neu- 
 tral potassium urate. On passing carbonic acid gas into it one- 
 half the potassium is displaced, and the acid potassium urate pre- 
 cipitated according to the equation — 
 
 3C6HsKjN«Os+C02+HaO=KaCOs+3CsH8KN40, 
 Neutrxl poassiam urate Acid potassium urate 
 
 The acid urate being washed is decomposed by hydrochloric acid 
 and yields uric acid. 
 
 3. From guano by boiling with a solution of one part borax in 
 20 parts water; acidulate the solution and a brown, impure pre- 
 cipitate of uric acid is obtained, which, being washed and decom- 
 posed with hydrochloric acid, yields a purer uric acid. 
 
 3. From urine by adding to it one-fifth its volume of hydrochlo- 
 ric acid to decompose the urates, allowing to stand in a cool 
 place for several days, decanting, and dissolving the separated 
 crystals (adhering to the sides of the vessel) in sulphuric acid, and 
 preclpitatinsr with water. 
 
 Relationships. 1. Uric acid strongly heated decomposes with 
 formation of urea, hydrocyanic acid, cyanuric acid, and am- 
 monia. 
 
 2. Heated with concentrated hydrochloric acid in sealed tubes 
 to 170° C, uric acid splits into glyoocoll, carbon dioxide, and am- 
 monia. 
 
 3. Oxidizing agents cause splitting, and oxidation takes place, 
 either a mono-ureid or di-ureid being formed. Oxidation of uric 
 acid with lead per^x'de produces carbon dioxide, oxalicacid, uiea, 
 and allantoin (glyoxyl diureid). Oxidation with nitric acid, in the 
 cold, produces urea and alloxan, (mesoxalyl urea, a monoureid). 
 Wanning uric acid with nitric acid produces alloxan, carbon 
 dioxide, parabanie acid (ozalyl urea, CjHaNjOj). Parabanic acid 
 on addition of water passes into oxalurio add C3H4N20,, traces 
 of which occur in the urine, and which easily splits into oxalic 
 acid and urea. 
 
 4 Reduction of uric acid with sodium amalgam produces 
 xanthin and then hypofcanthin (sarcin). 
 
 5. Uric acid may be made syuthetically from isobarbituric acid, 
 a ureide of oxypyruvic acid or of alpha-beta dioxyacrylic aoid, 
 which when oxidized is transformed into an i.somf r of dialuric 
 acid. This last, heated to 100°C. (313° F.). with one molecule of 
 urea and seven times its weight of sulphuric acid, produces uric 
 acid which in every way resembles ordinary uric acid. 
 
 6 Uric acid is nearly related also to the followinsr other sub- 
 stances: Hydantoin, guanin, hlppuric acid, inosic (inosinic) acid, 
 the bile-acids, theobromine, caffein, and thein. 
 
 Chemical Reactions: 
 
 A. The Mubexide Test : This test is characteristic 
 of uric acid and urates, Treat a few crystals of uric 
 acid with a few drops of nitric acid, which dissolves the 
 former with a strong development of gas (nitrogen 
 and carbonic acid), and, after thoroughly drying on the 
 water bath {Fig. 26) and cooling., a beautiful red resi- 
 
90 URINARY ANALYSIS. 
 
 due (urea and alloxan) is obtained 
 which turns purple-red (raurexide 
 or purpurate of ammonia, C,!!, (N 
 H^)N,0,) on addition of a little am- 
 monia; or, after cooling, on addi- Fig. 26. Water bath, 
 tion of a little caustic soda solution a iluish-violet, 
 the latter disappearing quickly on warming (differen- 
 tiation from guanin, etc.) 
 
 Note. — The test as above described is not so uniformly successful 
 as the author's modification of it, as follows: Add one cubic ct^nti- 
 meter of nitric acid to ten c.c. nf water, mix thorouuhly, pour 
 into a test-tube, add uric acid crystals to the amount, say of 30 or 
 30 milliKrams (about half a grain), bbil thorous;hly over a spirit- 
 lamp till the uric acid is all dissolved and efifervesopnce cnas i. 
 Evaporate to dryness over the water-bath, let cool, tnuch witli a 
 rod which has been dipped into ammonia and a brilliant purple- 
 red at once appears, changed to bluish-violet on addition of 
 caustic soda solution. If the uric acid solution in dilute nitric 
 acid is evaporated on a flat porcelain surface, the student may 
 trace his initials on the residue, using a glass rod which has been 
 dipped into ammonia. The letters stand out in brilliant purple 
 red. as compared with the yellowish residue which has not been 
 moistened with the ammonia. 
 
 ' B. Schiff's test: Dissolve a little uric acid in as 
 small a quantity of sodic carbonate solution as possible ; 
 a piece of filtering paper being moistened with some 
 solution of silver nitrate, a drop of the uric acid solu- 
 tion in the sodic carbonate, carried on a glass rod, is 
 made to touch the paper, when a greyish stain of me- 
 tallic silver appears. The stain is black, if the uric 
 acid is in amount 0.001 per cent, or more. 
 
 C. E.BDUOTION OF OuPEIO SOLUTIONS : 
 
 Boil a little Fehling's solution {see Sugar) with a 
 solution of uric acid, and a reddish precipitate of 
 cuprous oxide forms. An alkaline solution of bismuth 
 is not similarly reduced. 
 Quantitative determination of uric acid. 
 
 All urates are decomposed by dilute hydrochloric 
 acid, with liberation of . uric acid, according to the 
 equation: Na,(C,H,N,0,)+2HCi+C,H,N,0,. On this 
 
 soilium urate uric acid 
 
 fact is based a method for determining the quantity of 
 uric acid, which is done by adding to a given volume 
 urine one- tenth its volume of hydrochloric acid, col- 
 lecting the crystals of uric acid which separate, drying 
 
CHEMISTRY OF URIC ACID. 
 
 91 
 
 and -weighing. Full details of this process are given 
 in Chemical Exercise V. (For the Ludwig-Salkowski, 
 Haycraft, Hopkins, and other methods, see Appendix.) 
 
 Fig. 
 
 27. Eva . 
 Dish. 
 
 'latiDg 
 
 CHEMICAL EXERCISE V. 
 
 1. The student having obtained some urine of specific 
 gravity not less than 1020 should measure otf 20u c.c.(7 
 fl. oz.)intoa porcelain evaporating 
 Aish{Fig. 27).. add 10 c.c. (3 flui- 
 drachms) of chemically pure hy- 
 drochloric acid, stir with a glass 
 rod, and set aside in a cool, dark 
 place for 24 to 48 hours. At the 
 end of that time crystals will be 
 observed adhering to the dish. Decant 
 the urine, rub off the crystals, by 
 means of a glass rod having a bit of 
 rubber tubing on the end, and pour 
 the whole into a tapering glass vessel 
 of any kind, using wash-bottle {Fig. 
 28) if necessary. Let settle, decant 
 supernatant fluid, add more water, let 
 settle again, and the crystals re- 
 maining at the bottom will now 
 be in condition for the murexide 
 test, which try. 
 
 Fig. 28. Wash- 
 bottle. 
 Note — The wash-bottle enables the operator to blow a fine 
 stream of water with considerable force into the dish, thus re- 
 moving crystals which otherwise cannot be poured off with the 
 rest. 
 
 2. Procure some urine of specific gravity not less 
 than 1025, or concentrate any urine by boiling until 
 of that specific gravity, and set aside in a cold (40° F.) 
 place. It becomes cloudy from deposition of acid 
 urates, which are less soluble in cold water than in 
 warm. Now remove to a warm room, or set the glass 
 in hot water, and the urine becomes clear again, owing 
 to the ready solubility of these urates in hot water. 
 
93 URINARY ANALYSIS. 
 
 MIOEOSOOPIOAL EXEEOISE 11. 
 
 Into the sediment of uric acid crystals obtained in 
 Chemical Exercise III. dip a camel's-hair brush, and 
 remove the crystals adhering to it to a glass slide. 
 Examine with a power of 150 diameters or upward, 
 and note a large number of crystals of various forms, 
 but all of yellowish-red color, which latter is character- 
 istic. (Study of the forms vrill be taken up under the 
 head of Urio Acid Sed^ments.) 
 
PHYSIOLOGY OF UBIC ACID. 93 
 
 CHAPTEE XII. 
 
 PHYSIOLOGY OF URIC ACID. 
 
 History. — Soheele discovered uric acid in 1Y76 and 
 thought it solely a constituent of urinary calculi, hence 
 named it Uthio acid, from the Greek lithos, signifying 
 a stone. In 1797 "WoUaston showed that gouty concre- 
 tions were composed of sodium urate. In 1848 Gar- 
 rod claimed that an excess of uric acid existed in the 
 blood prior to an attack of true gout and at the period 
 of it. In 1884 to 1892 Alexander Haig has found that 
 the excretion of uric acid can be made to vary at any 
 time and in any direction. In 1892 Sir William Rob- 
 erts made the announcement that the amorphous urates 
 are quadrurates normally, and that any departure from 
 this condition must be regarded as pathological. 
 Horbaczewski has shown that uric acid originates from 
 nuclein, and Kuehnau that the leucocytes are the princi- 
 pal, if not the exclusive source of the formative materials 
 of uric acid. 
 
 Difficulties. — Almost insurmountable difficulties lie 
 in the way of reconciling the theories of different ob- 
 servers as to the formation, source, and quantity of 
 uric acid. For example Haig, using Haycraft's pro- 
 cess, speaks of large quantities of uric acid in abnormal 
 conditions, sometimes producing a ratio of urea to uric 
 acid as low as 14 or 12 to 1. Herter, on the other 
 hand, asserts that a ratio of urea to uric acid lower 
 than 20 to 1 is impossible. The trouble is due to the 
 different chemical processes used for determination of 
 uric acid, which in the same sample of urine will show 
 widely different results. 
 
 The following is a resume of the different theories 
 which comprise our knowledge to date. 
 
 Formation In tlie body — ^Since uric acid is regarded 
 as a diureid of acrylic acid, i. e. , by oxidation, sj ' " 
 
04 URINARY ANALYSIS. 
 
 up into two molecules of urea and one of a non-nitro- 
 genous acid, it has been assumed that, when the 
 process of oxidation is imperfectly performed within 
 the body, free uric acid will be found in excess in the 
 urine. But although uric acid is indeed a less oxidized 
 substance than urea, the latter is probably derived 
 from a different source, at least in greater part. 
 Minkowski finds, so far as birds go, that ammonia and 
 lactic acids have to do with the formation of uric acid, 
 and that the liver is the chief seat of formation. 
 Geese with their livers extirpated show a very signifi- 
 cant decrease in elimination of uric acid, while elimi- 
 nation of ammonia is increased, and considerable 
 amounts of lactic acid occur in the urine. The rem- 
 nant of uric acid in the urine after extirpation of the 
 liver originates from xanthin or similar products. 
 
 Ebstein's theory is that uric acid is a by-product 
 from insuificient oxidation of the nitrogenous waste 
 into urea. Jaksch tends to uphold this theory, hav- 
 ing recently concluded that the "uric acid diathesis" is 
 due to disorders of the red blood-corpuscles, the vehi- 
 cle by which oxygen is carried. 
 
 Horbaczewski and his pupils think that uric acid 
 originates from nuclein, probably through the inter- 
 mediary of adenin, which is related to xanthin and 
 hypoxanthin. TJrio acid is, according to this view, 
 formed in the spleen, and is not notably influenced by 
 alimentation. 
 
 Kuehnau concludes that the leucocytes are the 
 principal, if not the exclusive, source of the forma ive 
 materials of uric acid. 
 
 Quantity. — The average amount of uric acid ex- 
 creted in twenty -four hours is said to be 0.7 gm. (lOf 
 grains), with a possible range of from 0.4 to 0.8 o-m 
 (6i to 121- grains). ° 
 
 The ratio of urea to uric acid is differently stated. 
 Haig calls it 33 to 1 ; Parkes, 45 to 1 ; Meyer, 50 to 1 ; 
 Herter, 50 to 1 ; Yvon-Berlioz, 40 to 1 * Hammarsten, 
 from 50 to 1 up to 70 to 1. The statement of Haig 
 that the formation of uric acid is always in relation to 
 the urea formed, and as 1 is to 33, is said to be entirely 
 
PHYSIOLOGY OF URIO ACID. 95 
 
 disproved by the fact shown recently that the ratio 
 varies normally at different periods of the day. 
 
 The author's observations tend to show that assump- 
 tion of a fixed urea-uric acid ratio for that of health is 
 entirely out of the question. The ratio of urea to uric 
 acid fluctuates, but in all probability within more or 
 less definite limits in the same individual. E. E. 
 Sm.ith has, independently, arrived at the same con- 
 clusion and thinks the range to be from 45 to 1 to 60 
 to 1. The author is in the habit of regarding any 
 ratio below 30 to 1 as certainly indicating very large 
 excess of uric acid, and is skeptical about the ratios below 
 20 to 1 reported by some observers. With uric acid 
 determinations carefully conducted I have never seen 
 a ratio below 20 to 1, though by means of the older 
 processes, and perhaps one or two of the more modern 
 ones, whose value is yet doubtful, ratios below 20 to 
 1 have often been found by me. It is said that in 
 infants the ratio may be as low as 14 to 1, but in a 
 child two years old I recently found the ratio 45 to 1 . 
 
 EFFECT ON UEIO ACID OF DIET AND EEGIMEN. 
 
 The only point, says Roberts, which is really clear 
 about diet, is that the excretion of uric acid is height- 
 ened by increasing the albuminoid ingredients of the 
 food. Sugar, fat, and fruit are not proved to have the 
 slightest direct influence on the production and excre- 
 tion of uric acid. I hold, on the contrary, that it is 
 a clinical fact, which has been verified time and again, 
 that abstinence from sweets improves the general con- 
 dition of uricsemio patients, at least those subject to 
 v/ric acid deposits. 
 
 It is said that on an abundant meat diet uric acid 
 may amount to 2 gms. (31 grains) in 24 hours. The 
 author has, however, eaten heartily of butcher's meat, 
 three times daily for the last five years, but has not 
 found more than 1 gm. of uric acid at most in his 
 urine. Things which increase uric acid according to 
 various authors are milk, beef-tea and beef-extracts, 
 alcoholic drinks, especially champagne, muscular 
 fatigue, hot rooms, weather in which there are warm 
 
96 URINARY ANALYSIS. 
 
 southwest winds. Uric acid is said to be decreased by 
 vegetable diet, moderate exercise, such as bicycle rid- 
 ing in moderation, copious draughts of water. 
 
 According to, Haig the excretion of uric acid is rel- 
 atively large during the three or four hours after 
 breakfast, i. e., during the period of " alkaline tide." 
 
 Action of drugs The drugs which are said to 
 
 increase uric acid in the urine are the following : 
 
 Euonymin, Quinine (in small doses), Salicylates. 
 
 Mercuric chloride, Phosphate of sodium, Colchicum, 
 
 Alkalies generally. 
 
 Thoae which decrease it in the urine are, according to 
 Haig: 
 
 Acids, Lead, Acid phosphate of sodium- 
 
 Iron, Manganese Various sulphates, 
 
 Lithia, Calcium chloride, Various chlorides; 
 
 also, 
 
 Opium, Antipyrin, Hyposulphites, 
 
 Cocaine, Caffeine, Strychnine. 
 
 Mercury, The nitrites, 
 
 Haig's View of Ubic Acid. Haig's observations are that 
 uric acid is not influenced by dietary or medication in its forma- 
 tion, that being regarded as constant and uniform with the pro- 
 duction of urea in the ratio of 1 to 33. As a substance insoluble 
 in acid media, uric acid, when the blood and fluids of the tissues 
 decrease in alkalinity, is no longer held in solution by thesp 
 liquids and thus carried through the renal system, but is deposited 
 in the organism, largely in the liver and spleen. If, for any 
 reason, this decreased alkalinity be overcome, and a wave of in- 
 creased alkalinity induced, as by administration of alkalies, these 
 deposits are redissolved and carried in the current, producing an 
 excess in actual circulation. 
 
 The Lithia Question. — Haig admits that compounds 
 of lithium will dissolve uric acid in the test-tube, but 
 insists that in the body the lithium salts never have a 
 chance to affect uric acid, since lithium forms, accord- 
 ing to Kose, a nearly insoluble triple phosphate with 
 the phosphate of sodium or with the triple phosphates 
 of ammonium and sodium, salts generally present in 
 animal fluids. Again sodium phosphate is a good sol- 
 vent of uric acid, and the lithium, by uniting with it, 
 robs the blood of one of the natural solvents of uric 
 acid. Moreover, Haig found, taking lithia himself, 
 that uric acid was decreased in his urine, and accounted 
 for it as above. 
 
PHYSIOLOGY OF URIC ACID. 97 
 
 Chemists doubt the value of lithium salts as uric acid 
 solvents in the body. Clinical testimony, however, as 
 to the diuretic action of certain lithium compounds, 
 (benzoate and citrate) is certainly great, and also as to 
 the benefit derived from their action on patients sup- 
 posedly suffering from uric acid complaints. Dr. Mary 
 Putnam Jacobi, in objecting to Haig's theories, speaks 
 of a typical lithaemic patient whom mild diet with 
 lithia and vichy greatly relieved. Discussion of this 
 subject properly belongs to a work on therapeutics and 
 will not be continued here. 
 
 Opponents of Haig's Yiews : Many observers fail 
 to agree with Haig, some attacking him on one side, 
 others on another. Clinically his dietary and regimen 
 are of undoubted benefit in some cases, though not in 
 others. The profession, however, is under obligations 
 to him for his brilliant and earnest research work. 
 His position has been strengthened by the observation 
 recently made, that in 1,000 consecutive determinations 
 of the urea-uric acid ratio in an individual the ratio of 
 urea to uric acid was found to be 35 to 1. 
 
URINARY ANALYSIS. 
 
 CHAPTEE XIII. 
 
 PATHOLOGY OF URIC ACID. 
 
 In considering the increase of uric acid in the urine, 
 the increase in the total quantity for twenty-four 
 hours is meant. 
 
 It is probable that a sediment of amorphous urates, 
 especially if occurring in urine of specific gravity less 
 than 1026, is fairly reliable evidence that uric acid is in 
 excess in that urine, but the latter may be in excess 
 and yet no sediment betray it, hence quantitative de- 
 termination of the whole uric acid in twenty-four 
 hours should be made. 
 
 On the other hand, a sediment of uric acid itself 
 gives no indication of an excess of the total uric acid, 
 signifying merely some change in the saline constit- 
 uents, coloring-matters, or acidity, hence again quan- 
 titative determination is needed. 
 
 In general it is held that uric acid is increased when- 
 ever either an increased formation of leucocytes, rich 
 in nuclein, takes place in the blood or an increased 
 destruction of leucocytes occurs. In general, then, an 
 excess of uric acid is an indication of some nutritional 
 disturbance. 
 
 DISEASES IN WHICH TJEIO ACID IS INOEEASED IN THE 
 
 TTBINE. 
 
 I. Fevers. 
 
 II. Leukaemia. 
 
 III. Diseases of the spleen. 
 
 IV. Acute articular rheumatism, in which increase 
 of uric acid is an unfavorable sign, and decrease a favor- 
 able one. 
 
 V. Diseases of the lungs and heart, in which respi- 
 ration is hindered (dyspnoea); also in ascites; large 
 abdominal tumors. 
 
 VI. Whooping-cough. 
 
PATHOLOGY OF URIC ACID. 99 
 
 YII. Poisoning by carbonic oxide gas ; after alcohol- 
 ic excesses. 
 
 YIII. Inanition. 
 
 IX. Cachexias in which there is great destruction of 
 the corpuscle tissues. 
 
 X. Extensive burns. 
 
 XI. Some skin diseases, as lepra and eczema. 
 
 XII. Chorea. 
 
 DiSBASES IN WHICH UEIC ACID IS DECREASED IN THE 
 
 UEINE. 
 
 In general those in which but little leucocyte forma- 
 tion takes place, and where but slight destruction of 
 them occurs : 
 
 I. Chlorosis and anemia. 
 
 II. Osteomalacia. 
 
 III. Disturbances of nutrition ; chronic lead-poison- 
 ing. 
 
 IV. After use of quinine and atropine. 
 
 V. In chronic gout when the urates are deposited in 
 the joints. 
 
 VI. In arthritis, especially the gouty form. 
 
 VII. In hydruria and urina spastica. 
 
 VIII. In chronic diseases of the spinal cord. 
 
 CLINICAL NOTES. 
 
 1. In diabetes melUtus uric acid is more often dimin- 
 ished than increased. 
 
 2. In the beginning of cirrhosis of the liver uric acid 
 is increased ; in the stage of atrophy decreased. 
 
 3. In interstitial nephritis uric acid is significantly 
 decreased ; in chronic parenchymatous nephritis uric 
 acid is much increased. 
 
 4. Dr. J. W. Hunter, of Texas, reports a number of 
 cases of asthma caused by uric acid, and cured by ap- 
 propriate treatment. 
 
 5. According to Drs. C. N. Pierce and E. C. Kirk, 
 the morbific element in pyorrhoea alveolaris is uric acid. 
 
 6. Haig speaks of a characteristic uric acid headache, 
 which may be produced at will, and which is accom- 
 panied by a very large excretion of uric acid. The 
 
100 URINARY ANALYSIS. 
 
 headache, he holds, is due to increase of vascular tension 
 caused by excess of uric acid in the circulntion. 
 
 7. Sutherland thinks that uric acid produces trouble 
 in children with two classes of symptoms,* those due 
 to presence of uric acid in the system, and those due 
 to excretion of it. In the former case catarrhal dis- 
 orders are prominent, in the latter abdominal pains. 
 
 8. According to Jaksch uric acid is not responsible 
 for the acid intoxication of fever. 
 
 9-. Krauss, Pryor, Herter, and others believe that 
 the pathogenic role of uric acid has been greatly exag- 
 gerated. 
 
 10. Levison regards it as proved that a simple excess 
 of uric acid is not enough to cause lasting excess in 
 the blood, but that there must also be a faulty elimin- 
 ation by the kidneys. 
 
 11. Haig in his latest work (1896) thinks uric acid 
 a factor in the cause of high arterial tension, head- 
 ache, epilepsy, mental depression, paroxysmal hemo- 
 globinuria, and anaemia, Bright's disease, diabetes, 
 gout, and rheumatism. Eaynaud's disease and hys- 
 teria are added to this list by others. 
 
 12. E. E. Smith thinks that if the ratio of the urea 
 and uric acid is expressed by a number above 45, the 
 uric acid excretion is probably normal ; while if it is 
 expressed by a number below 40 there is good ground 
 to believe that the excretion is in excess. 
 
 CHEMICAL EXERCISE VI. 
 
 Quantitative determination of uric acid. — The 
 
 student having collected and measured his twenty - 
 four hours' urine should determine the quantity of uric 
 acid in it, using the method of Heintz, the simplest 
 clinical method, as follows: 
 
 Measure off 200 c.e. (7 fluidounces) of the twenty- 
 four hours' urine, add to it 10 c.c. (one-third of a fluid- 
 ounce) of hydrochloric acid. Let stand twenty-four to 
 forty-eight hours in a cool, dark room. Collect the 
 precipitated uric acid crystals on a previously weighed 
 
 *See author's article in Tooker's "Diseases of Children," p. 464. 
 
PATHOLOGY OF URIC ACID. 101 
 
 small filter, wash with cold distilled water, dry in dry- 
 ing oven, {J*'ig. 29) and weigh. The difference in the 
 weight of the filter before and after filtering represents 
 the weight of uric acid in 200 c.c. of urineal. If 
 albumin is present, the urine should be acidulated with 
 a few drops of acetic acid, boiled, and filtered, the 
 filtered urine being used for the uric acid determination. 
 Technique. — The above directions, given in several 
 of our books, seem simple and easy to carry out, but 
 there is a chance for various errors unless the follow- 
 ing precautions are observed : 
 
 1. Before weighing or filtering first dry the filter 
 which should be done in the drving oven at a temper- 
 ature of 100° C. (212° F.). 
 
 2. After it ceases to lose weight, for which will be 
 required about an hour's drying, 
 record the weight. Use prefer- 
 ably milligram weights {Fig. 30). V- 
 The small filters weigh from ^^0 \^^g^ 
 to T50 milligrams when dry. \W^'' 
 
 3. Fold the filter, insert into li- 
 the funnel, and filter the urine 
 through it, being careful to swve yiq. 30. Milligram^ 
 the filtered urine. weights. 
 
 4. Rub off the crystals of uric acid adhering to the 
 dish by use of a glass rod, tipped with rubber tubing, 
 and wash them into the filter, using filtered urine 
 for washing purposes. 
 
 6. Let the urine run completely through, then fill 
 up the filter about two-thirds full with distilled water, 
 using the wash bottle, and washing as thoroughly as 
 possible with the amount of water used. This should 
 not exceed 30 to 40 c.c. (about one fluidounce). 
 
 6. After the water has run through, remove filter 
 from the funnel with small pincers, being careful not 
 to tear it, set it in a porcelain dish in the drying oven 
 and dry it for several hours, if necessary, until it 
 ceases to lose weight. 
 
 1. Measure the amount of filtered urine plus wash- 
 water, which will usually be 250 c.c, multiply the 
 
102 UBINART ANALYSIS. 
 
 number of c.c. obtained by 48, and point off three 
 places. The result is usually 1^ milligrams. (Correc- 
 tion of 4.8 milligrams for every 100 c.c. of urine, 
 adopted by chemists on account of the solubility of 
 uric acid in water). 
 
 8. "When the filter is dry, weigh it; subtract the 
 weight obtained before filtering from the weight now 
 obtained, and add 12 milligrams (or the result obtained 
 in Y). The final result is in milligrams, the amount 
 of uric acid in 200 c.c. of urine. Multiply by 5 to 
 ascertain grammes per liter, pointing off three places ; 
 and multiply this product by the number of liters of 
 the twenty -four hours' urine to get grammes of uric 
 acid per twenty-four hours. 
 
 Notes: — (1) According to Sohwanert the uric acid crystals 
 should be washed on the filter until a solution of silver nitrate 
 gives no precipitate with the filtered wash- water. The writer has 
 found that this precaution makes the results lower by about 4 
 milligrams than when only 30-40 c.c. of water are used as above, 
 that is, when the correction is made as in 7. Thorough washing 
 with say 100 to 135 c.c. of water will take off 10 milligrams from 
 the weight, but the correction, as in 7, will bring up the total. 
 
 (2) Urine cloudy with urates should first be warmed before the 
 hydrochloric acid is added. 
 
 (3) Urines less than 1020 in specific gravity should be concen- 
 trated over the water-bath until the specific gravity rises to that 
 figure. 
 
 Calculation of results: Suppose weight of dried filter before 
 filtering is 750 milligrams. Suppose after drying again it i^ 820 
 milligrams. Suppose the filtered urine and wash-water amount 
 to 250 c.c. Then we have the following: 830 minus 750 is 70 mil- 
 ligrams; 250 times 48 divided by 1.000 equals 12 milligrams; 70 
 plus 12 equals 82 milligrams of uric acid in 200 c.c. of urine. 
 Then 82 x 5 equals 410 milligrams of uric acid in a liter (1000 c.c.) 
 of urine or 0.4 gm. Suppose total urine in 24 hours is 850 c.c; 
 0.4 gm. times 0.850 is 0. 34 gm of uric acid in 24 hours. Turn now 
 to Tables 6 and 7. We find 0.4 gm. per liter is just about normal, 
 but 0.34 gm. in 24 hours is about two-thirds the usual normEil 
 average. Reduce to American measures by the Tables. Suppose 
 total urea is 13.6 gm.; 13.6 divided by 0.34 equals 40. Ratio of 
 urea to uric acid is 40 to 1 in this case. See Table 11. 
 
 Note —Inasmuch as the term relative uric acid, relative phos- 
 phoric acid, etc., are used by some German writers to mean the 
 total quantity of uric acid, phosphoric acid, etc., compared with 
 the total quantity of nitrogen, care must be taken to notice that 
 the author uses this term always with reference to the quantity of 
 Tvater of the urine. When used in the sense the Germans use it.' 
 full explanation will be given. 
 
PATBOLOOY OF URIC ACID. 
 Apparatus Required. 
 
 103 
 
 1. Small filters, 6-6 centimeters (about two inches) in diameter. 
 8. Chemical balance (Fig. SI.) 
 
 Fio. 81. Chemical balance. 
 
 Fig. 39. Drying oven. 
 
 8. A drying oven, (Fig. $9.) 
 
 4. A glass rod tipped with rubber tubing. 
 
 6. An evaporating dish holding 300 c.c. (half-a-pint) of urine. 
 (Fig. S7.) 
 
 Note: — Unless what is called rapid filtering paper is used, the 
 operation according to Sohwanert's directions is a very slow one 
 requiring several hours unless a filter-pump is at hand. 
 
104 URINARY ANALYSIS. 
 
 CHAPTER XIY. 
 
 SUBSTANCES RELATED TO URIC ACID. 
 
 The substances of minor clinical importance related 
 
 to uric acid are, in alphabetical order, as follows : 
 
 AUantoin; Kreatin; Kreatinin; Xanthin, and allied substances. 
 
 These substances all contain nitrogen, and together 
 
 with urea and uric acid, are the means by which this 
 
 important element is excreted in the urine. 
 
 AUantoin, or glyoxyldiureid, CiHsN^Os, an organic substance, 
 occurs in the urine of children within the first eight days after 
 birth. In small amounts in the urine of grown persons; rather 
 abundantly in that of pregnant women. 
 
 Related to uric add. Formed by oxidizing uric acid with lead 
 peroxide. Colorless prisms soluble in hot water, slightly in cold, 
 insoluble in alcohol and ether. Precipitated by mercuric salts. 
 
 Detection: Precipitate urine with baryta water, filter, remove 
 baryta with sulphuric acid, filter, precipitate the allantoin with 
 mercuric chloride in alkaline solution, decompose precipitate with 
 sulphuretted hydrogen, concentrate strongly, purify the crystals 
 by recrystallization. 
 
 Kreatin. — This organic substance, CiHiNaO, one of the nitrog- 
 enous substances of urine, occurs normally in alkaline urine in 
 greater quantity. In acid urine kreatinin appears in greater 
 quantity. Kreatin is easily transformed into kreatinin, which see. 
 Also converted by certain germs into methylguanidin, which causes 
 symptoms resembling uraemia. 
 
 Ereatinin. — Important because of the nitrogen it 
 contains. 
 
 Chemical constitution, C4H,NaO, or NH=C<;^^^^ >CHj, 
 an anhydride of kreatin, one of the strongest bases in the body. 
 
 Form. — Crystallizes in large colorless prisms. (See 
 Sediments. ) 
 
 OcGurrenoe. — Constantly in solution in the urine. 
 
 Solubility. — Easily' soluble in water, hence rarely 
 in the sediment. Less soluble in alcohol. Insoluble 
 in ether. 
 
 Properties. — Alkaline in reaction, converted by 
 bases into kreatin. Combines with both acids and 
 Baits. A characteristic compound of the latter class is 
 
SUBSTANCES RELATED TO URIC ACID. 105 
 
 hreatinhi- chloride of sine (O^B[,]S',0)jjZnClj, diffi- 
 cultly soluble in water. 
 
 Kreatiniu has strong reducing properties, as on 
 Trommer's and Fehling's test-liquids, but not on 
 alkaline bismuth solutions. 
 
 Tests. — (1) Add to the urine a few drops of freshly 
 prepared very dilute solution of nitroprusside of sodium 
 and, afterward, a few drops of dilute sodium hydrox- 
 ide solution, when a red color appears which changes 
 to yellow on standing. Now add acetic acid in excess, 
 and heat, when a greenish, then blue color appears, 
 and finally a precipitate of Berlin blue. 
 
 (2) Add to the urine a little picric acid solution and 
 a few drops of dilute sodium hydroxide solution, when 
 a red coloration appears, which lasts for an hour, and 
 changes to yellow on addition of acid (glucose gives 
 this red color on warming). (For quantitative deter- 
 mination, see Appendix.) 
 
 Physiology. Kreatinin has its origin in the muscles, 
 being formed from the kreatin of them. The change 
 probably takes place in the muscle. Bunge thinks 
 muscle kreatinin ultimately converted into urea and 
 urine kreatinin derived from the food. The average 
 quantity in the urine per twenty-four hours is 0.6 to 
 1.3 gramme, the most on an exclusive meat diet. 
 It is diminished by fasting. 
 
 Pathology. Increased in acute diseases, especially 
 in pneumonia, typhoid, and intermittents ; also in some 
 cases of diabetes mellitus. Diminished in convales- 
 cence from acute diseases, in advanced Bright's, and 
 in tetanus ; also in diseases characterized by muscular 
 wasting. (See also Sediments.) 
 
 Xanthin bodies. — These are xanthin, hypoxanthin, 
 carnin, adenin, paraxanthin, and heteroxanthin. Or- 
 ffanic, related to uric acid. Thus, uric acid CJi,N',Oj, 
 xanthin C.H.N^O,. Xanthin occurs in very small 
 quantity in human urine, according to Neubauer, 1 
 gramme in 300 liters. The xantliin bodies are almost 
 insoluble in water, unite with bases, acids, and salts, 
 are precipitated by ammoniacal silver solutions like 
 uric acid, and give at red-heat, like uric acid, the odor 
 
106 URINARY ANALYSIS. 
 
 of hydrocyanic acid. Xatithin is insoluble in alcohol 
 and ether,' readily soluble in alkalies, and also in dilute 
 nitric and hydrochloric acids. It sometimes occurs as 
 a deposit (see Sediments), and is a constituent of a rare 
 form of calculus, found always in case of young 
 persons. 
 
 Detection. — Eemove albumin from the urine by 
 boiling and filtering, and treat the urine inter- 
 mittently with phospho-tungstio acid, and hy- 
 drochloric acid, until no more precipitate takes 
 place. The precipitate is allowed to settle for twenty- 
 four hours, then washed with dilute sulphuric acid 
 (6 :100) by decantation till free from chlorine, filtered 
 and treated with excess of barmin hydroxide and 
 application of heat to remove uric acid. The filtrate 
 is precipitated with ammoniacal solution of silver, and 
 the precipitate which contains the xanthin bases is 
 washed. Dissolved in dilute hydrochloric acid hexa- 
 gonal crystals of xanthin separate on evaporation. 
 Evaporated to dryness with nitric acid a yellow resi- 
 due remains, which turns red with caustic potash 
 solution, and reddish violet when heated. (For 
 quantitative determination see Appendix). 
 
 Pathology : The pathology of xanthin, paraxan- 
 thin, etc., has been experimentally investigated 
 by B. K. Eachford {Medical Record, 1895). He 
 calls these bodies uric acid leucoTnains, and asserts 
 that paraxanthin and xanthin are etiologically related 
 to a group of nervous disorders which are m.anifesta- 
 tions of leucomain poisoning.. The three clinical forms 
 of the auto-intoxication are as follows: 1, A true 
 migraine or leucomain headache ; 2, a migrainous epi- 
 lepsy, or leucomain epilepsy; 3, a migrainous gastric 
 neurosis, or leucomain gastric neurosis. Paraxanthin 
 is by far the most poisonous of all leucomains, xanthin 
 is much less poisonous. His conclusions are as fol- 
 lows: 
 
 "1. Paraxanthin and xanthin are poisonous leuco- 
 mains of the uric-acid group, capable of producing the 
 most profound nervous symptoms. They are readily 
 soluble in water, urine, and blood. 
 
SUBSTANCES BELATED TO URIC ACID. 107 
 
 " 2. Paraxanthin is found in normal urine in such 
 small quantities that its poisonous properties are lost 
 in dilution. Salomon found only 1.2 gm. in 1,200 
 liters of urine. This quantity is so minute that its 
 presence cannot be satisfactorily demonstrated in such 
 quantities of normal urine as can conveniently be ob- 
 tained from patients. In a recent personal communi- 
 cation Salomon says : ' Nine liters of urine is a very 
 small quantity to prove the presence of paraxanthin, 
 if one has not previously worked with larger quantities 
 so as to master the details of the work, and very much 
 harder would it be to prove the presence of paraxan- 
 thin in four liters of normal urine, as I know from ex- 
 perience. ... I would advise that not less than 
 ten liters of normal urine be used to demonstrate the 
 presence of paraxanthin. ' My own experience is in 
 accord with Salomon's. In previous papers I have 
 recorded my failure to demonstrate the presence of 
 paraxanthin when working with as little as four liters 
 of normal urine ; and since these papers were written 
 I have made a large number of examinations of normal 
 and other urines, and I have always failed to demon- 
 strate the presence of paraxanthin in four liters of nor- 
 mal urine. Upon this evidence I have concluded that 
 paraxanthin is present in abnormally large quantities 
 when I can find it in less than four liters of urine. 
 Xanthin also, as a rule, requires more than four liters 
 of urine to demonstrate its presence, but I have fre- 
 quently found small quantities of xanthin where I 
 could not find paraxanthin in working with four liters 
 of urine. 
 
 " 3 Paraxanthin and xanthin are not formed in the 
 kidney. They are excreted from the blood by the 
 kidneys. The presence, therefore, of large or small 
 quantities of xanthin bodies in the urine means that 
 these bodies were present in large or small quantities 
 in solution in the blood previous to their elimination 
 by the kidneys." (Rachford.) 
 
 4. In certain cases of migraine paraxanthin and 
 xanthin are excreted in great excess during the at- 
 tacks, but not in the intervals. 
 
108 URINARY ANALYSIS. 
 
 5. In the study of a case of migrainous epilepsy the 
 following was ascertained by him : During the attack 
 
 , the patient excreted a quantity of paraxanthin and 
 xantkin enormously in excess of normal, but during 
 the interval between the attacks not enough paraxan- 
 thin was excreted to be detected in three liters of 
 urine. The paraxanthin excreted in such large quanti- 
 ties just following these attacks must have been in 
 solution in the blood during the paroxysms. 
 
 6. In a case of migrainous gastric neurosis the quan- 
 tities of xanthin and paraxanthin in the urine during 
 the attacks, were enormously increased, two liters of 
 urine being enough to allow separation of both bodies 
 Two minims of '-iinal fluid," 3 c.c. in volume, thrown 
 into the muscles in the back of a mouse produced death 
 in from 15 to 30 minutes. In four liters of urine 
 between the attacks no paraxanthin was found and 
 the final fluid was not poisonous to mice. 
 
 See Appendix for the process of isolation and 
 detection. 
 
AROMATIC COMPOUNDS. ■ 109 
 
 CHAPTER XY. 
 
 AROMATIC COMPOUNDS IN THE UEINE. 
 
 The aromatic compounds in urine may be classified 
 as follows : 
 
 I. Aromatic compounds of glycooin, as hippurio 
 acid. 
 
 II. Olycuronia acid combinations with aromatics. 
 
 III. Uncombined aromatic substances. — As cumarin, 
 hydroparacumaric acid, etc. 
 
 IV. Ethereal sulphates as phenol-sulphuric acid, 
 indoxyl-sulphuric acid, etc. 
 
 Hippuric acid, CjHtNOs, HCCgHgNOs), a monobasic organic 
 acid occurs in small amounts, 0.7 gramme daily in normal urine. 
 By diet rich in fruits and vegetables as cranberries, prunes, plums, 
 etc., it may be increased to two grammes (31 grains). 
 
 Chemical constitution. — Chemically hippuric acid is benzoyl 
 
 CHa.NH(C,H.CO) 
 
 dc 
 
 300H, 
 
 and is a derivative of benzoic acid, from which it may be formed 
 within the body by oxidation, when benzoic acid, or a number of 
 other substances, is taken internally. 
 
 Origin. Not definitely ascertained. 
 
 Phenyl-propionic acid produced in the body during the process 
 of intestinal putrefaction is absorbed into the blood and thought 
 to be transformed there into benzoic acid (phenyl-formic acid). 
 Benzoic acid coming into contact with glycocoU, a substance 
 probably produced during intestinal putrefaction, probably forms 
 hippuric acid accordins; to the equation 
 
 C,H, + CHjNH, = OHjNH(C,HjCO) + H,0 
 
 COOH COOH COOH 
 
 Benzoic acid Glycocoll Hippuric acid. 
 
 Solubility. It is soluble in 600 parts of cold water, easily solu- 
 ble in hot water, readily so in hot alcohol and ether, insoluble in 
 petroleum-ether, and benzene; soluble in ammonia water, IhsoIu- 
 ble in hydrochloric acid. 
 
 Occurrence. In solution in all normal urine and occasionally in 
 the sediment. (See Sediments). 
 
 Physical characteristics. Colorless, odorless, of slightly bitter 
 taste. 
 
 Form. When obtained from urine or made synthetically, it 
 forms fine needles or vertical rhomhoid prisms. According to 
 Heitzmann the prisms in urioe often show indentations, (See 
 Sediments), 
 
no • URINARY ANALYSIS. 
 
 Detection. Evaporate the urine with nitric acid, heat residue 
 dry in a test tube, and an odor like oil of bitter almonds indicates 
 presence of hippuric acid. More conclusive is the following: 
 Make the urine alkaline with sodium carbonate, concentrate by 
 evaporation as much as possible, and extract the residue with 
 absolute alcohol. The alcohol is evaporated, the remaining mass 
 dissolved in water, the solution made acid with sulphuric acid 
 and extracted with five fresh portions of acetic ether by shaking 
 repeatedly. The ethereal extract is several times washed with 
 water, then freed from the latter and evaporated at moderate 
 temperature. The hippuric acid is now freed from benzoic acid, 
 fat, and the like by washing with petroleum-ether, dissolved in 
 a little warm water, and the solution evaporated at about 50° C. 
 (132° F.) to crystallization. The crystals are them collected and 
 weighed. 
 
 Micro-ohemical detection. If the urine contain excess of hip- 
 puric acid, the latter may be detected by evaporating slightly, and 
 feebly acidulating with hydrochloric acid. On standing a few 
 hours hippuric acid crystallizes out and may be recognized by the 
 microscope. (See sediments). 
 
 Physiology : Hippuric acid in the organism owes its 
 origin to the oxidation of albumin, and its quantity 
 depends on th« degree of albumin decomposition in 
 the intestine. It is present in comparatively large 
 amount in the urine of herbivora, much less in. that of 
 omnivora, and absent in the urine of carnivora. It is 
 increased by vegetable diet and by such fruits as cran- 
 berries, etc. , already mentioned. It is also increased 
 by administration of benzoic acid, oil of bitter almonds, 
 toluol, cinnamic acid, benzylamin, phenylpropionic, 
 and Mnic acid. It is decreased by an animal diet but re- 
 mains in small quantities even on an exclusive meat diet. 
 
 Pathology : Increased in acute febrile processes, 
 diseases of the liver, chorea, diabetes mellitus. (See 
 Sedimenis). 
 
 Decreased in amyloid degeneration of the kidneys. 
 
 In acute and chronic parenchymatous nephritis ad- 
 ministration of benzoic acid does not result in elimina- 
 tion of hippuric acid. 
 
 Glycuronic Acid Combinations:— Small quantities of this or- 
 ganic substance in combination with aromatics occur in the urine. 
 Normally it occurs in very slight traces, hence will not be con- 
 sidered here. See Abnormal Constituents. 
 
 Cumarin: — An organic aromatic substance said to occur in urine. 
 
 Hydroparacumaric acid:— One of the uncombined aromatic 
 substances, C8Hi.(0H)CHa.CHa.C00H, produced by the decay of 
 tyrosine. Organic. 
 
 Oxyphenylacetic acid is another one of the uncombined aro- 
 matic substances occurring in urine. 
 
AROMATIC COMPOUNDS. Ill 
 
 Ethereal sulphates. — The ethereal sulphates in 
 urine are combinations of sulphuric acid with phenol, 
 parakresol, pyrocateohin, indoxyl, and skatoxyl. 
 They contain the radical HSO3 and are incorrectly 
 called sulphonates. Also called sulpho-GonJugated 
 acids, or conjugate sulphates, sometimes also arofnatic 
 sulphates. 
 
 They are derived in small part from aromatic sub- 
 stances in the food, being chiefly due to putrefactive 
 changes in the intestine. They serve as a guide to us 
 of the amount of putrefaction in progress within the 
 body, and are also of diagnostic importance when we 
 wish to determine whether febrile diseases, exanthems, 
 etc. , depend on intestinal processes, or whether mel- 
 ancholia is a sequence of intestinal disturbance. 
 
 Increase of ethereal sulphates takes place in deficient 
 absorption of normal products of digestion, as in peri- 
 tonitis and intestinal tuberculosis; in fermentative 
 diseases of the stomach ; in putrefactive processes out- 
 side the alimentary canal, as in putrid cystitis, ab- 
 scesses, peritonitis, etc. Discharge of putrid matter 
 diminishes the quantity. As no simple clinical method 
 is known for quantitative determination of them, see 
 Appendix for complete process. 
 
 Test. — To test for the conjugate sulphates 25 c.c. of 
 urine are treated with about the same volume of an 
 alkaline barium chloride mixture (2 volumes of a solu 
 tion of barium hydrate and 1 volume of a solution of 
 barium chloride both saturated at ordinary tempera- 
 tures) and filtered after a few minutes, the mineral 
 (preformed) sulphates as well as the phosphates being 
 thus removed. The filtrate is then strongly acidified 
 with hydrochloric acid and boiled, when the occur- 
 rence of a precipitate will be referable to conjugate 
 sulphates. 
 
 In the quantitative method (see Appendix), the same 
 procedure is followed and the precipitate being filtered 
 off is washed, dried, and weighed. 
 
 Significance. — The normal ratio of the mineral 
 (preformed) sulphates to the ethereal sulphates is 10 
 to 1. This ratio may be enormously decreased in 
 
112 URINARY ANALYSIS. 
 
 coprostasis, the result of carcinoma, as low as 2 to 1 
 having been observed. C. E. Simon has seen the 
 ratio 1.5 to 1 in a case of volvulus of ten da3-s' 
 standing. 
 
 The degree of intestinal putrefaction may he meas- 
 v/red directly hy the elimination of the ethereal sul- 
 phates: — Increased degree of intestinal putrefaction 
 accompanies diminution of secretion of hydrochloric 
 acid by the stomach, and vice versa. 
 
 In obstructive jaundice Simon has noticed an increase 
 of the ethereal sulphates, while in non-obstructive 
 jaundice the total sulphates (mineral and ethereal) were 
 decreased. 
 
 In diarrhoea the total sulphates were diminished, 
 likewise the ethereal sulphates, while the ratio of the 
 mineral to the ethereal increased. Terpenes and 
 camphor cause a decrease in the excretion of the 
 ethereal sulphates. Carlsbad and Marienbad waters 
 at first cause an increase but subsequently a decrease 
 of the ethereal sulphates. Kefir, -in doses of from 1 
 to 1.5 liters a day, has proved an excellent remedy 
 for checking intestinal putrefaction. 
 
 John A. Wesener of Chicago deserves mention for 
 original work in connection with the ethereal sulphates 
 and, in view of the rather scanty space in text- books 
 which is accorded most investigators on this side of 
 the water, we insert his paper almost in full : 
 
 The literature of the aromatic sulphates has been summed up 
 by Wesener as follows: Baumann noticed in a patient with a 
 fistula in the upper part of the small intestine, that urine during 
 the time in which the intestinal contents did not pass out by the 
 natural means, showed a considerable diminution of aromatic sul- 
 phates, containing only traces of phenol and indol. When this 
 fistula was closed and the intestines restored to their normal func- 
 tion, it was noticed that the elimination of the aromatic sulphates 
 was increased very much, An exactly similar case was reported 
 by Ewald. These observations go to show that in the jejunum a 
 certain number of aromatic combinations are produced by the 
 action of micro-organisms and the intestinal juices on the food 
 Baumann and WaslifE found a decrease of aromatic sulphates in 
 the urine of starving dogs, and an entire absence of the same 
 after the intestine had been disinfected by large doses of calomel 
 given several consecutive days. It misht be well to mention here 
 the researches of Ortuiler, who ascertained that in febrile diseases 
 not involving the intestinal tract, which are accompanied by 
 
AROMATIC COMPOUNDS. 113 
 
 destructive tissue clianges, there is no increase of indican in the 
 urine. 
 
 If these aromatic combinations are not products of intestinal 
 decay, then why do we not find them in the muscles and healthy 
 organs? All investigations have failed to show their prespnoe 
 there, while on the other hand the intestinal discharges of starv- 
 ing animals always show the presence of considerable indol; fur- 
 thermore, it has been proved by Kiihne and Nencke that indol 
 is exclusively a product resulting from the action of bacteria on 
 albuminoids. If we consider that micro-organisms do not occur 
 in the tissues of healthy organs, as has been conclusively proved 
 by Meisner, Zahn, and Henser, we must necessarily come to the 
 conclusion that the formation of aromatic combinations in the 
 organs outside of the intestinal tract is, under physiological con- 
 ditions, out of the question. 
 
 Salkowski has shown that there is an increase of indol and phe- 
 Bol in the urine of patients who suffer from ileitis and peritonitis. 
 Brieger has shown that in chronic anaemia and in cachexia there 
 is much indoxyl and little phenol in the urine, whereas in diseases 
 of the stomach there is an increase of phenol, leading one to infer 
 that free HCl is a large factor in lessening putrefaction. 
 
 He found an increase of phenol in tuberculosis of the periton- 
 aeum, acute peritonitis with constipation, empyema of the lungs, 
 septic and puerperal fevers, diphtheria, erysipelas, etc. He con- 
 cludes from this that phenol shows either increabed decomposition 
 of the contents of the intestine or the presence of a putrid area in 
 the body. 
 
 Jatfe found an increase of indoxyl in diseases of the small intes- 
 tiues; a decrease in dysentery, pathological conditions of the large 
 intestine, stomach, and duodenum. 
 
 Senator reports an increase of indol in chronic wasting diseases 
 — such as malignant lymphoma, chronic peritonitis, and cancer 
 of the stomach. 
 
 The writer of this paper (Wesener) has found the aromatic com- 
 binations greatly increased in one case of pernicious anaemia and 
 in a number of chlorotics. It may be said here, before admin- 
 istering iron to these cases, it is absolutely necessary to disinfect 
 the intestinal canal. 
 
 Heninge says that a large amount of indoxyl is present in the 
 urine of pernicious anaemia, typhus, cholera, chronic suppuration, 
 progressive atrophy of muscles, and Addison's disease. He 
 attributes it in part to the increased separation of the constituent 
 of the albuminoids and in part to an increase in the amount of 
 pancreatic juice. 
 
 Hoppe-Seyler, as a result of exact clinical investigation, has 
 come to the conclusion that in general the excretion of these 
 bodies goes hand and hand with an increase of those processes 
 which impair the digestion in the small intestine. The investiga- 
 tions of Hirsohler, T. E. MtlUer, Helden and others show that the 
 aromatics are diminished in the urine when the albuminoids are 
 excluded from the food and a large amount of carb ^hydrates is 
 used instead. As a result of these observations we can see that 
 the derivatives of the aromatic series appear in the urine under 
 physiological conditions as the result of the putrefaction of sub- 
 stances containing water, 
 15 
 
114 URINARY ANALYSIS. 
 
 Ortwiler found that bismuth subnitrate in large doses had no 
 effect on intestinal putrefaction; large doses of castor oil produced 
 an increase of the aromatic sulphates. East ascertained that 
 neutralizing the stomach with large doses of alkaline carbonates 
 had a very decided and lasting effect in the increase of aromatic 
 sulphates; in hyperacidity of the stomach the aromatic sulphates 
 were diminished. 
 
 Morax, in his experiments performed upon animals, found that 
 calomel and iodoform diminished the aromatic sulphates, whereas 
 ordinary doses of calomel given to human beings did not act as 
 an intestinal disinfectant. 
 
 Rovighi found that large doses of the terebene group and cam- 
 phor given to animals diminished the putrefaction to a consider- 
 able extent; these compounds administered to healthy persons had 
 very little effect. 
 
 Biernecky found that on an exclusive milk diet the aromatic 
 sulphates diminished one-half in twenty-four hours. 
 
 Winternitz, by his experiments, has proved that albuminous 
 putrefaction is greatly lessened in the presence of milk sugar, 
 glycerine, and lactic acid. He found that on adding a large 
 quantity of milk to beef extract, albuminous putrefaction was 
 greatly diminished. 
 
 In experiments performed with dogs, who were first fed on 
 meat, then on a milk diet, it was found that in the former the 
 aromatic sulphates were three times and a half as high as when 
 the latter was given. 
 
 According to Carl Schmit, milk sugar is the compound in milk 
 which prevents intestinal putrefaction. He fed dogs on meat and 
 milk sugar, and the aromatic sulphates were greatly lessened. 
 
 The writer (Wesener), in order to determine whether casein or 
 milk sugar is the compound which disinfects the small intestine, 
 undertook the following experiment: Casein was precipitated 
 from milk and then washed with hot alcohol until all milk sugar 
 was removed. This diet was given for three days, the total 
 twenty-four hours' urine being saved; the aromatic sulphates 
 were not diminished. When albuminoids are removed from the 
 food and carbohydrates substituted, the putrefaction is diminished 
 largely; this result is brought about in all probability by the 
 starvation of those bacteria which live upon proteids. It is very 
 probable that in the course of intestinal putrefaction there are, 
 besides the aromatic compounds, other unknown chemical combi- 
 nations which are, perhaps even more poisonous than the former. 
 Observations have shown that more aromatic sulphates are 
 excreted during the day than during the night. If the subject for 
 experiment receives no water, and we examine the urine, we find 
 the aromatics lessened. It appears from this that drinking causes 
 an increase of the aromatic sulphates, and it is therefore neces- 
 sary in ascertaining the amount of aromatics excreted to 
 iigrure on the total amount of tlie urine that has been passed 
 during twenty-four hours. 
 
 Wesener' s conclusions are as follows : 
 
 1. Saline cathartics at first increase the aromatic 
 sulphates, then decrease them. 
 
AROMATIC COMPOUNDS. 115 
 
 2. Calomel in large doses for two or three days 
 slightly diminishes them. 
 
 3. Oil of eucalyptus given for three to four days 
 diminishes them. 
 
 4. Kumyss reduces putrefaction to a minimum, 
 diminishing the aromatic sulphates 85 to 100 per cent. 
 
 Ohas. E. Simon, of Baltimore, in his excellent work 
 on "Clinical Diagnosis" summarizes in regard to the 
 ethereal (conjugate) sulphates as follows : 
 
 1. An increase in the conjugate sulphates in a gen- 
 eral way points to increased intestinal putrefaction, 
 the direct cause for which must, according to our 
 present knowledge, be sought in a total anachlorhydry, 
 or at least a hypochlorhydry of the gastric juice, asso- 
 ciated with intense bacterial fermentation, provided 
 that lactic acid and butyric acid are not present in 
 large amounts ; an obstruction to the flow of bile and 
 intestinal obstruction may, however, produce the same 
 result. 
 
 2. A diminution in the quantity of conjugate sul- 
 phates, on the other hand, may be referable to hyper- 
 chlorhydry associated with torular fermentation, ulcer 
 of the stomach forming an exception, in which, not- 
 withstanding the fact that conjugate sulphates are 
 frequently eliminated in increased amount, hyper- 
 chlorhydry usually exists. 
 
 3. In cases of diarrhoea the absolute as well as the 
 relative quantity of total sulphates and of conjugate 
 sulphates is diminished, while the ratio of the mineral 
 sulphates to the conjugate becomes greater. 
 
116 UBINABY ANALYSIS. 
 
 CHAPTER XYI. 
 
 THE AEOMATIG COMPOUNDS— CONCLUDED. 
 
 The remaining aromatic compounds to be considered 
 are: 
 
 iNDOXYL-SULPHURIC ACID (INDICAN), PHENOL-SULPHURIC AMD, 
 ETC. 
 
 INDOXYL-SULPHURIC ACID. 
 
 Nomenclature: — This substance is usually, though 
 incorrectly, called indioan, being thought to be identi- 
 cal with vegetable indican, which is a glucoside. The 
 substance occurring in the urine is, however, an 
 ethereal (conjugate) sulphate. 
 
 Synonyms: — German, Indoxyl-schwefelsdtire, Har- 
 nindioan; French, indican. 
 
 Clinical constitution: — Potassium indoxyl-sulphate, 
 
 aHsNO.KSOg or SO,<q|'^|'^^ a conjugated sul- 
 
 pho-acid salt of potassium. 
 
 Origin in the hody: — Indol formed during the pro- 
 cess of intestinal putrefaction is oxidized to indoxyl in 
 the blood, thus : 
 
 OsHjN + O = 08H,N0 
 
 Indol Indoxyl. 
 
 Indoxyl combining with sulphuric acid forms in- 
 doxyl-sulphate according to the equation 
 
 OgHjNO + SO,<g| = m,<^^'^^ + H2O 
 
 Indoxyl Sulphuric acid Indoxyl sulphate Water. 
 Indoxyl-sulphate and dipotassic hydrophosphate are 
 eliminated in the urine as indoxyl- potassium sulphate 
 and potassium dihydrophosphate as follows : 
 
 K2HPO4 + SO,<g^^«^^ = KHPO4 H- 
 
 gQ C.HsNO 
 
AROMATIC COMPOUNDS. -INDICAN. 117 
 
 Occurrence: — In solution in the urine 
 
 Form: — When isolated as potassium indoxyl-sul- 
 phate, it occurs in white tablets and plates. Obtained 
 from urine it is a clear, brown syrup. 
 
 Solubility: — Soluble in water, sparingly in alcohol. 
 
 Effect of oxidation: — By oxidation of indoxyl- 
 potassium sulphate indigo-blue is formed and the blue, 
 green, and some red tints of urine in disease are prob- 
 ably derived from different stages of oxidation of this 
 substance. A bluish-red pellicle may often be seen in 
 decomposing urine consisting of microscopic crystals 
 of indigo -blue and red, formed from decomposition of 
 the substance. (See Sediments). 
 
 Ord has described a calculus composed of indigo. 
 
 Tests: — 1. The most convenient test is Stokvis's 
 modification of Jaflfe's well-known test : Mix a few 
 c.c. of the whole 24 hours' mixed urine with an equal 
 volume of concentrated pure hydrochloric acid. Add 
 2 or 3 drops of a strong solution of sodium hypo- 
 chlorite, calcium hypochlorite, or common saltpeter, 
 and 1 or 2 c.c. of chloroform. Shake the mixture 
 thoroughly, and set aside. The chloroform is colored 
 blue by the indigo set free from the indican, and the 
 intensity of the color compared with a 2i hours' 
 normal specimen shows the degree of increase of 
 indican. 
 
 Note:— Since methods for the qnantitative determination of 
 indican. except by the spectroscope, are inaccurHte. leno;thy, and 
 complicated, they will not be described here Tne method given 
 above, if used systematically, on the same quantity of urme in 
 each case and with the same quaatity of reageuts each time, 
 enables the physician to judge of the degree of increase fairly 
 accurately. 
 
 In performing the above test bile-pigment, if pres- 
 ent, must be removed by careful addition of a solution 
 of subacetate of lead (avoiding excess) and filtration. 
 Yery dark urines should be treated in the same way. 
 Urine to be tested for indican should not contain 
 potassium iodide, as the iodine set free on addition of 
 acid will color the chloroform. Albumin does not 
 interfere with the test. 
 
118 URINARY ANALYSIS. 
 
 2. Keilmann's test:— Equal parts of urine and strong hydro- 
 chloric acid are shaken together and a little chloroform added. 
 In presence of indican the chloroform becomes blue and falls to 
 the bottom of the tube. Add, drop by drop, a 5 per cent solution 
 of calcium hypocTilorite, and judge of the amount of indican 
 present by the number of drops of hypochlorite necessary to 
 decolorize it. Three or four drops may be enough, but in some 
 cases 50 to 80 are required. 
 
 3. Marten's test: — Warm the urine and add yellow nitric acid, 
 when a dark brown color appears becoming black on further 
 addition of acid. 
 
 4. The spectroscopic method of McMunn:— Equal parts of 
 urine and hydrochloric acid with a few drops of nitric acid are 
 boiled together, cooled and shaken with chloroform. The latter 
 is colored violet, and shows an absorption band before D, due to 
 indigo-blue, and another after D. due to indigo-red. 
 
 Physiology: — The chemistry of its origin in the 
 body has already been considered. Indol is a specific 
 product of albuminous putrefaction in the presence of 
 organized ferments. Indican being derived from in.- 
 dol, micro-organisms are always concerned in the pro- 
 duction of indican and, in health, the large intestine is 
 its only source. 
 
 The quantity eliminated normally in the urine varies 
 vsrith the kind of diet, 6.6 milligrams per liter being 
 the average of eight observations of Jafife. Eed meats 
 increase it, milk or kumyss decrease it. The urine of 
 new-born children does not contain it. Starvation 
 increases it, since secretions rich in albumin putrefy in 
 the intestine. 
 
 Pathology: — Indican is increased in the urine in the 
 following : — 
 
 1 . Whenever there is an increase of intestinal putre- 
 faction as in anachlorhydry, hypochlorhydry ; in car- 
 cinoma of the stomach ; in acute, subacute, and chronic 
 gastritis ; also in ulcer of the stomach, although hyper- 
 chlorhydry may simultaneously occur. 
 
 Note:— Hypochlorhydry the secretion of a deficient amount of 
 free hydrochloric acid, less than 0.1 per cent; anachlorhydry, ab- 
 sence of hydrochloric acid; hyperchlorhydry, excessive secretion 
 more than 0.2 per cent ' 
 
 2. In conditions in which the peristaltic movements 
 of the small intestines have become impeded : ileus, 
 acute and chronic peritonitis, no matter what the state 
 of the gastric juice is. 
 
AROMATIC COMPOUNDS.— INDIOAN. 119 
 
 3. In diseases in which, in general, abundant albu- 
 minous putrefaction is progressing in some part of 
 the body, as pleurisy with abundant unhealthy exuda- 
 tion, peritonitis with formation of putrid pus, fetid 
 bronchitis, multiple lymphoma, empj'ema, gangrene 
 of the lungs. In such cases phenol- sulphuric acid 
 may be more abundant relatively in the urine than 
 indican. 
 
 4. In anumber of diseases as Addison's, cholera, can- 
 cer of the liver, chronic phthisis, central and peripheral 
 diseases of the nervous system, typhoid fever, dysen-= 
 erty, diabetes mellitus, trichiniasis, paraplegia, long 
 standing suppurations. In the majority of these C. 
 E. Simon holds that the indicanuria is merely an 
 index of the condition of the gastric juice. 
 
 5. After use of certain drugs as turpentine, oil of 
 bitter almonds, nux vomica, and creosote. 
 
 ounicaij notes. 
 
 1. Dr. 0. E. Simon, of Baltimore, has studied the 
 relation between indican (indoxyl- sulphuric acid) and 
 the acidity of the gastric juice. His conclusions 
 are as follows : 
 
 1. The gastric juice possesses antiseptic and germicidal 
 properties. 
 
 2. Tliese properties are referable to the presence of free hydro- 
 chloric acid. 
 
 3. A subnormal amount of free hydrochloric acid will call forth 
 an increased degree of intestinal putrefaction. 
 
 4. The conjugate sulphates form an index of the degree of 
 intestinal putrefaction. 
 
 fi. The increased intestinal putrefaction in cases of subaciditv 
 and anacidity of the gastric juice is largely referable to an 
 increased formation of indol. 
 
 6 The elimination of indican in the urine may be regarded as 
 an index of the amount of free hydrochloric acid present. 
 
 7. A normal •acidity of the gastric juice is never associated 
 with increased indicanuria. 
 
 8. Oases of ulcer of the stomach apparently form an exception 
 to this rule, an increased indicanuria being usually associated 
 with hyperchlorhydry. 
 
 9. In othpr cases of hyperchlorhydry a subnormal or normal 
 amount of iadican is eliminated. 
 
 1<|. Simple constipation is rarely accompanied by an increased 
 elimination of indican. 
 
 11. Diarrhoea referable to a catarrhal condition of the colon, 
 often following a previously existing ooprostaais, as well as 
 
120 URINARY ANALYSIS. 
 
 diseases of the colon in general, is not associated with an increased 
 indioanuria. 
 
 12. In the differential diagnosis between ileus and coprostasis, 
 a small amount of indican excludes the former condition. 
 
 13. In cases of an achlorhydry with much lactic acid, the indi- 
 can is not necessarily increased. 
 
 14. No indican, or but little indican, with delayed Qilnzburg 
 potassium-iodide reaction, indicates the absence of free hydro- 
 chloric acid, with much lactic acid. (The Giinzburg test is for 
 free HCl in the stomach.) 
 
 15. Much indican. with a normal or anticipating Gtinzburg 
 reaction, is suggestive of ulcer. 
 
 16. In cases in which the use of the gastric tube is impractic- 
 able or contra-indicated, or in cases of a mere superficial examina- 
 tion, the indican reaction will furnish a valuable index of the 
 condition of the patient's digestive powers 
 
 17. By means of the indican reaction we are enabled to follow 
 very closely the results of treatment instituted in cases of gastro- 
 intestinal disease. 
 
 Given aa premises: 
 
 1. That a resorption of decomposing pus is not taking place 
 aay where in the body, as such a process itself is capable of pro- 
 ducing; an increased elimination of indican. 
 
 3. That there does not exist a stenosis of the small intestine. 
 
 3. A normal mixed diet containing no excessive amounts of 
 red meats. 
 
 Note:— Simon finds that a large quantity of indican may be 
 of decided value in differential diagnosis of ileus, since diseases of 
 the large intestine alone are never associated with an incrdase in 
 the amount of indican. 
 
 2. Suppuration may be suspected as taking place in 
 the body if, after administration of intestinal dis- 
 infectants (naphthol, bismuth), indioanuria still per- 
 sists. 
 
 3. Fahn finds indican increased in tuberculosis. 
 
 4. Herter finds indioanuria (1) in chronic intesti- 
 nal dyspepsia with clay-colored stools and mental de- 
 pression, (2) in neurasthenia from sexual excess, (3) in 
 chronic constipation, (4) in chronic epilepsy, especially 
 after the attacks. 
 
 Marten out of 6 cases of indioanuria found in all but 
 one some intestinal trouble or other. The exception 
 wag a drunkard subject to fits. 
 
 6. According to C. E. Simon, examination of the 
 urine for indican is at least as important as that for 
 albumin and sugar 
 
 Skatoxyl-Sulphuric acid:— Formula, C.HeN.O.SOj.OH, an 
 aromatic substance, ethereal {conjugate) sulphate, found in noi-mal 
 urine. It re.sembles indican in that it is an organic product of the 
 decomposition of albumin. 
 
AROMATIC COMPOUSDS.— PHENOL. 131 
 
 Test: — Jaffe's test for indicau, when performed on urine rich in 
 skatoxyl, shows a dark-red to velvet color on addition of hydro- 
 chloric acid. If nitric acid be used, a cherry-red color is de- 
 veloped; if hydrochloric acid, ferric chloride, and heat are used 
 a red color occurs, which can be removed from the fluid by ether 
 or acetic ether, while on heating with zinc dust skatol is liberated. 
 
 Significance: — It is found in very small quantities in normal 
 urine and its significance is said to be much the same as that of 
 mdican, so far as increase goes. Urines rich in skatoxyl darken 
 nn exposure to the air, as in carboluria, while at the same time 
 thev take on from the surface a reddish or velvet color, often al- 
 most black. 
 
 Phenol-Sulphuric Acid:— Formula, C.HsO.SOj.OH, anorganic 
 aromatic substance, ethereal or conjugate sulphate, found in 
 very small quantity in the urine. The phenol is a product of 
 intestinal fermentation, and some of the sulphate is derived from 
 tyrosine. 
 
 Detection: — Acidulate the urine with sulphuric acid and distill. 
 Add (a) bromine-water to distillate and a deep-yellow precipitate 
 of tribromphennl appears, if phenol is present. Or (b) warm the 
 distillate with Millon's reagent, and a cherry-red color appears. 
 
 Note: — Millon's reagent is made by dissolving 10 grammes of 
 mercury in 20 grammes of nitric acid (sp. gr. 1.42) and diluting 
 with 30 c.c. of water. 
 
 A third test (o) may be tried by adding ferric 
 chloride solution to the distillate, when a deep violet 
 color appears. 
 
 Significance: — Phenol-sulphuric acid is increased by internal or 
 HXternal use of phenol (carbolic acid), also in certain diseases as 
 tuberculous enteritis, pyaemia, intestinal obstructions, etc. 
 
 Carboluria is the name given to the voiding of dark 
 urine, the result of excessive use of carbolic acid which splits up 
 in the urine into pyrocatechin and hydroquinone, which sub- 
 stances, on exposure to the air, become dark-brown in alkalme 
 urine. 
 
 Phenol has been found in the urine of patients taking guaiacol 
 carbonate in large doses. 
 
 Other conjugate sulphates: — Several other conjugate 
 sulphates ocfur in urine: they are paracresol-sulphuric acid 
 CtHT.O.SOj.OHj forming paracresol-potassium sulphate, pyro- 
 catechin, ' and hydroquinone. Hydroqunone is recognized by 
 tUf development of a quinone-like odor, when heated with ferric 
 chloride. 
 
 16 
 
123 URINARY ANALYSIS. 
 
 CHAPTEE XVII. 
 
 NORMAL URINARY COLORING MATTERS AND 
 CHROMOGENS. 
 
 Ueinaet pigments are of two classes {a) those 
 already formed and (5) those appearing only on addi- 
 tion of certain reagents. 
 
 Preformed coloring matters: — These are uro- 
 clwome and uroerythrin. Urochrome is the substance 
 to which the normal yellow color of urine is due to a 
 certain extent. It is probably identical with the nor- 
 mal urobilin of MacMunn, is derived from hilirubin, 
 and results from oxidation of the latter in the intes- 
 tinal tract. Bilirubin, as is known, has its origin in 
 the haematin and haemoglobin of the blood. Uro- 
 chrome may also originate directly from blood-pig- 
 ments. It is increased in oases in which resorption of 
 large extravasations of blood is taking place, *. «., 
 whenever an increased destruction of red corpuscles is 
 noted, and decreased in conditions associated with 
 deficient formation of red corpuscles, 'as in anaemia, 
 Bright's disease, diabetes, diseases of the bone mar- 
 row, etc. It is closely related, chemically, to a color- 
 ing matter known as urobilin, or better, pathological 
 urobilin, from which, however, it may be' readily 
 distinguished by the spectroscope. [See Abnormal 
 Coloring Matters and do not confound notes on "uro- 
 bilinuria" in books and journals with the voiding of 
 urine containing normal urobilin or urochrome. Much 
 confusion exists in regard to these substances]. 
 
 Urochrome or normal urobilin of MacMunn may be obtained 
 from normal urine by acidulating with 1 to 3 grammes of dilute 
 sulphuric acid for each liter of urine, filtering, and saturating 
 with ammonium sulphate; the flakes which are found in an 
 excess of the ammonium sulphate are dried, treated with warm, 
 slightly ammoniacal absolute alcohol, and the pigment ubcained 
 on evaporation of the alcohol. 
 
NORMAL URINARY PIGMENTS. 123 
 
 An alcoholic solution of the pigment thus obtained 
 exhibits a beautiful greenish fluorescence when treated 
 with ammonia and a few drops of solution of zinc 
 chloride, in this respect resembling pathological uro- 
 bilin, but it differs from the latter spectroscopically 
 in that its acidulated alcoholic solutions present a 
 broad band of absorption at "F" extending more to 
 the left than to the right of this line, while the 
 remainder of the spectrum at the same time is ab- 
 sorbed to the right end from a point somewhat to the 
 left of "G." 
 
 Uroerythrin Is the pigment to which the red color 
 of urate sediments and uric acid crystals is due. It is 
 related chemically to haemoglobin, h^matoidin, and 
 bilirubin. When abundantly present in urine, it gives 
 a salmon-red color to urinary sediments. Its quantity 
 may be judged by the following test : Add solution 
 of barium chloride or of neutral lead acetate to the 
 urine and let the precipitate settle, waiting ten or fif- 
 teen minutes; a milky-white precipitate indicates 
 absence of uroerythrin, a pale rose-colored one pres- 
 ence of uroerythrin in appreciable amounts, and a 
 more pronounced rose-color large quantities. 
 
 Uroerythrin is, when present in notable quantities, 
 indicative of hepatic insuffioienoy, in which the liver, 
 owing to a greatly increased destruction of red cor- 
 puscles, is either unable to transform all the blood 
 pigment carried to it into bile pigment or else an abso- 
 lute insufficiency on part of the hepatic cells exists, so 
 that the organ is not even able to bring about trans- 
 formation of a normal quantity of haemoglobin. The 
 diseases in which uroerythrin is found in large quan- 
 tities in the urine are hepatic cirrhosis, carcinoma of 
 the liver, pneumonia, malarial fever, erysipelas, spinal 
 curvature, etc. 
 
 According to recent writers normal urine contains two other 
 pigments, namply urospectrin and hcematoporphyrin. Urospec- 
 trin is extracted from urine by sliaking thie latter witii acetic- 
 ether wliich removes about two-ninths of the coloring matter. 
 The residue left upon evaporation of the acetic-ether extract is 
 soluble in ether. The ether extract contains the chvomogen of 
 urobilin and urospectrin. Upon exposure to Hght the urobilin 
 chromogen is decomposed and the urobilin may be removed by 
 
134 URINARY ANALYSIS. 
 
 shaking with water. Solutions of urospectrin in ether and alka- 
 lies give four absorption bands; acid solutions give two bands. 
 
 Hasmatoporphyrin may be extracted from urine by adding 
 20 CO. of a ten per cent solution of sodium hydroxide to every 
 100 c.c. of urine; the precipitated phosphates are collected and 
 washed with water. The precipitate is dissolved in rectified spirit 
 and acidified with hydrochloric acid; the solution shows the bands 
 of acid hffimatoporphyrin. Ammonia is then added to precipi- 
 tate the phcspliates and acetic acid to redissolve them; chloroform 
 t hen extracts the pigment completely and shows the bands of the 
 :ilkaline pigments. 
 
 Normal chromogens: — Ohromogens are substances 
 which when treated with certain reagents yield 
 pigments. The chromogens of normal urine are 
 indican, urohsematin, and an unknown chromogen 
 which yields urorosein, when treated with mineral 
 acids, hence called uroroseinogen. Indican has 
 already been considered under the heading of conju- 
 gate sulphates. Urohoematin appears to be the 
 chromogen of the red pigment found in urine and 
 called by various names, as the red pigment of Soberer, 
 indigo-purpurin of Bayer, urrhodin of Heller, indigo- 
 red, etc. It is probably an indoxyl derivative ; when 
 present in increased amount, it is conveniently 
 detected by the reaction of Mosenhach, as follows : 
 Boil the urine and add to it, while boiling, nitric acid, 
 drop by drop. In presence of large amounts of the 
 red pigment the urine will assume a dark Burgundy 
 color, which sometimes takes on a bluish tinge, if 
 lield to the light; the mixture becomes cloudy, and 
 the foam assumes a blue color. In some cases addition 
 of from 10-20 drops of acid will suddenly change the 
 color from red to yellow, while in others the 
 Burgundy color is not changed. 
 
 Rosenbach's reaction is an important one and its 
 significance is the same as the well-marked indican 
 reaction, namely, greatly increased intestinal jputref ac- 
 tion, as in extensive disease of the small intestine, in 
 carcinoma of the stomach, acute and chronic peri- 
 tonitis. The reaction has been found to be absent in 
 carcinoma of the colon, occlusion of the large intestine, 
 stricture of the oesophagus, and chronic diarrhoea. 
 If constant and continued in spite of medical or 
 
NORMAL URINARY PIGMENTS. 125 
 
 surgical measures, Eosenbach's reaction is of had 
 prognosUo significance. 
 
 Uroroseinogen is the chromogen which yields a rose-red pig- 
 ment, urorosein, apparently identical with Heller's urophain. It 
 is not a conjugate sulphate, but otherwise little or notliing is 
 known of its chemical nature. It occurs normally only in traces 
 but appreciable amounts are found pathologically and may be 
 detected a4 follows: — Treat 5 or 10 c.c. of urine with an equal 
 amount of concentrated hydrochloric acid and 1 or 2 drops of a 
 concentrated solution of bleaching powder. If much inditjan is 
 present the mixture first assumes a dark greenish, blackish, or 
 dark-blue color, owina: to formation of indigo. Wlit-n the mix- 
 ture is shaken with chloroform, the supernatant fluid will exhibit 
 a beautiful rose-color due to urorosein. This may then be ex- 
 tracted with amyl alcohol, and separated from any other pigment 
 present at the same time, by shaking with sodium hydrate, by 
 means of which the solution is decolorized. On the addition of a 
 drop or two of hydrochloric acid to the alcoholic extract the rose- 
 color will reappear. 
 
 A rose-red ring due to this pigment may be noticed in patho- 
 logical urines when Heller's cold nitric acid test is used for detec- 
 tion of albumin. 
 
 Appreciable amounts of this pigment are met with in patholog- 
 ical conditions associated with grave disturbances of nutrition, 
 as nephritis, diabetes, carcinoma of the stomach and dilatation, 
 pernicious aDismia, typhoid fever, phthisis, and at times in pro- 
 found chlorosis. It is also apparently increased by vegetable diet. 
 
 CHEMICAL EXERCISE VH. 
 
 The student having collected his twenty-four hours' 
 urine should test it for the following : 
 
 1. Indiean: — Chapter XVI, Stokvis-Jaflfe test. 
 
 2. Slcatoxyl: — Chapter XVI, Jaffe's test. 
 
 3. Obtain urooh/rome by the process outlined in 
 chapter XVII. 
 
 4. Test for uroerythrin with neutral lead acetate 
 solution : Chapter XVII. 
 
 5. Try Rosenbacli' s reaction: Chapter XVII. 
 
 6. Test for urorosein: Chapter XVII. 
 
 7. Compare the Stokvis-Jaffe test for indiean witli 
 Hichardsoii' s test, as follows : Take equal quantities 
 of urine and hydrochloric acid, add a few drops of 
 a solution of hydrogen dioxide, and then chloroform 
 as in Jaffe's test. 
 
126 URINARY ANALYSIS. 
 
 CHAPTEE XVIII. 
 
 THE NON-NITROGENOUS ORGANIC ACIDS OF NORMAL 
 
 URINE. 
 
 The non-nitrogenous organic acids occurring 
 normally in urine may be classified as follows : 
 
 1. Oxalic acid combined with calcium forming 
 calcium oxalate. 
 
 2. Succinic and lactic acids. 
 
 3. Acids of the fatty acid group : Formic, acetic, 
 butyric, propionic. 
 
 4. Grlycero-phosphoric acid. 
 
 Oxalic acid: — In combination forming calcium oxalate CaCjOj 
 held in solution by the sodium dihydric phosphate of the urine. 
 
 Sediments therefore contain calcium oxalate when the urine is 
 diminished in acidity or on standing exposed to the air. The 
 occurrence of calcium oxalate in the sediment does not then 
 necessarily indicate excess of it in the urine. For the quantitative 
 determination of the oxalic acid in urine no simple process is 
 known. See Appendix for complete process, and Sediments for 
 other information, pathology, etc. 
 
 Oxalic acid is related to uric acid as is also another acid found 
 in normal urine known as oxaluric acid, which occurs in traces 
 in the tirine as ammonium oxalurate. 
 
 Succinic acid has occasionally been found in urine after 
 ingestion of asparagus and asparagin. It is a third acid of the 
 oxalic series. The relationship of the acids of the oxalic series 
 may be seen by the formulas, as follows:- 
 
 Oxalic acid, HjCjOi or COOH.COOH. 
 
 Oxaluric acid, (CONijH,).CO COOH. 
 
 Succinic acid, COOH.CjH4.COOH. 
 
 Lactic acid probably does not occur in urine, but sarco-lactic is 
 said to occur after severe muscular labor and physiological dis- 
 turbances. It is, however, chiefly met with in pathologic states 
 and should be considered among the constituents of abnormal 
 urine. There are no tests for it available for clinical purposes. 
 It has been found in trichinosis, acute yellow atrophy of the liver, 
 phosphorus poisoning, rickets, leukaemia, osteomalacia, cirrhosis 
 of the liver. 
 
 Tlie Fatty acids occur in traces under normal conditions and 
 are probably formed in the lower segment of the small intestine. 
 They are formic, acetic, butyric, and propionic, and occur appar- 
 ently in the free state. They are increased slightly in (a) febrile 
 disorders and greatly in (6) hepatic diseases aflfecting the structure 
 
NORMAL ORGANIC ACIDS. 137 
 
 proper of the liver; they are also increased (c) in diabetes. The 
 condition when they are present in increased amount is known as 
 lipaeiduria. 
 
 There is no simple method of detection; the usual method of 
 detection is to distill the urine with phosphoric acid, neutralize 
 the distillate carefully with sodium carbonate, evaporate to dry- 
 ness on the water bath, extract the residue with boiling alcohol, 
 filter, evaporate again, dissolve in water, and test as follows: — 
 
 1. Treat solution with sulphuric acid and alcohol. Odor of 
 acetic ether shows presence of acetic acid. 
 
 3. To another portion add ferric chloride solution: a red tint 
 appears which disappears on boiling leaving a rusty precipitate. 
 
 3. Addition of silver nitrate solution causes a white precipitate 
 which rapidly blackens if for~mic acid is present. 
 
 Glycero-phosplioric acid, CsHjPOe, occurs in small traces in 
 normal urine, resulting as a decomposition product of lecithin, 
 which is a combination of choline and glycero-phosphoric acid, 
 occurring in the bile, brain, yolk of egg, etc. 
 
 The normal quantity of glycero-phosphoric acid in urine is said 
 to be about 15 milligrams per liter. It is increased in chyluria, 
 pernicious anaemia, dementia, lesions of the brain substance, 
 diabetes mellitus, and after chloroform narcosis. 
 
 Inasmuch as in the writer's experience the phosphoric acid of 
 the urine (oxidized phosphorus) is certainly diminished in condi- 
 tions of nerve waste, it is reasonable to suppose that the glycero- 
 phosphoric acid (unoxidized phosphorus) is increased at the same 
 time. The experience of Robin would appear to confirm this 
 view, hence the use clinically of the glycero-phosphates, phospho- 
 albumins, etc. 
 
 Unfortunately it is a difficult matter to determine the glycero- 
 phosphoric acid in urine hence see Appendix for processes. 
 
128 URINARY ANALYSIS. 
 
 CHAPTER XIX. 
 
 CARBOHYDRATES NORMALLY PRESENT IN URINE- 
 
 The carbohydrates normally present in urine may 
 be classified as follows : 
 I. Glucose. 
 II. Grlucosazone. 
 
 III. A substance allied to dextrine. 
 
 IV. A carbohydrate in combination with benzoyl. 
 V. Animal gum. 
 
 VI. Inosite. 
 VII. Lactose. 
 
 The total amount of carbohydrates with reducing properties 
 eliminated daily in normal urine, has been shown by Baisch to be 
 from 0.12 to 0.32 gm. (about 2 to 5 grains), of which glucose itself 
 amounts to from 0.08 to 0.18 gm. or about IJ to 2i grains. 
 Among the other carbohydrates are glucosazone, a substance 
 allied to dextrine, and a carbohydrate in combination with 
 benzoyl. 
 
 Animal gum is a mucin product. It is precipitated by alcohol 
 but does not reduce alkaline solutions of cupric salts. 
 
 Inosite, a sugar found in small quantities in normal urine. 
 CjHiaOe.2H20, muscle-sugar. It is usually found in normal 
 urine only after use of large quantities of water. 
 
 Form: — Crystalline, when obtained pure, forming large, fine, 
 clinorhombic or monoclinio tables. Impure it crystallizes in 
 cauliflower-like masses. 
 
 Soluhility: — Soluble in 16 parts water at 10* C, insoluble in 
 absolute alcohol and ether. 
 
 Properties: — Sweetish taste, does not rotate plane of polariza- 
 tion, does not ferment. In alkaline solution it does not reduce 
 hydrated cupric oxide. It yields sarco-lactic acid when 
 fermented with putrefying albumin. 
 
 Tests: (1) Seherer's test: — On evaporating a solution contain- 
 ing inosit on the water bath nearly to dryness in a porcelain dish, 
 having added a few drops of common nitric acid, and then treat- 
 ing the nearly dry residue with some drops of a freshly-prepared, 
 not too dilute, watery solution of ammonia and calcium chloride 
 solution, a rose-red mass remains, which, after some time, 
 becomes changed in color. 
 
 (2) Oallois's test: — An aqueous solution treated in a porcelain 
 dish with a little mercuric nitrate Hg (NOs)^ in solution — a drop 
 will suffice— gives a yellowish precipitate. If this is spread out 
 on the edge of the dish quickly, and heated carefully, it becomes 
 
NORMAL CARBOHYDRATES IN URINE. 129 
 
 dark red. The color disappears on cooling to reappear on heat- 
 ing. Albumin, sugar, and tyrosin interfere with the reaction. 
 
 Preparation from urine:— A large quantity of urine (sev eral 
 liters) is feebly acidified, precipitated completely with neutral 
 acetate of lead, filtered, and the warmed filtrate treated with 
 basic acetate of lead, as long as a precipitate forms. After stand- 
 • ing for forty-eight hours this precipitate is filtered off, washed, 
 suspended in water, and treated with a stream of sulphuretted 
 hydrogen. From the filtrate, after some hours, uric acid sepa- 
 rates, from which the fiuid is poured off. The solution is then 
 evaporated to a syrup on the water bath, and precipitated with 
 absolute alcohol. The precipitate is dissolved in hot water and 
 three or four times as much alcohol of 90 per cent as water 
 added. The alcohol is then treated with ether until the clouding 
 is permanent, when the inosit crystallizes out. The watery 
 solution can be used for Scherer's reaction directly (Salkowski 
 and Leube). 
 
 Pathology : — Inosite is found in the urine in increased 
 quantity in diabetes, mellitus and insipidus; also in 
 Bright's disease. 
 
 Lactose, milk-sugar, an organic substance, carbohydrate 
 CiaHaaOii.HsO, is found in the urine of nursing-mothers and in 
 lesions of the mammary glands. Positive detection of it is diffi- 
 cult because of its resemblance to glucose in answering to tests. 
 The writer has found, however, that it reduces Haines's test- 
 liquid more slowly than glucose. (See writer's Chemistry, 4th 
 edition, p. 535.) Its presence may be inferred if a positive result 
 is obtained with Trommer's and Nylander's tests for glucose (see 
 Chap, on Sugar), while the phenylhydrazin and fermentation tests 
 give negative results. It is said that persistent and copious elim- 
 ination of lactose in the urine is a sign of a good wet-nurse. 
 The most certain means for its detection is to isolate it according 
 to the method of F. Hofmeister. Precipitate the urine with 
 sugar of lead, filter, wash with water, unite the filtrate and wash- 
 water, and precipitate with ammonia. The liquid filtered from 
 the precipitate is again precipitated by sugar of lead and ammo- 
 nia, until the last filtrate is optically inactive. The several pre- 
 cipitates, with the exception of the first, which contains no sugar, 
 are united and washed with water. The washed precipitate is 
 decomposed in the cold with sulphuretted hydrogen and filtered. 
 The excess of sulphuretted hydrogen is driven off by a current of 
 air; the acids set free are removed by shaking with silver oxide. 
 Now filter, remove the dissolved silver by sulphuretted hydrogen, 
 treat with barium carbonate to unite with any free acetic acid 
 present, and concentrate. Before the evaporated residue is 
 syrupy it is treated with 90 per cent alcohol until a flocculent 
 precipitate is formed, which settles quickly. The filtrate from 
 this when placed in a desiccator deposits crystals of milk-sugar, 
 which are purified by re-crystallization, decolorizing with animal 
 charcoal and boiling with 60-70 per cent alcohol. 
 
 17 
 
130 URINARY ANALYSIS. 
 
 THE MUCOUS CLOUD (NUBECULA) IN URINE. ENZYMES. PTOMAINES 
 
 Normal urine, on standing, deposits a slight cloud 
 in the case of men, but a bulky one in the case of 
 women. If this "cloud" be removed by means of a 
 pipette and sedimented in the centrifuge the micro- 
 scope shows it to consist of a few mucous corpuscles 
 and pavement epithelia in the case of men, but in 
 women a great mass of epithelia may be seen, of 
 vaginal origin. Traces only of mucin or a mucin-like 
 substance or even none at all are to be found in the 
 urine of healthy men, while in women admixture of 
 vaginal fluids causes a mucin-reaction in almost every 
 sample of urine examined. See Mucinuria in Chap- 
 ter on "Albumin." 
 
 The enzymes found in urine are the following: 
 
 Diastase:— Mmxiie quantities of ptyalin or a similar diastatic 
 ferment have been obtained from urine. 
 
 Pepsin, an organic ferment, has been isolated from normal 
 urine and is found most abuadant in the morning. Small pieces 
 of fibrin soaked in urine absorb the pepsin from it and, on being 
 removed to 0.1 per cent hydrochloric acid solution, they are then 
 rapidly digested. 
 
 Rennet: — Traces of a ferment which curdles milk have been 
 found in urine. 
 
 Jftoniaines: — These organic substances, and leucomaines, 
 poisonous substances of an unknown kind, which are often called 
 alkaloidal substances, occur in normal urine according to Bou- 
 chard and others. (See Toxicity of Urine.) 
 
INOBQANIO CONSTITUENTS OF URINE. 131 
 
 CHAPTER X5. 
 
 INORGANIC NORMAL CONSTITUENTS OF URINE. 
 
 The inorganic normal constituents of urine will be 
 considered under the following 
 Classification. 
 
 I. Compounds of the negative elements phosphorus, 
 chlorine, and sulphur, forming phosjjhates, chlorides, 
 and sulphates, occurring in considerable quantity in 
 the urine. 
 
 II. Compounds of other elements occurring in small 
 quantit}'^ or in traces in the urine — nitrates, nitrites, 
 carbonates. 
 
 III. Free gases. 
 
 THE PHOSPHATESo 
 
 Introductory: — Phosphoric acid, H3PO4, occurs in 
 the urine entirely in combination with bases, forming 
 phosphates. 
 
 There are several kinds of phosphates in urine, and 
 this is why the beginner meets with difficulty. Let it 
 be remembered, first, that all urine normally contains 
 phosphates dissolved in it, and, second, that under 
 certain circumstances some of these phosphates appear 
 in the urinary sediment. But all the phosphates in 
 urine are not found in the sediment under any circum- 
 stances. The phosphates which are always in solution 
 and never in the sediment are the phosphates of sodium 
 and potassium, and are called alkaline phosphates. 
 The phosphates which are sometimes in solution and 
 sometimes in the sediment are the phosphates of cal- 
 cium and magnesium, the so-called earthy phosphates. 
 
 The question now arises. When does the urine con- 
 tain phosphates in the sediment? The answer is, 
 when the reaction is feebly acid, neutral, or alkaline. 
 The phosphates of calcium and magnesium are dis- 
 
132 URINARY ANALYSIS. 
 
 solved by acid urine, but when the urine, for any 
 reason, leses its acidity these phosphates separate, and 
 form a dirty- white flocculent sediment. The other 
 phosphates, those of sodium and potassium, however, 
 are not affected by any change in the reaction, but 
 remain always in solution. We have, then, the 
 following : — 
 
 Aoid urine: — Phosphates of sodium and potassium 
 in solution, H2]S[aP04 and H KPO4. Phosphates of 
 calcium and magnesium, in solution, G'd,i(POi)i and 
 MgHP04.7H30. 
 
 Alkaline urine: — Phosphates of sodium and potas- 
 sium in solution. Phosphates of calcium and mag- 
 nesium in the sediment. 
 
 Ammojiiacal urine: — Same as alkaline urine plus 
 triple phosphate, NHjMgPOi. 6H2O (ammonio-mag- 
 nesium phosphate), in the sediment. 
 
 I hope that this table makes matters sufHoiently 
 clear. Nearly every year my students are disconcerted 
 by the fact that the alkaline phosphates do not appear 
 in the sediment, whilst the earthy phosphates may. 
 
 Solubility: — When feebly acid or alkaline urine is 
 boiled, it becomes cloudy from precipitation of phos- 
 phates. These phosphates thus precipitated are 
 always the earthy phosphates, those of calcium and 
 magnesium, never the alkaline phosphates, those of 
 sodium and potassium. The alkaline phosphates are 
 always in solution in the urine, whether it be aoid or 
 alkaline in reaction, or hot or cold in temperature. 
 
 Now, inasmuch as albumin, if present in the urine, 
 is coagulated by boiling, the earthy phosphates, when 
 urine is feebly acid or alkaline, may be, and, to my 
 knowledge, frequently are, mistaken for albumin. 
 Addition of acetic acid, however, dissolves the phos- 
 phatic cloud but does not affect the albuminous 
 coagulum, if such it be. So then, not only do the 
 earthy phosphates form a sediment or deposit in 
 alkaline urine, but if either feebly acid or alkaline 
 urine is boiled, they are thrown out of solution. In 
 other words, the phosphates of calcium and mag- 
 nesium possess the remarkable property of being less 
 
PHOSPHATES. 133 
 
 soluble in hot than in cold water. The alkaline phos- 
 phates, those of sodium and potassium, are not affected 
 by boiling the urine, and cause no trouble. 
 
 Again, when urine is tested for sugar, either by 
 liquor potassse, by Haines' liquid, Trommer's or 
 Fehling's test, a complication ensues from presence 
 . of phosphates. Inasmuch as these tests all involve 
 addition of strong alkalies to the urine, and boiling, it 
 follows, from what is said above, that the earthy 
 phosphates will be precipitated whether or not sugar 
 is present. Hence, when sugar is absent, a dirty 
 white precipitate of earthy phosphates will always be 
 seen, sometimes more conspicuous, sometimes less. 
 Whenever urine is hoiled with an alkali or with a blue 
 sugar-test liquid (which contains alkali) fiocks of 
 precipitated earthy phosphates will he seen. These 
 phosphates are the phosphates of calcium and mag- 
 nesium, not of potassium and sodium. We have then 
 the following : 
 
 Summary: — Phosphoric acid, H3PO4, combined 
 with bases, is found in all urine, forming phosphates. 
 
 1. Alkaline phosphates: — Phosphates of sodium and 
 potassium, present in solution in every sample of urine, 
 never in the sediment, not affected by boiling, nor by 
 addition of alkali. Do not complicate the albumin 
 tests nor the sugar tests. 
 
 3. Earthy phosphates: — Phosphates of calcium and 
 magnesium. Present in solution in every sample of 
 urine and also in the sediment of every alkaline urine. 
 Precipitated from solution in feebly acid, neutral, or 
 alkaline urine when the latter is boiled. Precipitated 
 whenever an alkali like liquor potassas is added to the 
 urine, as in the various tests for sugar. Ee-dissolved 
 when any acid is added to the precipitate, or to the 
 sediment. 
 
 The composition of the phosphates may vary some- 
 what with the reaction of the urine. Thus in acid 
 urine we may have acid phosphates, JSTaH-PO, and 
 CaH,(P04).; in neutral urine, neutral phosphates, 
 lS^aoHP04,CaHP04,MgHP04; in alkaline urine, basic 
 phosphates ]S[aaP04, etc. 
 
134 URINARY ANALYSIS. 
 
 3. Triple phos])hate: — In addition to the phos- 
 phates already mentioned there is still another phos- 
 phate, known as ammonio-magnesium phosphate, or 
 "triple" phosphate. (It is called triple phosphate, 
 ITHiMg.POi.eH.O, because of the water of crystal- 
 lization forming the third part of its formula.) This 
 phosphate is naturally not found in normal urine but, 
 if for any reason, through disease (septic inflammation 
 of the urinary passage), retention of urine takes place, 
 either in the kidney-pelvis or in the bladder, and there 
 is decomposition of urea, ammonium carbonate being 
 formed, some of the ammonium unites with the mag- 
 nesium phosphate of the urine to form the double salt, 
 ammonio-magnesium phosphate, which, however, 
 ownig to the presence of six molecules of water in its 
 formula, has received the name of "triple" rather 
 than "double." So, then, triple phosphate is found 
 in the sediment of am^moniacal urine. It is also some- 
 times found in slightly acid urine (acidity probably 
 due to some salt which reddens litmus) and in alkaline 
 urine without odor of ammonia. 
 
 Urine which turns red litmus paper permanently 
 blue is said to be alkaline from fixed alkali (carbonates 
 of sodium and potassium). Urine which turns red 
 litmus paper blue, the latter fading on exposure to air, 
 and which has odor of ammonia, is said to be alkaline 
 from volatile alkali. It is in urine alkaline from vola- 
 tile alkali that we find the triple phosphate. Such 
 urine is always, when freshly voided, significant of dis- 
 ease. Care must be taken to note the words 'when 
 freshly voided." 
 
 Chemical tests: — From what has already been said 
 it is easy to see that a simple test for earthy phos- 
 phates is to add to any sample of urine sufiicient liquor 
 potassae to render it alkaline, and then boil. Flocks 
 of phosphates at once appear. They are usually dirty 
 white, but may be reddish or brownish. To' detect 
 the alkaline phosphates, filter the sample and add to 
 the clear filtered urine one-third its bulk of magnesian 
 fluid, when a snow-white deposit takes place. 
 
PHOSPHATES. 135 
 
 Magnesian fluid is made by dissolving 10 grams (155 
 grains) of pure magnesium sulphate and a like amount 
 of pure ammonium chloride in 10 c.c. of strong aqua 
 ammoniiB and 80 c.c. of distilled water. 
 
 How may the quantity of phosphates in the urine 
 be determined? Accurate analyses are made with 
 difficulty for the general practitioner, so that the 
 volumetric determination of the total phosphoric acid 
 is the best method to be followed. It is given in 
 Chemical Exercise ( ?). 
 
 physiology of the phosphates. 
 
 Quantity: — Different observers make from 2 to 4 
 grams of phosphoric acid normal per twenty^four 
 hours. The author inclines to the opinion that for 
 Americans 2 to 2.5 grams (31 to 38 grains), is not too 
 small.* Of this quantity about one- third is bound to 
 the earthy phosphates, and two-thirds to the alkaline. 
 The total quantity of phosphates is variously reckoned 
 at from 3 to 5.5 grams per twenty-four hours (45 to 
 85 grains). Of this the earthy phosphates form 1 to 
 1.5 grams (15 to 22 grains), and the alkaline 2 to 
 4 grams (30 to 60 grains). These figures are 
 altogether to high in case of Americans, so far as my 
 experience goes. The proportion of calcium phos- 
 phate to magnesium phosphate is given by Tyson as 
 33 to 67. The potassium phosphate is the smallest in 
 amount of aU the phosphates. 
 
 Source: — Phosphoric acid in the urine comes largely 
 from the blood, but also partly from the decom- 
 position of lecithin (a phosphorized fatty body, 
 C42H84NPOg, occurring in brain and nerve tissue), 
 and nuclein (an albuminoid' substance occurring 
 in the nuclei of corpuscles, in spermatozoids, brain, 
 milk, etc.), which also contains phosphorus. 
 Nerve tissue yields relatively more phosphorus 
 than muscle tissue. 
 
 Formation: — In the blood phosphoric acid is found 
 combined with bases forming phosphates : neutral 
 
 •Ten medical students in health, whose urine was examined by 
 the writer, averaged a grams (31 grains). 
 
136 URINARY ANALYSIS. 
 
 sodium and neutral potassium phosphates in the blood 
 appear in the urine as aoid salts, for the reason that 
 by the act of secretion the bicarbonates and neutral 
 phosphates in the blood become carbonates and acid 
 phosphates, according to the equation : 
 
 HNaCO. + HNajPO, = Na^CO, + H^NaPO* 
 
 Bodinm central sodiam sodiatn 
 
 bicarbonate, eodiam carbonate, acid 
 
 phosphate, phosphate. 
 
 The acid salts pass out in the urine, obeying the law 
 of diffusion, but the carbonates remain in the blood. 
 
 Excretion: — The maximum excretion is in the even- 
 ing, the minimum about mid-day. The excretion 
 varies somewhat with the amount of food taken, being 
 increased by meat diet, since this tends to increase 
 formation of alkaline phosphates. According to Dr. 
 Long the phosphates in urine have decreased since 
 changes in milling processes have made material reduc- 
 tions in the percentage of phosphates in flour. Phos- 
 phatio beverages arcsaid to increase the phosphates in 
 the urine, but in the writer's experience no great ex- 
 cess has been found in any considerable number of 
 cases from any cause whatever, the general tendency 
 being toward figures considerably lower than those of 
 the European observers. The phosphates are said to 
 be increased by drinking freely, but increased elimina- 
 tion is followed by a certain degree of retention. 
 
 Ratio of urea to phosplioric acid in health:— 
 Like all other ratios this is given differently by differ- 
 ent observers. From 8 to 1 to 10 to 1 is adopted by 
 some. E, E. Smith thinks it to vary between 12 and 
 15 to 1. In my own experience out of 36 cases 
 recently examined in which this ratio was determined, 
 in persons in whose urine no abnormal constituents 
 could be found, and who were, so far as I know, 
 healthy, the following was the result : 
 
 Ratios less than 10 to 1.. q 
 
 lOtol. V 
 
 11 to 1 "-"::":::::::::::::;::: lo; 
 
 IStol ^ 
 
 IStOl q' 
 
 14tol. 4 
 
 16tol " I' 
 
INORQANIC CONSTITUENTS OF URINE. 137 
 
 In other words, S7 out of 36 were not over 12 to 1, 
 so that ratios above 12 to 1 must be regarded as infre- 
 quent. I incline to the opinion that the ratio varies 
 between. 8 to 1 and 12 to 1, when the clinical urea 
 instruments are used. 
 
 It must be borne in mind, however, that the clinical process for 
 determining urea is not accurate, chemically speaking, while the 
 volumetric determination of PaOs by uranium nitrate is in most 
 oases accurate. In all research work the ratio of total nitrogen 
 to phosphoric acid is to be preferred. See Appendix for Kjel- 
 dald-Gunning method. 
 
 CHEMICAL EXERCISE VIH. 
 
 DETECTION AND ESTIMATION OF PHOSPHATES IN THE UEINE. 
 
 The presence of phosphates in the urine is very 
 readily shown by means of certain simple tests. 
 Moreover in testing for albumin and for sugar these 
 substances are often precipitated since all urine con- 
 tains them in greater or less amount. 
 
 A. Detection of earthy phosj)hates: — To half a test 
 tube full of urine add a few drops of ammonia or 
 other alkaline solution, shake well, and boil ; whitish 
 flocks appear, indicating presence of earthy phosphates. 
 'If blood is present, the flocks are blood red ; if bile, 
 yellow-brown; if vegetable colors (as rhubarb, senna) 
 rosy -red. 
 
 B. Detection of alkaline phosphates: — Filter the 
 mixture obtained in A and to the filtrate add one-third 
 its volume of magnesian fluid. A snow-white pre- 
 cipitate, crystalline ammonia - magnesium phosphate, 
 mixed with amorphous calcium phosphate, occurs. 
 (The crystals thus rapidly formed have a fern-leaf 
 shape (Fig. 31), not prismatic, nor coifin-lid, as in spon- 
 taneous deposits. See Sediments). 
 
 Note: — The student should bear in mind the difference in 
 results obtained by tests A and B, and understand the reason for 
 it. The earthy phosphates in test A are actually seen, being 
 thrown out of solution on addition of alkali. .The alkaline phos- 
 phates (of sodium and potassium) on the other hand do not thus 
 appear in test B. Owing to the ready solubility in water of com- 
 pounds of sodium and potassium, it is difficult to precipitate them 
 unchanged from solution. We must have recourse to another 
 method, i. e., that of splitting them up by double decomposition 
 18 
 
18S URINARY ANALYSIS. 
 
 as it is termed and obtaining a precipitate of a new and insoluble 
 compound. Tlie phosphates of sodium and potassium are split 
 up by the magnesian fluid, the phosphate radical uniting with 
 the ammonium and magnesium to form a new and insoluble 
 compound, ammonio-magnesium phosphate. By insoluble 
 understand in the fluids used. 
 
 G. Precipitation of phosphates hy heat: — Obtain 
 some urine which is feebly-acid, as after a hearty meal 
 or at time of "alkaline tide" (10:30 a. m.), filter 
 clear, through three thicknesses of filter paper, into a 
 tall, narrow test-tube. Fill it about three-quarters 
 full. Hold tube by closed end between thumb and fore 
 finger, and boil ujyper third of the liquid over a spirit 
 lamp. A cloud appears owing to precipitation of 
 earthy phosphates. Add ten drops of 20 per cent 
 acetic acid, and shake; the cloud disappears, the 
 phosphates being dissolved by the acid. 
 
 D. Approximate determination of earthy phosphates: — A test- 
 tube, 16 centimeters (6.2992 iiiuiins) long and 3 centimeters (.787 
 inch) wide, is filled one-third with clear or filtered urine, to which 
 a few drops of caustic ammonia or caustic potash solutiou are 
 added, and warmed gently o-.er a spirit lamp until the earthy 
 phosphates begin to separate in flakes. It is then placed aside 
 for ten or fifteen minutes for them to subside. If the layer of 
 sediment is one centimeter (.3937 inch) high, the earthy phos- 
 phates are present in normal amount; if they occupy two to three 
 centimeters (.787 to 1.181 inch), they are increased; if, on the 
 other hand, only a few flakes are visible, the earthy phosphates 
 are diminished. 
 
 E. Approximate determination of alkaline phosphates: — To a 
 suitable quantity of urine placed in a beaker-glass about one-third 
 as much of the magnesian fluid is added. All of the phosphates 
 are thrown down in the shape of a snow-white deposit. If tlie 
 entire fluid present a milk like cloudy appearance, the alkaline 
 phosphates may be considered present in normal amount; if it is 
 denser, more cream-like, there is an increase. If, on the other 
 hand, the fluid is but rilightly cloudy, transmitting light distinctly, 
 the phosphates are diminished.* 
 
 APPARATUS REQUIEED. 
 
 Test-tube rack and t^st-tubes. 
 
 Bunsen burners or alcoliol lamps. 
 
 Aqua ammonisB or liquor potassa. 
 
 Funnels and filters. 
 
 Magnesian fluid. 
 
 Test-tubes, 6i inches long and J-inch in diameter. 
 
 * In tile writer's teaching experience, students cannot be depended on to 
 decide by tliis test wheitiBr the phosphates are normal or increased. 
 Whenever possible the volumetric det- rmmation of phosphoric acid should 
 be made. 
 
INOROANIC CONSTITUENTS OF URINE. 
 
 139 
 
 MICEOSCOPIOAL BXBECISE. 
 
 A. Let the precipitate of earthy phosphates settle, 
 or obtain some already deposited in urine, and exam- 
 ine a drop of the sediment with both low and high 
 power (150 and 500 diameters).. JSTote that the sedi- 
 ment is amorphous, and consists of minute, pale gran- 
 ules in irregular patches. (See Sediments of Phos- 
 phates for figures). 
 
 B. Let the precipitate with magnesian fluid settle, 
 and examine a drop. In addition to the granular 
 patches will be seen amongst others the so-called 
 "■ '■fern-leaf ''^ crystals of. ivv^le phosphate which is the 
 
 Fia. 33. Fern-leaf crystals of triple phosphate. 
 
 form the latter assumes when rapidly developed. 
 (See Sediments of Phosphates for figures). No "cof- 
 fin-lid" crystals are seen, but several other forms. 
 
140 URINARY ANALYSIS. 
 
 CHAPTEE XXL 
 
 PATHOLOGY AND CLINICAL SIGNIFICANCE OF THE 
 PHOSPHATES IN URINE. 
 
 After making several thousand volumetric deter- 
 minations of phosphoric acid in the 24 hours' urine 
 the writer has come to the conclusion that decrease of 
 phosphoric acid is far more common in disease than 
 increase. In fact decrease of phosphoric acid is one 
 of the commonest accompaniments of disease. 
 
 A. Diseases in which the total * phosphates may he 
 increased in the urine: 
 
 1. Some cases of diabetes mellitus. 
 
 2. In the condition known as phosphatio diabetes 
 (Tessier, Ealfe, and others). 
 
 3. Earthy phosphates increased in diffuse diseases 
 of the bones, and in diffuse periostitis ; in diseases of 
 the nerve centers. 
 
 According to Zuelzer and others, phosphoric acid is 
 also increased in : 
 
 4. Convalescence from febrile diseases. 
 
 5. Epileptic attacks. 
 
 6. Sraall-pox. 
 
 7. Cerebro-spinal meningitis. 
 
 8. Cholera infantum. 
 
 9. Leukaemia, just before death. 
 
 10. Pseudo-leukasmia. 
 
 According to Eobin an increased elimination of 
 phosphoric acid during the fastigium of typhoid fever 
 is an unfavorable omen, while a decrease during defer- 
 vescence is favorable. 
 
 EXAMPLES FROM THE WBITEK'S CASES. 
 
 In 25 cases of diabetes mellitus with polyuria, the greatest 
 amount of phosphoric acid found in 24 hours' urine was 5.8 gm. 
 (90 grains). From 4 to 5 gm. were voided by four patients, and 
 
 * The 24 hours' quantity is meant. 
 
PHOSPHATES IN URINE. 141 
 
 from 8 to 4 grams by ten patients. Nineteen patients voided 
 at one time or other from 3 grams down. In 18 collections of 
 24 hours' urine of diabetics the quantity of phosphoric acid 
 exceeded 3 grams, and in 33 collections it fell below that. So 
 that not even in diabetes mellitus is excess of phosphates in S4 
 hours more common than deficiency, taking 3 grams (46 grains) 
 as average normal. 
 
 The highest relative excretion was 3.25 gm. per liter, about one 
 grain per ounce. It is said that in diabetes mellitus the quantity 
 of PjOe rises and falls in inverse ratio to that of sugar. 
 
 B. Diseases in which jphosfhorio acid is especially 
 deficient* 
 
 1. Chronic Brighfs disease^ especially the inter- 
 stitial form. 
 
 2. Addison's disease. 
 
 3. Many nervous diseases. 
 
 4. Pyuria. 
 
 5. Exophthalraio goitre. 
 
 6. Tuberculosis. 
 
 7. Cancer. 
 
 8. Diseases of the uterus. 
 
 According to Zuelzer, phosphoric acid is also dimin- 
 ished in : 
 
 9. Acute infectious diseases. 
 
 10. In pneumonia, typhus, scarlet fever, paroxysms 
 of intermittent fever, febrile phthisis. 
 
 11. Acute nephritis. 
 
 12 Arthritis, acute and chronic articular rheuma- 
 tism, osteomalacia. 
 
 13. Chronic anaemia. 
 
 14. Chronic diseases of the brain and chronic 
 mania. 
 
 1 6 . Hysterical attacks, in proportion to the intensity . 
 
 16. Chronic lead poisoning. 
 
 17. Acute yellow atrophy of liver (absence possible). 
 
 18. Cirrhosis of liver. 
 
 Zuelzer mentions decrease of phosphoric acid in 
 Addison's disease, in which the writer also has noted 
 marked decrease. 
 
 In some of these diseases the phosphates set free 
 may possibly be utilized in the building up of new 
 leucocytes, hence the deficiency in the urine. 
 
 * According to the writer's experience. 
 
143' URINARY ANALYSIS. 
 
 Ratio of nitrogen to phosphorio acid: — According to 
 Zuelzer, the ratio of nitrogen to phosphoric acid in 
 normal urine is 5 to 1. He finds this ratio increased 
 wherever there is notable elimination of pus corpuscles 
 through other channels; in febrile diseases during the 
 febrile period (pneumonia especially), in rachitis, 
 anEemia, in all conditions of excitation of the brain, 
 in diabetes melhtus, in scurvy, empyema, and ia 
 Addison's disease. The ratio is diminished in re-con- 
 valescence from febrile diseases, in all conditions of 
 depression of the brain, in tumors of the brain, in 
 meningitis, tabes, myositis ossificans, arthritis de- 
 formans, and progressive pernicious anaemia. 
 
 Note:— The term "relative phosphoric acid" is used by the 
 Germans to indicate the ratio of nitrogen to phosphoric acid. 
 Thus Zuelzer says the -'relative phosphoric acid" is diminished 
 when the proportion of nitrogen to phosphoric acid is increased 
 above 5 to 1. This term must not be confused with phosphoric 
 acid relative to water (grams per liter, grains per ounce), as 
 used by the writer. The term relative value of phosphoric acid 
 is used by some writers to indicate the relation which exists 
 between the elimination of nitrogen and phosphoric acid. This 
 value suppo-es the absolute amouot or value of phosphoric acid 
 to vary between 2 and 3 grams a day, and is found according 
 to the following: 
 
 N : P.O. = 100 : x, and x = 10". ^-^s 
 
 N 
 la which N indicates die amount of nitrogen .ictiially observed, 
 PjOs the amount of phosphoric acid in the sumn urine, and x the 
 amount of phosphoric acid corresponding to 100 grii. of N. Nor- 
 mally the relative vnlue of PjOs in urine i.s from 17 to 30, an 
 increase in this value has been noted in apoplexy (as high as 34.3), 
 brain-tumors, tabes, arthritis deformans (30), pernicious anaemia 
 (33.8 to 38). The value is decreased in anaemia, cerebral cxciia- 
 tions, and especially preceding an attack of epilepsy, in chmnic 
 cerebral aflEeciiions, delirium tremens, and acute hydroceplialus. 
 In progressive paralysis following syphilis the value is low. but 
 rises greatly after administration of potas<iuin iodide. In the 
 excitement of mania the value decreas.-s; in tliH stage of depres- 
 sion and in melancholia the alkaline phosphates are diminished 
 and the earthy increased. 
 
 The method of determining the total nitrogen of 
 the urine is not ready enough for clinical purposes and 
 is hence described in the Appendix. For ordinary 
 clinical purposes we consider the ratio of urea to phos- 
 phoric acid. 
 
 The ratio of urea to phosphoric acid: — The ratio of 
 urea (determined by the chnical instruments) to phos- 
 
PHOSPHATES IN URINE. 143 
 
 phoric acid is likely to be specially increased (above 
 14 to 1) in the following diseases in Americans: 
 
 1. Pyuria. 
 
 2. Chronic interstitial nephritis. 
 
 3. Addison's disease. 
 
 It is not likely to be greatly increased in. oases .of 
 Bright's with dropsy and abundantly albuminous 
 urine. 
 
 Zuelzer finds the ratio of nitrogen to phosphoric 
 acid increased in diabetes melhtus. So far as the 
 writer's experience goes in 26 cases recently examined, 
 the ratio of urea (determined by clinical instruments) 
 to phosphoric acid was as follows: Less than 10 to 1 
 in 7 cases; 10 to 1 in 8 cases; 12 to 1 to 14 to 1, 
 inclusive, in 7 cases (of which 3 were 12 to 1, 2 13 to 
 1, 2 14 to 1); 16 to 1 in 3 cases. 
 
 EXAMPLES FROM THE WRITER'S OASES. 
 
 Bright s Disease: — 
 
 1. In the majority of 53 fatal cases of Bright's * dist»ase the total 
 quantity of phosphoric acid per 24 hours was found to be less than 
 25 grains (1.5 grammes). 
 
 2. The average for the whole of the fatal cases was only 18 
 grains (1.14 grammes) in 24 hours. 
 
 3 Less than 15 grains (1 gram) was found in about 33 per cent 
 of the analyses. 
 
 4. More than 23 grains (1.5 gm.) occurred in about 33 per cent 
 of the cases. 
 
 5. More than 30 grains (2 gm.) occurred in only about 12 per 
 cent. 
 
 6. In no cases were more than 35 grains (2.2 gm.) found. 
 
 7. Phosphoric acid seems to be decreased compared with urea 
 in cases where pus is abundant in the urine. 
 
 8. Phosphoric acid seems, as a rule, not to be decreased more 
 than urea in cases where albumin is abundant in the urine. 
 
 9. Phosphoric acid is sometimes decreased far more than urea 
 in cases in which but little albumin is found. 
 
 In Bright's disease there seems to be an actual insufficiency on 
 the part of the kidneys in the elimination of phosphates. 
 
 In the case of 67 patients, in whose urine albumin together with 
 numerous granular, fatty, or waxy casts were found, and who are 
 still living, the excretion of phosphoric acid was as follows: 
 
 The majority of patients voided 1 to 2 gm. in 24 hours or 15 to 
 30 grains; seventeen voided more and five less. The greatest 
 quantity voided was 5.94 gm. (90 grains) and the least 0.3 gm. 
 (about 5 grains). The average excretion was 1.8 gm., 28 grains 
 
 The comparison between the excretion of phosphoric acid by 
 those who died and by those who lived may be made as follows: 
 
 » Granular, fatty, or waxy casts In the urine of aV, these patients, together 
 with albumin. 
 
144 URINARY ANALYSIS. 
 
 THE DEAD. THE LIVINO. 
 
 Above 2 gm 13 per cent of the patients . . 24 per cent. 
 
 Above 1.5 gm 34 " " " -- 57 " 
 
 Above 1.0 gm 71 " " " - 88 
 
 Below 1.0 gm.- 31 " " " -- 10 " 
 
 Greatest quantity per 
 
 24 hours 3.2 gm 5.94gm. 
 
 Average excretion... 1.14 gm — 1.8 gm. 
 
 In other words the percentage of those who passed more than 
 1 gm. (15 grains) in 34 hours of both the living and the dead is not 
 BO very unlike, namely, 71 per cent of the dead and 88 per cent of 
 the living, the excretion being nevertheless in favor of the living; 
 but when it comes to a question of voiding from 1.5 gm. up, the per- 
 centage is greatly in favor of the living. Twice as many people 
 lived as died of those having albuminuria with granular, or fatty. 
 or waxy easts when at the same time they voided more than 1.5 
 gm. {S3 grains) of phosphoric acid in S^ hours. On, the other 
 hand, now, three times as many people died as lived when in addi- 
 tion to albuminuria with granular, or fatty, or waxy casts they 
 voided less than 1 gm. {15 grains) of phosphoric acid in ^ hours. 
 
 Those -who thus far are alive voided on an average 1.8 gm. (28 
 grains) of phosphoric acid, whilst those who are dead voided but 
 1.14 gm. or about 18 grains. 
 
 It would appear from the above that, when albumin together 
 with granular, fatty, or waxy casts is found in the urine of a 
 patient, estimation of phosphoric acid is of value as a factor in 
 the prognosis. 
 
 Addison's disease: — In the case of a well-known Chicagoan who 
 died recently of Addison's disease, repeated determinations of 
 phosphoi-ic acid, made by the writer, showed marked deficiency, 
 and a high urea-phosphoric acid ratio. The total phosphoric acid 
 in the last year of life averaged about 1 gram (15 grains) and 
 the ratio of urea to phosphoric acid ranged from 17 to 1 up to 
 more than 30 to 1. So far as I know, no one, except Zuelzer, has 
 called attention to a high urea-phosphoric acid ratio in this 
 disease. 
 
 Nervous diseases: — Less than 1.5 gm. (22 grains) in 34 hours has 
 been found by me in the following nervous diseases: Various 
 nervous disorders in women, reflex from uterine disease, 10 cases 
 out of a total of 13 recorded; neurasthenia, 5 cases; uraemia 
 chronica, 3 cases; neurasthenia with tumor, 2 cases; epileptic 
 children, 3 cases; hysteria, 3 cases, one in a male patient; in one 
 case each of cerebral hemorrhage, paralysis from softening of the 
 brain, hypochondria, hemiplegia, oxaluria with mental and nerv- 
 ous symptoms, neuritis, feeble-minded state, nervous symptoms 
 reflex from genito-urinary disease in a man. 
 
 The smallest excretion was 0.46 grammes, 7 grains, in 24 hours, 
 in the case of the man whose nervous symptoms were apparently 
 reflex from genito-urinary disease. Small excretions, 0.6 gm. 
 each, were noticed in the case of a feeble-minded woman and a 
 woman subject to fits. 
 
 Moderate decrease, 1 .5 to 3 gm. (33 to 31 grains), was noticed in 
 the following: Localized chorea, neurasthenia (3 or 4 cases), par- 
 alysis agitans, ui-iceemia and anaemia, rheumatism, neuritis in a 
 neuropath, in an epileptic child, cerebral hemorrhage and hemi- 
 plegia, brain symptoms following sunstroke, cephalalgia following 
 
PHOSPHATES IN URINE. 145 
 
 pneuisoBia, two cases of nervous disorder reflex frem uterus, 
 chronic cerebral meningitis and facial paralysis. 
 
 Above 2 gm., 30 grains, in the following: Melancholia followed 
 by suicide (38 to 50 grains), cerebral tumor (33 grains), nervous 
 symptoms, reflex from rectal disease (44 grains), torticollis ia a 
 neuropath, pregnancy (49 grains), epilepsy (42 grains), nervous 
 symptoms from worry and abuse of tobacco (43 grains), Melan- 
 cholia (36 grains), nervous symptoms reflex from uterus (33 
 grains). 
 
 MISCELLANEOUS. 
 • 
 
 Exophthalmic goitre:— One patient with this disease voided 1.4 
 gm., about 20 grains. 
 
 Uterine fibroid:— One woman with a fibroid voided less than 
 one gram, 14 grains. 
 
 Cancer: — A woman who died of a cancerous growth voided less 
 than one gram, 14 grains. 
 
 Tuberculosis: — A man who died of tuberculosis voided but O.C 
 gm., 10 grains nearly. 
 
 Phosphoric acid in the urine of children: — In view of the dearth 
 of information regarding the elimination of phosphoric acid by 
 children the following may be of interest: 
 
 Boys: — Infant, 1 year old, slowly sinking from albuminuria, 
 hematuria, and uraemia, 3.5 grains in 34 hours (0.15 gramme) 
 Boy of 4 years, 10 grains (0.65 gramme). Boy of 6 years, weight 
 45 pounds, poorly nourished, 13.5 grains (0.8 gramme). Boy of 9 
 years with slight persistent albuminuria without casts, 30 grains 
 (1.3 gramme). Feeble-minded boy, 10 years old, 10 grains (0.65 
 gm.). Boy weighing 84 pounds, 25 grains (1.6 gm.). Epileptic 
 boy of 10, 34 grains (1.6 gm.). Epileptic boy of 11, 19 grains (1.3 
 gm.). Epileptic boy of 13, weight 50 pounds, 40, 32, 37, 37 grains 
 (2.6 gm., 3gm.. 1.76 gm.). Boy with chronic diffuse nephritis, 
 11, 14 grains (0.7, 0.9 gm.). Boy of 10, with diabetes mellitus, 40, 
 32, 38, 35 grains (2.6, 2, 1.83, 1.6 gm.). Boy of 15, with nocturnal 
 enuresis, 31 grains (1.3 gm.). 
 
 Erom this it will be seen (a) that boys with epilepsy or diabetes 
 mellitus may void as much phosphoric acid as grown people; (6). 
 that boys 10 years old cm: less may not void more thaa 10 or 13 
 grains of phosphoric acid; (c), that a boy of 4 may void as much 
 under certain conditions as a boy of 10 under other conditions. 
 
 GlKLS: — A healthy female child, 3 years old, voided 16 grains 
 (1 gm.) in 34 hours; a girl of 5, with persistent albuminuria (with- 
 out casts), voided 6, 7, 10, 18, 14, 15 grains (0.39, 0.4, 0.65, 0.8, 0.9, 
 0.95 gm,); a girl of 6 voided 13 grains (0.78 gm.); a girl of 8 voided 
 19 grains (1.3 gm.); a girl of 10 voided 17 grains (1.04 gm.); a girl 
 of 10 voided 16 grains (1 gm.): a girl of 10, with inflammatory 
 rheumatism, voided 30 grains (1-3 gm.); a girl of 12, with diabetes 
 mellitus, voided 38 grains (1.52 gm.); a girl, age unknown, voided 
 35 grains (3.3 gm.); a girl of 15 voided 38 grains (1.82 gm.). 
 19 
 
146 
 
 URINARY ANALYSIS. 
 
 ACTION OF DRUGS ON ELIMINATION OF PHOSPHORIC 
 
 ACID. 
 
 Potassium bromide, cocaine, and quinine are said to 
 diminish phosphoric acid. Salicylic acid and the 
 glycero-phosphates increase it. 
 
 Cerebral excitants increase the ratio of nitrogen to 
 phosphoric acid, cerebral depressants decrease it. 
 Among the cerebral excitants are strychnine, small 
 doses of alcohol, phosphorus, .valerian, cold baths, and 
 salt water baths. Among the cerebral depressants are 
 chloroform, morphine, chloral, large doses of alcohol, 
 potassium bromide, mineral and vegetable acids, pro- 
 longed cold baths, Turkish baths, and low temperature. 
 
 CHEMICAL EXERCISE IX. 
 
 1. The student having collected and measured his 
 twenty-four hours' urine should proceed to determine 
 the total quantity of phosphoric acid in it : 
 
 APPARATUS NEEDED FOE VOLUMETBIO DETERMINATION OF 
 PHOSPHORIC ACID IN URINE. 
 
 Two burettes of fifty cubic centimeters capacity, 
 preferably those provided with a blue stripe on a white 
 background, and with glass stop-cocks. (Fig. 33.) 
 
 Fig. 33, Burettes. 
 One burette support (Chaddock) for two burettes 
 provided with two milk-glass plates. (Fig. 33.) 
 
PHOSPHATES IN URINE. 147 
 
 One short Bunsen burner with top 
 for water-bath, (Fig. 34) and rubber 
 tubing. 
 
 One copper water-bath, capacity of 
 a pint. 
 
 Three lipped beakers, capacity four 
 or five fluid ounces, of size so that they 
 Fia. 34. may fit quite closely but not too tightly 
 Bunsen burner, j^^q ^^^ ^j ^^^ j.-^gg of ^^^ water-bath. 
 
 Six stirring-rods of the lightest possible weight. 
 
 One 5 CO. graduate. One 50 o.c. flask. 
 (Fig. 35.) 
 
 One pound bottle, each, of the standard solu- 
 tions as follows : Uranium nitrate, sodic ace- 
 tate, potassic ferrocyanide. (To describe how 
 these standard solutions are made would here/ 
 take up too much space.* They may be had I 
 ready made, but care must be taken to specify j^ 
 that they are wanted for the phosphoric acid 50 o.o" 
 analysis in urine. ) Flask. 
 
 METHOD OF DETERMINATIOK. 
 
 "When the twenty -four hours' urine has been col- 
 lected and measured, and the result in o.c. noted down, 
 fill one of the two burettes with urine and measure off 
 exactly fifty cubic centimeters of it into one of the 
 lipped glass beakers. 
 
 Add to it just five cubic centimeters of the standard 
 sodic acetate solution, using the five c. c. graduate as 
 a measure. Stir well with a glass rod. Fill the 
 water-bath not quite full of water, set it on the sup- 
 port over the Bunsen burner, light the gas, and raise 
 the water in the bath to boiling. As soon as it begins 
 to simmer, set the beaker containing urine and sodic 
 acetate in the water, supported by the ring. The 
 beaker should not be fitted tightly into the ring, for 
 fear of breaking it, and about one fourth of it should 
 be above water. In this way the boiling water con- 
 stantly surrounds the liquid in the beaker. While the 
 water in the water-bath is being heated, place ten or 
 
 * See appendix tor complete instructions. 
 
148 URINARY ANALYSIS 
 
 twenty drops of the standard potassio ferrooyanide 
 solution on one of the clean, dr^, milk-glass plates 
 forming the foot of the burette stand. The drops 
 should be placed singly, and be separate from one 
 another on the plate. 
 
 As soon as the water in the water-bath has begun 
 to boil, fill the second burette up to the mark exactly 
 with the standard uranium nitrate solution. Set the 
 burette of uranium solution over the middle of the 
 beaker which is on the water-bath, turn the stopcock, 
 and let five c.c. of uranium solution run into the 
 liquid in the beaker. Stir well with a glass rod and 
 transfer a drop of the mixture, by means of the rod 
 to one of the drops of the standard potassic ferrooyan- 
 ide solution. If a slight reddish color appears the 
 operation is over, if not, run in another five c. c. of the 
 uranium solution and transfer a drop from the beaker 
 again to another drop of ferrooyanide on the plate. 
 If no color yet appears, add say another five c.c. of 
 uranium solution and try again. If no color even yet, 
 then proceed more cautiously adding only two c.c. of 
 the uranium solution at a time, stirring well, and trans- 
 ferring a drop as before. Finally, if when twenty 
 c.c. of uranium solution have been added there is still 
 no color obtained on transferring a drop to the fer- 
 rooyanide drops, then run in only one c.c. of uranium 
 solution until, at last, transference of the drop shows 
 the reddish color. 
 
 In urines below 1015 in specific gravity not more 
 than fifteen c.c. of uranium solution are, as a rule, 
 necessary, and often much less. In the case of urmes 
 above 1020 in specific gravity, from fifteen c.c. up- 
 wards of uranium may be required 
 
 To calculate the amount of phosphoric acid in the 
 urine, divide by ten, the number of cubic centimeters 
 of uranium nitrate solution, necessary to be added until 
 transference of a drop of the mixture in the beaker 
 gives a slight but perceptible reddish color with the 
 potassio ferrooyanide drop on the plate. The quo- 
 tient equals grammes of phosphoric acid per liter of 
 urine. Convert this to grains per fluid ounce by 
 
PHOSPHATES IN URINE. 149 
 
 dividing by 2.125, or simply by consulting table in 
 appendix. 
 
 Thus, suppose the urine in twenty-four hours amounts 
 to fifty-six fluid ounces (1680 c.c). Suppose the 
 amount of uranium solution used was twenty-two cubic 
 centimeters: Twenty-two divided by 10 equals :i. 2 
 grammes of phosphoric acid in every liter of urine, 
 and 2.2 divided by 2.125 equals 1.03. Then this 
 urine contains 1.03 grains of phosphoric acid in every 
 fluid ounce. If there are fifty-six fluid ounces of urine 
 then 1.03 times 56 equals 57.68 grains of phosphoric 
 acid in the twenty-four hours, or about 8.7 grammes. 
 
 EXAMPLES FOE PBAOTIOE. 
 
 X Urine in 24 hours, 30 fluid ounces ; number of 
 c. c. of uranium used, 17. Eequired grains per fluid 
 ounce of phosphoric acid and also grains per 24 hours. 
 Answers: O.S and 24. Convert to grammes per liter 
 and per 24 hours. 
 
 2. Urine, 33^ fl. oz. ; uranium, 11^ o.o. Answers: 
 0.5 and 18. 
 
 3. Urine, 13 fl. oz. ; uranium, 21 o.o. Answers: 
 1 and 12^. 
 
 4. Urine, 38 fl. oz. ; uranium, 11^ o.o. Answers: 
 0.63 and 20. 
 
 6. Urine, 18-|- fl. oz. ; uranium, 23 o.o. Answers: 
 1 and 20. 
 
 Comparisons with normal averages may be made by 
 remembering, that in health adults pass about one 
 grain per fluid ounce of phosphoric acid, or forty to 
 fifty grains at most in 24 hours. The tables in the 
 Appendix are convenient for reference, giving, as they 
 do, at a glance the comparison with normal. 
 
 It is my opinion that the English and French observ- 
 ers place the normal excretion too high. Sixteen esti- 
 mations of the phosphoric acid in the writer's urine 
 showed the average quantity to be two-thirds of a 
 gram per oimce and 33 grains per £4- hours. 
 
 fi. Urine, 1200 c.c. ; uranium, 14 c.c. Sex, male. 
 What per cent of the normal averages, both relatively 
 and absolutely? 
 
ISO UBINAR Y ANA L YSIS. 
 
 7. Uritie, 800 c.c. ; uranium, 25 c.o. Sex, female. 
 What per cent of the normal averages, both relatively 
 and absolutely? 
 
 Notes on Manipulation:— 
 
 1. Cochineal as Indicator: — Instead of using potassium ferro- 
 cyanide as an indicator, tincture of cochineal may be substituted 
 as follows: A few grammes of cochineal granules are digested 
 with 250 c.o. of a mixture of 3 volumes of water and 1 volume of 
 94 per cent alcohol in the cold. The solution is then decanted and 
 a few drops of it added to the 50 c.c. of urine plus 5 c.c. of the 
 acetate mixture used. The mixture being heated to the boiling 
 point uranium solution is run in until a trace of greenish color is 
 noted in the precipitate, which does not disappear on stirring. 
 
 S. Separate determination of the earthy and alkaline phos- 
 phates: — 300 c.c, of filtered urine are made strongly alkaline with 
 ammonium hydroxide and set aside, in a covered dish, for several 
 hours, until tlie earthy phosphates precipitated have settled. The 
 supernatant liquid is carefully drained off and the balance poured 
 upon a filter, washed with dilute ammonia (1 part ammonia water 
 to 3 of water) and then transferred to a beaker with the aid of a little 
 water containing a few drops of acetic acid, a small hole being 
 made in the filter. The precipitate is then dissolved in as little 
 acetic acid as possible, diluted to 50 c.c. with distilled water and 
 titrated with uranium solution. The difference between the total 
 amount of P^Ot and the amount now obtained is the quantity of 
 phosphoric acid combined with the alkaline earths. 
 
CHLORIDES IN URINE. 151 
 
 CHAPTER XXII. 
 
 CHLORIDES IN THE URINE. 
 
 Next to urea the most abundant constituent of the 
 urine is common salt, chloride of sodium, which, 
 together with potassium chloride, forms nearly one- 
 quarter by weight of the total solids eliminated by the 
 urine. In clinical interest, however, the chlorides are 
 inferior to the phosphates. 
 
 Synonyms: — Chlorides; Chloride of sodium, com- 
 mon salt : Geeman, Chlornatrium, Kochsaltz; French, 
 chlorure de sonde, sel comm,un. 
 
 Occurrence: — Chiefly as sodium chloride with a 
 small amount of potassium, magnesium, and ammon- 
 ium chloride. In solution in the urine. Never in the 
 sediment. 
 
 Chemical constitation: — Sodium chloride, NaCl, 
 common salt. Potassium chloride, KCl, ammonium 
 chloride, JMHiCl, magnesium chloride, MgCl2, chlorine 
 in combination with the bases sodium, potassium, and 
 ammonium. 
 
 Chemical test: — To show the presence of chlorides 
 in the urine add ten or fifteen drops of nitric acid to 
 10 0.0. (one-third of a fluidounce) of urine, and then 
 a few drops of silver nitrate. A white, curdy precipi- 
 tate takes place. Let it settle, pour off supernatant 
 urine, add ammonia-water freely, shake well, and the 
 precipitate is dissolved. 
 
 Note: — This test depends upon the fact that the chlorine in the 
 chlorides unites with the silver in the silver nitrate to form silver 
 chloride, according to the equation 
 
 AgNO, + NaCl = AgCl -\- NaNO,. 
 Silver chloride is soluble in ammonia-water. 
 
 The object of adding nitric acid first is to prevent precipitation 
 of phosphates. 
 
153 
 
 USINARY ANALYSIS. 
 
 Determination of quantity of chlorides: — The 
 
 above test may be utilized for determining 
 in a rough way whether the chlorides are 
 in excess or greatly diminished. The method 
 as proposed by Ultzmann is faulty in that 
 more nitric acid than a few drops is required 
 to prevent precipitation of phosphates, etc. 
 The author's method is as follows : Fill a 
 percentage tube (Fig. 35), such as is used 
 in centrifugal analysis, to the 10 c.c. mark 
 with urine. Add not less than 15 to 30 
 drops of nitric acid, and then fill up to the 
 15 c.c. mark with standard solution of silver 
 nitrate, 1 to 8 (one drachm of the crystals 
 to eight drachms of distilled water). Mix 
 thoroughly, let settle, or better, settle in 
 the centrifugal machine. * (See Centrifugal 
 Machine). If the bulk of the precipitated 
 chlorides is not greater than the fifth or 
 sixth mark on the tube, chlorides are con- 
 siderably diminished ; if normal, the bulk 
 Fig. 36. of the precipitate should reach the tenth to 
 Percentage twelfth mark. Results may be expressed in 
 " ^' bulk percentage figures, 5 per cent, 6 per 
 cent, etc. Inasmuch as for clinical purposes all that is 
 wanted is knowledge of a marked diminution in the 
 chlorides, or increase after such diminution, the above 
 method answers full well. 
 
 [For volumetric quantitative methods (Mohr's, Yol- 
 hard's, etc.) see Appendix]. 
 
 Physiology: — The chlorides are derived from the 
 food and their daily quantity varies from 10 to 16 
 grammes (155 to 250 grains) or a total of from 6 to 
 10 gm. (93 to 155 grains) of chlorine. The chlorides 
 are, then, next in quantity to urea. Twelve grammes 
 (185 grains) may be taken as a common average per 
 24 hours but those who are fond of salt may pass 
 double this quantity. 
 
 Decrease in chlorides follows deficient nourishment 
 and in starvation traces only from the bodily fluids are 
 
 * Use a speed of 1000 revolutions per minute for three minutes. 
 
CHLORIDES IN URINE. 158 
 
 found. If at this stage salt food be taken, a portion 
 of the salt will be retained in the body until the equi- 
 librium is restored; so also after ingestion of large 
 quantities of water. Rest diminishes the excretion. 
 Beer is said to diminish it also. 
 
 Increase of chlorides will follow any increase in the 
 amount of circulating albumin, for on account of the 
 great affinity between albumins and salt the latter is 
 previously retained by the albuminous bodies. Active 
 exercise and copious draughts of water increase the 
 elimination, but this increase is likely to be followed 
 by retention on account of the albuminous metabolism. 
 
 The chlorides increase and decrease with the volume 
 of urine. Common salt is contained in all the tissues 
 and secretions of the body, and by its presence metabol- 
 ism is increased, secretion stimulated, and it is needed 
 for the preparation of some of the secretions, as the 
 gastric juice. 
 
 Pathology: — 
 
 A. Diminution of Chlorides: — The chlorides are 
 diminished in the following diseases : — 
 
 1. Many acute febrile disorders as pneumonia, 
 pleurisy, typhus, scarlatina, roseola, variola, recur- 
 rens, acute yellow atrophy where the diminution runs 
 parallel to the height of the fever. 
 
 2. Diarrhoea and Asiatic cholera. 
 
 3. Acute and chronic diseases of the kidneys with 
 albuminuria and dropsy. 
 
 4. In chronic diseases generally; a significant 
 decrease occurs in anemia, marasmus, rickets, leu- 
 kaemia, chlorosis, also in melancholia and idiocy; in 
 dementia, chorea, and pseudo-hypertrophic paralysis 
 (less marked decrease) ; chronic hyper-secretion of 
 gastric juice, in dilatation of the stomach, in carcinoma 
 of the stomach, in ulcer of the stomach; also in im- 
 petigo, pemphigus foliaoeus ; in chronic lead poisoning. 
 
 Note: — In inflammationa with exudation, salt is found in the 
 exudation. In croupous pneumonia at the crisis there may be 
 but one-hundredth of the normal quantity of salt in the urine. In 
 diarrhceal diseases the bulk of the chlorides is found in the dejec- 
 tions. In dropsies the salt is stored up in the dropsical fluid. 
 
 20 
 
154 UBINABY ANALYSIS. 
 
 Intermittent fever is an exception to the rule of diminution of 
 salt in fevers; during the paroxysms more chlorides are excreted 
 than during the apyrexial period. In acute febrile diseases m gen- 
 eral there is (a) less salt ingested (b) retention in the blood due 
 probably to increase in the amount of circulating albumm, (c) 
 diminished renal secretion of water, (d) possible elimination else- 
 where as in diarrhoeas, formation of serous exudates, etc. 
 
 B. Increase of chlorides: — Chlorides may be in- 
 creased in the later stages of those diseases in which 
 they were greatly diminished at first. After the res- 
 olution of exudates and dropsies ; also in diabetes in- 
 sipidus (29 grn. in 24 hours) ; in paralytics in the first 
 stage (due to increase of food) ; in polyuria after epi- 
 leptic attacks ; in prurigo (29.6 gm.); and after chloro- 
 form inhalations. 
 
 Clinical notes: — 1. An increase of chlorides in 
 acute febrile conditions and especially in pneumonia 
 is regarded as a favorable sign. A decrease to 0.0 o 
 gramme in 24 hours is a grave condition. 
 
 2. Potassium salts, notably neutral potassium phos- 
 phate (K2HPO4), some diuretics, and chloroform in- 
 crease the chlorides. Salicylic acid is said to increase 
 them temporarily 
 
 3. An elimination of from 10 to 16 grammes daily 
 indicates a fair condition of appetite and digestion. 
 
 4. An increase in cases of oedema when associated 
 with serous exudates is a good sign. 
 
 5. A continued elimination of more than 15 to 20 
 grammes is usually significant of diabetes insipidus. 
 
 EXAMPLES FROM THE WRITER'S OASES. 
 
 In a case of asthma and bronchitis the writer found the chlorides 
 about one quarter normal. In chronic nephritis, several oases, 
 including one of puerperal nephritis (without convulsions) the 
 same low figure was found. Women quite frequently pass com- 
 paratively small amounts of chlorides, half to two thirds the nor- 
 mal for men, without discoverable serious disorder. One of tlie 
 smallest total quantities of chlorides (about one-quarter normal) 
 was passed by a man weighing 125 pounds, seemingly in good 
 health. In 50 or 60 determinations recently made by the chem- 
 ical method described above, but four were above 12 per cent in 
 bulk percentage. 
 
 Both large percentage and total quantity, once and a quarter 
 normal for a man, were found in the urine of a diabetic uom in. 
 In a case of hematuria no increase occurred. The largest per- 
 centage ever seen, 18 per cent bulk, occurred in a case of urcemia 
 chronica not long before death. 
 
CHLORIDES IN URINE. 155 
 
 CHEMICAL EXERCISE X. 
 
 The student having collected and measured his urine 
 for 24 hours can determine the quantity of chlorides 
 in it roughly as follows : 
 
 1. Compare quantity of urine in 24 hours with the 
 normal average, and express in per cent of normal. 
 
 2. Determine bulk percentage of chlorides by 
 author's method already given, and compare with 10 
 per cent — the normal average. 
 
 3. Multiply the figure obtained in 1 by that obtained 
 in 2 and compare with 100 as normal. For example, 
 suppose the volume of urine in 24 hours is 80 per cent 
 of the normal average, and that the bulk percentage 
 of chlorides is 5, the latter is about 50 per cent of 
 normal. Hence in urine which is about 80 per cent 
 of normal volume, we have chlorides about 60 per 
 cent of normal percentage, therefore 50 per cent of 
 80, or 40, represents the total of chlorides compared 
 with 100, which may be assumed to represent the 
 normal excretion. In other words the individual is 
 passing less than half the normal amount of chlorides. 
 This method is only roughly approximate, but serves 
 to give an idea as to whether a marked increase or 
 deficiency exists. 
 
 4. Observe the difference in bulk of the chloride 
 precipitate in the percentage tube when only 5 drops 
 of nitric acid are used, and when 15 to 30 drops are 
 used to prevent precipitation of phosphates. 
 
 5. See whether addition of 15 drops and of 30 
 drops, respectively, of nitric acid makes any difference. 
 
 (For work of this kind Purdy's electric centrifuge 
 is useful). 
 
 For research work in chlorides see Appendix. 
 
 APPABATUS KECJ0IRED. 
 
 Purdy's percentage tubes. Solution of silver nitrate, 1 in 8, say 
 20 grammes in 160 c.c. of distilled water (310 grains in 5 fl. oz.). 
 C. P. nitric acid. 
 
15d 
 
 URINARY ANALYSIS. 
 MICROSCOPICAL EXERCISE IH. 
 
 Let a drop of urine dry on the slide and notice the 
 dagger-shaped crystals of common salt combined with 
 urea. (Fig. 37.) 
 
 A* Chloride of sodium, in combination with urea, an^ 
 
 evaporated quickly from urine. 
 B. Chloride of sodium, crystallized from distilled water, 
 
 and resembling oxalate of lime ; never exists in urine, 
 
 and is soluble in water, while the oxalate is not. 
 C* Chloride of sodium crystallized slowly from urine', 
 
 also resembles oxalate of lime, but differs in being 
 
 soluble in water. 
 D. Chloride of sodium resembling crystals of cystine 
 
 Fig. 37. Chloride of Sodium Crystals. (John King.) 
 
 The autjior has noticed in giving microscopical 
 exercises to classes that students are oftener puzzled 
 by the drying of the drop on the slide, and the appear- 
 ance of these crystals than by almost anything else in 
 the course. 
 
INORGANIC SULPHATES IN URINE. 157 
 
 CHAPTEE XXIII. 
 
 INOKGAITIO SULPHATES IN THE UEINBl, 
 
 Introductory: — There are three kinds of sulphates 
 in the urine as follows : 
 
 1. Ordinary sulphates of potassium and sodium, 
 called "preformed" sulphates. 
 
 2. Incompletely oxidized sulphates, whose com- 
 position is unknown. 
 
 3.. Ethereal or aromatic sulphates, called "combined 
 sulphates" organic compounds of sulphuric acid with 
 indol, phenol, skatol, etc. , containing the radical HSO3. 
 Already considered. 
 
 The above mentioned sulphates are always in solu- 
 tion, never in the sediment. Calcium sulphate and 
 magnesium sulphate occasionally occur in the urine, in 
 which case they may be found in the sediment. (See 
 Sediments.) 
 
 THE PBEFOEMED SULPHATES. . 
 
 Synonyms: — Sulphates : German, Sulfate- Feenoh, 
 les sulfates. Preformed sulphates : German, Sul- 
 phatschwefelsdure, prqformirte Schwefelsdure,' French, 
 lei sulfates preformes. 
 
 Occurrence: — The preformed sulphates are found in 
 solution in all normal urine. Of the total sulphates 
 the preformed constitute about eight-tenths, the incom- 
 pletely oxidized one-tenth, and the ethereal one-tenth. 
 
 Chemical constitution: — The preformed sulphates 
 are the ordinary sulphates of sodium and potassium, 
 NaaSOi.lOHgO, and K2SO4. 
 
 Solubility: — Freely soluble in water, hence never 
 occurring in the sediment. 
 
 Chemical test and estimation: — To 10 c.c. of urine 
 (3 fluidrachms) add a few drops of chemically pure 
 hydrochloric acid, and then barium chloride solution, 
 
158 URINARY ANALYSIS. 
 
 in quantity about one half that of the urine. A white, 
 milky precipitate, barium sulphate, is formed accord- 
 ing to the equation. 
 
 Nag SO4 + Ba Clg = Ba SO4 + 2N"a CI. 
 Pour the whole into a percentage tube such as used 
 for chlorides, let settle, or better, settle in the centri- 
 fuge (speed 1000 revolutions per minute, time 3 min- 
 utes), and if the sediment is much below the first mark 
 on the tube (1 per cent bulk) sulphates are decreased, if 
 much above, increased ; if just a little below, about 
 normal. 
 
 Note : — For routine work make up a solution of the 
 barium chloride together with the hydrochloric acid 
 in water as follows : 
 
 Chemically pure hydrochloric acid, 8 c. c. (10 gm.) 
 
 Chemically pure barium chloride, io grammes. 
 
 Distilled water, 160 c. c. 
 
 Fill the percentage tube with urine up to the 10 c. c. 
 mark and the balance with the barium solution up to 
 the 15 c. c. mark. Mix. 
 
 In case a percentage tube is not to be had, try the 
 following : — To 10 0. 0. of urine in a test-tube add one- 
 third its volume of the acidulated barium chloride 
 solution ; if the turbidity resulting is milky, the sul- 
 phates are normal; if creamy, excessive; if merely 
 light and translucent, diminished. In the writer's 
 experience, three or more students trying this test will 
 report two or three different results so that the per- 
 centage tube and centrifugal machine are preferable for 
 chemical work. For the quantitative analysis of sul- 
 phates both preformed and conjugated see Appendix. 
 
 Physiology: — The mean of the daily quantity of 
 sulphuric acid in the urine is ^.5 gramm,es (38 grains), 
 of which that united to form the preformed sulphates 
 would be about 2 grammes or 30 grains. The quantity 
 of preformed sulphates, as such, would then be about 
 3 to 4 grammes (46 to 60 grains). Sodium sulphate 
 exceeds in quantity potassium sulphate. The sul- 
 phuric acid is derived chief/y from the decomposition 
 of proteids, by oxidation of the sulphur to sulphuric 
 acid. The sulphates are formed by neutralization of 
 
INORGANIC SULPHATES IN URINE. 159 
 
 the sulphuric acid by alkalies (neutral phosphates 
 transformed into acid phosphates and sodium sul- 
 phate). The excretion of sulphates, as a general 
 rule, runs parallel to that of urea. The ratio of the 
 total sulphuric acid to total nitrogen is 1 to 5 ; to 
 urea, 1 to 12. Foods or drinks rich in sulphates or 
 oxidizable sulphur compounds, nitrogenous diet, and 
 active exercise increase the sulphates in the urine. 
 Fasting and vegetable diet diminish them. 
 
 Pathology: — The sulphates are increased in febrile 
 diseases, especially pneumonia, meningitis, encephali- 
 tis, and rheumatism; in acute myelitis, eczema, dia- 
 betes mellitus, and leukaemia. They are diminished 
 in chronic diseases of the kidneys. 
 
 PEEFOEMED SULPHATES AND CONJUGATE SULPHATES. 
 
 1. The ratio of preformed sulphates to conjugate 
 sulphates is 10 to 1 (See chapter on Ethereal 
 Sulphates). 
 
 2. The excretion of total sulphates is increased by 
 animal diet. 
 
 3. In starvation the preformed sulphates are dimin- 
 ished, but the conjugate may be increased. 
 
 4. The total sulphates may average 2.46 grammes 
 in leukaemia, as compared with 1.51 grammes passed 
 by a healthy individual on the same kind of food 
 taken in the same amount; 5.8 gm. total may be 
 passed before death from acute leukaemia. 
 
 5. In both forms of diabetes, carcinoma of oeso- 
 phagus, progressive muscular atrophy, pseudo- hyper- 
 trophic paralysis, and eczema, the total sulphates are 
 increased. 
 
 EXAMPLES FROM THE ADTHOE'S OASES. 
 
 In the case of a woman with moderate diabetes mellitus without 
 marked polyuria and with but 3 per cent of sugar the sulphates 
 were relatively and absolutely about half the normal quantity. 
 In a case of inflammation of the neck of the bladder in a man they 
 were about one- third normal; so also in chronic nephritis in 
 several cases. The smallest amount found was in the case of a 
 woman already several times mentioned, as having uraemia 
 chronica. Not long before death in this case the sulphates were 
 only about one-sixth the normal total. The highest percentage 
 by bulk of sulphates seen^was in the case of a woman, who died of 
 
160 URINARY ANALYSIS. 
 
 uraemia from diffusa nephritis, about 48 hours before death; the 
 quantity was 5 per cent bulk, due doubtless in part to internal 
 medication. 
 
 In a severe case of diabetes mellitus in a man the sulphates were 
 once and a quarter the normal average bulk; but in an equally 
 severe one in a woman they were only one-third normal totai. 
 1 have noticed that when patients with acute or chronic nephritis 
 are heing flushed out with mineral water that the sulphates in the 
 urine are in relative excess compared with other constituents. 
 In the case of a man weigliing 360 pounds the sulphates were 
 barely the normal average both relatively and absolutely. 
 
 In an epileptic boy the sulphates were diminished compared 
 with other constituents, being only half normal in total. 
 
 In the case of a man who died, about a month after the analysis. 
 from chronic nephritis the sulphates were only one-sixth normal. 
 
 Clinical notes, 
 
 1. It is said that inhalations of oxygen increase the 
 sulphates. 
 
 2. The clinical significance of the preformed sul- 
 phates and of the incompletely oxidized sulphates is 
 slight compared to that of the ethereal sulphates. 
 
 3. Changes in the ratio of the preformed sulphates 
 to the ethereal sulphates are of considerable significance. 
 Thus, a urine rich in indigo, contains but little of the 
 preformed sulphates, and in carbolic acid poisoning it 
 is said they may disappear altogetlier. (Jaksch). 
 
 4. In two cases in which the author found very 
 small quantities of preformed sulphates — one-sixth the 
 usual average for 24 hours — death took place in a 
 month or two. These two were the only ones of 100 
 individuals in whose urine the sulphates were less than 
 one quarter the usual normal average for 24 hours- 
 
 CHEMICAL EXERCISE XI. 
 
 Determine the quantity of sulphates approximately 
 according tothe method described under chemical test 
 and estimation. Apparatus required ; Purdy's per- 
 centage tubes and acidulated solution of barium chlor- 
 ide as described. 
 
 See Appendix for more accurate quantitative analy- 
 sis of preformed and ethereal sulphates. 
 
INORGANIC SULPHATES n\ URINE. 16! 
 
 MISCELLAKEOXJS INOEGANIO CONSTITUENTS. 
 
 Ammonia: — Free ammonia occurs in the urine in traces, which 
 are greatly increased by the putrefactive changes. 
 
 Calcium occurs in the urine for the most part as phosphates. 
 (See Phosphates). 
 
 Carbon occurs in combination in the urine, forming carbonates. 
 Carbonates and biearbonates of sodium, ammonium, calcium, and 
 magnesium are present in minute quantities in fresh urine of 
 alkaline reaction, derived from fruit and vegetable acids. Form 
 deposits on standing. Oalcium carbonate is a rare constituent of 
 calculus. Detection: Add an acid to the urine and pass the gas 
 given oflE into lime-water, which becomes turbid. (See Sediments). 
 
 Carbonic acid, as a gas, occurs in normal urine in the propor- 
 tion of from 4 to 9 volumes of free gas; 3 to 5 combined. 
 
 Fluorine, in small quantity, is said to be present in urine. 
 
 Iron occurs in normal urine in small quantities, but in what 
 form is yet unknown. 
 
 Nitric acid: — This inorganic substance in combination forming 
 nitrates occurs in small quantities in the urine, probably originat- 
 ing from the drinking-water and the food. Meat diet diminishes 
 and vegetable increases. The average amount is about 42.5 milli- 
 grammes per liter. In decomposing urine nitrites may be found. 
 Schaffer's test (potassium f errocyanide and acetic acid) is suffi- 
 cient for qualitative research; Trommsdorf colorimetric method 
 for quantitative. 
 
 Nitrogen: — The free gases of the urine are chiefly carbonic 
 acid, oxygen, and nitrogen, which are in small proportion and 
 may be withdrawn by the air-pump. Nitrogen in combination 
 is found in urea, uric acid, kreatinin, hippuric acid, etc. 
 
 Oxygen may occur free, in small quantities, in urine, from 
 which it may be withdrawn by the air-pump. 
 
 Peroxide of Hydrogen, HaOa, inorganic, has been found in 
 traces in fresh urine, disappearing as decomposition sets in. 
 Tincture of indigo and dilute solution of ferrous sulphate serve as 
 a test, the color of the indigo being discharged by the peroxide. 
 il 
 
163 URINARY ANALYSIS. 
 
 CHAPTER XXIT. 
 
 ABNORMAL CONSTITUENTS OF UEINE; PROTEIDS. 
 
 Thb proteids found in urine are the following : 
 
 Serum-albumin; 
 
 Serum-globulin (paraglobulin); 
 
 Albumoses [peptones]; 
 
 Fibrin; 
 
 Haemoglobin; 
 
 Histen ; 
 
 Nucleo-albumin (mucin); 
 
 In addition to these, egg-alburaiu may be found after 
 
 diet rich in eggs. 
 
 BERUM- ALBUMIN, 
 
 Synonyms. German, Albumin, Eiweissstoff; 
 Feenoh, Albumiiie. 
 
 Chemical Constitution: The formula is not known. 
 It belongs to the true albuminoid substances which do 
 not contain phosphorus except as calcium phosphate. 
 It coHtains carbon, hydrogen, nitrogen, and oxygen. 
 Rich in sulphur. 
 
 Occurrence: It occurs in the urine only in solu- 
 tion, never in the sediment. Probably does not occur 
 at all in normal urine except in mere traces. 
 
 Form: It belongs to the colloids, uncrystallizable, 
 and does not penetrate animal membranes under normal 
 conditions. 
 
 Properties: — Serum-albumin is soluble in water, 
 dilute acids, and alkalies. Solutions of serum-albumin 
 have a specific rotatory power of — 56°, and are coag- 
 ulable at temperatures of from 50° to 90° C, (122° to 
 144® F.) according to the solvent. Solutions of serum- 
 albumiia are precipitated by the addition ®f large 
 quantities of mineral acids or by metallic salts, as 
 silver nitrate, mercuric chloride, etc. Also by alcohol 
 but not by sodium chloride or sodium carbonate. 
 
ALBUMIN IN URINE. 163 
 
 Serum-albumin resembles closely egg-albumin differ- 
 ing, however, in two respects (a) it is not coagulated 
 by ether (b) when coagulated by heat it is more readily 
 soluble in excess of nitric acid than is egg-albumin. 
 Albumin is converted into alkali-albumin by the action 
 of alkalies, as sodium or potassium hydroxides, and 
 into add- albumin by the action of acids, as hydro- 
 chloric and acetic. 
 Reactions: 
 
 1. Alcohol precipitates serum-albumin from urine 
 containing it. 
 
 2. Nitric acid added drop at a time precipitates 
 albumin, but the precipitate disappears on shaking 
 after addition of each drop, until a certain amount of 
 acid has been added, after which the precipitate is not 
 dissolved by shaking ; but when great excess of acid 
 has been added the precipitate is dissolved. 
 
 3. Boiling the urine coagulates albumin in it, if the 
 urine be acid, not if alkaline. 
 
 4. Acetic acid, citric acid, and vegetable acids gen- 
 erally do not precipitate albumin. 
 
 5. Boiling the urine previously acidified with acetic 
 acid will coagulate the albumin, ^provided the acetic 
 acid is not in excess. 
 
 6. Boiling the urine, previously acidulated with 
 acetic acid, and to which strong solution of common 
 salt or sulphates of sodium or magnesium have been 
 added, will coagulate the albumin. 
 
 7. Albumin is precipitated from urine containing it, 
 without heating, on addition of potassium ferrocyanide 
 solution and strong acidulation with acetic acid. 
 
 8. Albumin is precipitated from urine containing it 
 by a great number of solutions, as for example, those 
 of chromic acid, picric acid, potassio-mercuric iodide, 
 sodium tungstate, trichloracetic acid, metaphosphoric 
 acid, silver nitrate, etc. 
 
 Inasmuch as many of the substances mentioned 
 above precipitate other substances, besides albumin, 
 from the urine, much depends on the method of appli- 
 cation of the tests, which will be described in full 
 further on. 
 
164 URINARY ANALYSIS. 
 
 CHAPTEK XXY. 
 
 A CLINICAL TEST FOB SERUM-ALBUMIN. 
 
 Too much stress cannot be laid on the importance 
 of technique in albumin testing, especially when the 
 physician is unfamiliar with microscopical work. I 
 endeavor to drill my classes so that they can detect 
 even a trace of albumin in the urine. This cannot be 
 done by everyone readily and easily, and some few 
 men can never be depended on to recognize albumin 
 when present in but small quantities. 
 
 TBCHNIQITE OF ALBUMIN TESTING. 
 
 1. Filter the freshly voided urine. It is important 
 that the urine be freshly voided, because in all stale 
 urine what seems to be a trace of albumin can be found 
 by the test I shall now describe. It is important to 
 filter the urine since, by filtration, sedimentary mat- 
 ters, interfering with the test, are removed. More- 
 over, it is said that in certain urines the reaction due 
 to mucin may mislead in unfiltered urine. 
 
 In order to filter the urine, fold three small, white, 
 cut filter papers twice, the second time at right angles 
 to the first. Insert the papers into a small glass fun- 
 nel, set the tube of the funnel into a tall, narrow test- 
 tube, and pour the urine into the funnel-shaped pouch 
 made by the filters. [I advise use of three papers rather 
 than one, because in my experience nearly all freshly 
 voided urine filters clear through three thicknesses of 
 paper. More are not advisable, because, of danger of 
 traces of vegetable albumin.] 
 
 The urine filters slowly through into the test-tube 
 and is clear. Let it fill the tube three-fourths full. 
 Wipe off the outside of the tube with a rag until it is 
 entirely clean and bright. Hold the tube up to the 
 light, and see that both tube and urine are entirely clear 
 and transparent. 
 
TESTS FOB ALBUMIN. 165 
 
 2. Boil the upjp&r stratum of the urine in an alcohol 
 lamp flame. This is done by holding the tube hy the 
 closed end with the thumb and forefinger of the right 
 hand, inclining it over the flame in such a way that 
 the latter heats the urine about half an inch from the 
 surface of the liquid. Use an alcohol flame so as not 
 to crack the tube by too great heat. Do not let the 
 flame at any time touch the tube above the surface of 
 the liquid. Nearly all beginners fail to observe this 
 precaution, with result that the tube is decapitated, so to 
 speak, loses the upper quarter as neatly as if chopped off. 
 
 Boil thoroughly thirty seconds, removing from flame 
 whenever the urine threatens to boil over, but do not 
 boil the lower half of the urine at all. 
 
 3. Add three to six drops of twenty per cent acetic 
 acid to the ioiling urine. Shake to and fro gently 
 until acid and upper stratum of urine have thoroughly 
 mixed, then boil again for, say, thirty seconds. 
 
 4. Hold the tube against a dark hacTcground.^ as the 
 coat-sleeve, or better still, hold it helow a window sill 
 of a north window or any window where there is no 
 direct sunlight. 
 
 EESULTS. 
 
 A. If albumin is present, the upper, heated, acidulated 
 quarter, or possibly third, is now distinctly turbid as 
 compared with the lower, cool, remaining portion of 
 the urine. If much albumin is present, the whole up- 
 per third or half of the urine is milky and flocks soon 
 begin to fall. If only a moderate amount of albumin 
 is present, the upper quarter or third is cloudy. If 
 there is a distinct turbidity which cannot be seen when 
 the tube is held up to the light we call it &plain trace. 
 If there is an indistinct turbidity of the same charac- 
 ter, requiring careful adjustment of eye and back- 
 ground, in order to see it, we call it a trace. If the 
 turbidity is faint and only seen with great diificulty 
 we call it & faint or doubtful trace. Such faint traces 
 may possibly be due to mucin and not to albumin at 
 all. They may be observed in the urine of nearly all 
 
166 URINARY ANALYSIS. 
 
 women. [Women who have leucorrhoea are nearly 
 always found to have anywhere from a faint to a plain 
 trace of albumin by this test in their urine. In such 
 cases a vaginal tampon should be used, before the 
 urine is voided for examination, or a cleansing vaginal 
 injection taken.] 
 
 B. If no albumin be present in the urine, nothing 
 will be seen, the upper, heated, acidulated portion of 
 the urine resembling the lower in appearance. 
 
 C. If the urine be of deficient acidity, it will become 
 cloudy when heated, owing to precipitation of earthy 
 phosphates. The addition of six drops of the acetic 
 acid and gentle to and fro shaking will usually dissolve 
 the phosphatic cloudiness, and the urine becomes nearly 
 clear, in cases when albumin is absent, but more cloudy 
 still if albumin is present. 
 
 Now, in nearly all cases when .the acetic acid appar- 
 ently dissolves the phosphatic cloud, careful observa- 
 tion will show a faint haze to remain. If this haze is 
 really faint, and is not appreciably increased by further 
 heating, I usually assume serum-albumin to be absent. 
 Why not, it is asked, add the acetic acid first to the 
 urine before boiling? When albumin is present in 
 small quantities in acid urine, acidifying still further 
 makes the albumin soluble when the urine is boiled, 
 so that there would always be need to take the reac- 
 tion beforehand, and to use judgment as to the amount 
 of acid to be added, and so on, 
 
 If now, after boiling, a cloudiness appears, which, 
 however, apparently disappears when acetic acid is 
 added, but if after further boiling, a cloudiness in the 
 upper portion is now again plainly seen, a plain trace 
 of albumin is present, which was not seen at first, 
 owing to the phosphatic cloudiness, and may not in 
 the end be as noticeable as was the phosphatic cloudi- 
 ness. Do not mistake a ring-shaped coagulum of 
 phosphates remaining half way down the tube for 
 albumin. This merely means that the acetic acid has 
 not yet reached the lowest stratum of phosphatic 
 cloudiness. The coagulum of albumin is to be seen in 
 the ivpfer part of the tube, always, when it is present. 
 
TESTS FOR ALBUMIN. 167 
 
 Lastly, in strongly alkaline urine which foams when 
 the acetic acid is added, be not sparing of acid, for the 
 albumin in it is alkali-albumin, and will not be fully 
 coagulated by heat until the alkalinity is overcome by 
 the acid. In such cases, which are not very common, 
 if freshly voided urine is tested, add acetic acid, drop 
 by drop, and take reaction of the upper quarter with 
 blue litmus paper, continuing to add acid until the 
 blue slip is turned bright red, then boil again. 
 
 BEMABXS. 
 
 For adding the acetic acid a medicine dropper (Fig. 
 38) is useful. Three drops may be added to urines 
 
 Fig. 38. Medicine-dropper, 
 which do not become turbid on boiling, but five or six 
 will be necessary in cases where a cloud appears with 
 heat alone. 
 
 The object of adding acetic acid is two-fold, first, 
 to dissolve any phosphatic cloudiness; second, to con- 
 vert alkali-albumin into albumin coagulable by heat. 
 
 The advantages of acetic acid over nitric acid are 
 two-fold, first, the acid is neither dangerous nor cor- 
 rosive ; second, it does not act on the coloring matter 
 of the urine as does nitric acid. Plain traces of albu- 
 min shown hy the heat a/ad acetic acid test appear as 
 faint or doubtful traces when the heat and nitric acid 
 test is used. 
 
 DISCUSSION. 
 
 The possible sources for error in my test are mucin and resins. 
 Kirk claims that mucin alone will answer to the te.-^t but Saundby 
 has failed to confirm his statement. So far as my own observa- 
 tion goes, I find that the urine of women will sometimes show a 
 trace by my test, which other tests, as for example, Purdy's salt 
 and acetic acid, do not confirm, yet microscopical examination of 
 the sediment in such cases reveals presence of leucorrhoea. It is 
 said, moreover, that when the patient is taking tolu, balsam of 
 Peru, etc , that heat and acetic acid will precipitate the resin. 
 Alcohol, however, will dissolve this precipitate. For clinical pur- 
 poifes, therefore, I regard the test as useful, and open to less criti- 
 cism than any of equal readiness, simplicity, and expense. 
 
168 UBINABY ANALYSIS. 
 
 CHAPTER XXVI. 
 
 LIFE-INSURANCE TESTING FOR ALBUMIN. COLD NITRIC 
 ACID TESTS. 
 
 In this chapter and in the one following the physi- 
 cian will find the tests for albumin commonly recom- 
 mended to examiners by life insurance companies. 
 Under each test will b» considered the following : 
 
 1. Technique of the test; 
 
 2. Chances for error; 
 
 3. Different methods of applying the test; 
 
 4. Practical objections or advantages. 
 
 Since most companies still prefer the older tests — 
 those with nitric acid, heat, or both — special promi- 
 nence will be given them in these pages. 
 
 Preparing the Urine for Examination: — Before 
 the urine is tested for albumin it must first be clear. 
 
 To make the urine clear proceed as follows : — 
 
 A. The urine is already clear or but slightly turbid 
 and of either acid reaction or but slightly alkaline : — 
 
 Filter through three filter papers folded together. 
 In a large majority of cases this is all that is neces- 
 sary, especially in the case of freshly voided urines. 
 
 B. The urine does not filter clear through three 
 filters: — 
 
 Shake the filtered urine with magnesia usta and filter 
 again. This will usually suffice to clear it. 
 
 0. The filtered urine is still turbid. 
 
 If after the operations described in "A" and "B" 
 the urine is still turbid add to it., after filtering as in 
 B, half its volume of a ten per cent solution of potas- 
 siiXm, hydroxide (caustic potash) and hoil. It becomes 
 cloudy from precipitation of phosphates. Filter and 
 in most cases the bacterial debris which has made it 
 turbid will be precipitated with the phosphates and 
 will remain on the filter, the urine coming through clear. 
 
TESTS FOR ALBUMIN. 169 
 
 D. The filtered urine is still turbid. 
 
 Add to it a few drops of magnesian fluid, toil, and 
 
 filter again. 
 
 Note: — Magnesian fluid may be made by dissolving 100 grammes 
 (1554 grains) each of pure magnesium sulpiiate and ammonium 
 chloride in 800 c.c. (87 fluidounces) of distilled water with addition 
 of 100 c.c. (3 fl. oz) of ammonia water. 
 
 Different albuminous substances in urine: — In 
 
 order to avoid confusion it must be understood that 
 the urine may contain different albuminous substances. 
 These are : 
 
 1. Serum-albumin and serum-globulin. These 
 occur together and are coagulated both by heat (boil- 
 ing), and by mineral acids, as nitric acid. 
 
 2. Albumoses (propeptones), may occur with or 
 without serum-albumin. Are coagulated by mineral 
 acids but not by boiling. Peptones are now not 
 thought to be present in urine. 
 
 3. Nucieo-albumin (mucin) may occur with or with- 
 out serum-albumin ; not coagulated by boiling. Pre- 
 cipitated by strong acetic acid, especially in diluted 
 urine. 
 
 The term alhumvnuria is applied to the voiding of 
 urine containing serum -albumin. Albumosuria to 
 that containing the albumoses. In addition to the 
 substances named above the urine may contain 
 hcBinoglohin, fibrin, and histon, which will receive 
 special attention later on. 
 
 A. THE COLD NITEIO ACID TEST. HELLEk's TEST. 
 
 1. Usual method of application: — Pour half an 
 inch of pure, colorless nitric acid into a test-tube, hold 
 the latter inclined as in Fig. 39 (see page 170), and let 
 an equal quantity of clear urine trickle down the inside 
 of the tube. The urine floats on the surface of the acid. 
 
 Results: — If serum-albumin is present a sharply- 
 defined zone of whitish color will be observed at tie 
 point of contact between the acid and the urine, 
 becoming more or less pronounced according to the 
 amount of albumin present. If but little albumin is 
 23 
 
170 
 
 URINARY ANALYSIS. 
 
 present, it may be necessary to hold the tube against 
 a dark back-ground, as the coat-sleeve, in order to see 
 the zone. 
 
 Fig. 39. Nftric acid test. 
 
 If no zone be seen, set the tube aside for half an 
 hour or more. A t/race of albumin may then be seen 
 which is not visible at first. 
 
 Chances for error: 
 
 1. A generally diffused haziness does not indicate 
 albumin. If the latter is present a distinctly and 
 clearly-formed white ring is seen, provided the test be 
 carefully performed without too hasty pouring of urine 
 into acid. 
 
 2. A cloudiness not at point of contact but higher itp, 
 more diffused and spreading downward is not albumin, 
 but due to precipitation of urates especially in urines 
 of high specific gravity. In case of doubt perform 
 the test again as follows : Dilute the urine with two 
 or three times its volume of water, warm the nitric 
 acid before adding the urine and now no cloud will be 
 seen, if the previous cloud was due to urates. 
 
 3. A light cloudiness near the surface of the urine 
 is not albumin but due to nucleo-albu/min (mucin). 
 
 i. In all urines a transparent zone qf color, more or 
 
TESTS FOR ALBUMIN. 
 
 171 
 
 less intense, appears. This is not albumin but due to 
 oxidation of the normal chromogens of the urine by 
 the acid. The color is violet, reddish, or brownish, 
 and its transparency can be observed by holding the 
 tube up to the light. 
 
 5. A zone of slowly forming crystals may be 
 observed in urines of high specific gravity containing 
 3 per cent or more of urea. The crystals, are nitrate 
 of urea and will not form if the test be tried again 
 with dilute urine and warm acid as in 2. 
 
 6. A yellowish-white -sone, less plainly defined than 
 the albumin ring may be due to precipitation of cer- 
 tain resinous bodies, such as those contained in turpen- 
 tine, balsam of oopaiva, tolu, storax, cubebs, salicylic 
 acid, etc., taken by the patient. Shake the urine- 
 acid mixture with alcohol, which will dissolve the 
 resins but not affect coagulated albumin. 
 
 7. If blood is present, the albumin ring will be col- 
 ored Irown-red/ if bile, greenish or blue. 
 
 8. If the nitric acid contains nitrous 
 acid as an impurity, bubbles will rise, 
 even in acid urine, and may obscure the 
 ■ rings. These bubbles are probably due in 
 acid urine to decomposition of urea by 
 nitrous acid. In alkaline urine the bub- 
 bles are due to carbon dioxide liberated 
 from carbonates present by action of the 
 acid, and will hence always be seen even 
 if the nitric acid be free from nitrous acid, 
 and no decomposition of urea take place. 
 
 Different methods of applying the test: 
 
 1. The Truax-Greene aloumin tester: — By use of 
 this instrument (Fig. 40) the various rings are seen 
 better than when a test-tube is used. 
 Fig. 40. . Albu- g. The nseot conical glasses. C. E. Simon reoom- 
 min tester, mends the use of conical glasses as follows: 
 About 20 CO. (5 fluidrachms) of the clear urine are poured into 
 one of the glasses and from 6 to 10 c. c. (1 J to 2J fluidrachms) of 
 nitric acid added by means of a pipette which is carried to the 
 bottom of the vessel, when the acid is slowly allowed to escape by 
 dimin ishing the pressure of the finger on the tube. 
 
 Results: — If albumin is present a whitish ring is seen from 
 below upward at the zone of contact, If albumin is small in 
 amount, the upper border, in time, though at first as well-defined 
 
173 URINARY ANALYSIS. 
 
 as the lower, becomes less so, the cloudiness extending upward in 
 the form of small, irregular columns. 
 
 If excess of uric acid is present, after 5 or 10 minutes a distinct 
 ring appears from above downward in the clear urine, about 1 to 
 3 centimeters (i-inch to an inch) above the zone of contact. The 
 degree of excess is indicated by the size of the ring. 
 
 If uric acid is deficient the ring above the zone of contact does 
 not appear within 5 or 10 minutes. 
 
 If excess of urea is present an appearance like hoar-frost is seen 
 on the sides of the glass. In such a case urea is 25 gm. per liter 
 {13 grains perounce) or more. When not less that 45 gm. per liter 
 (23 grains per ounce) are present, spangles are seen. When urea 
 is 50 gm. per liter (25 grains per ounce) or more, a dense mass of 
 the urea nitrate may be seen to separate. 
 
 If the urinary pigrinent is normal, a transparent colored ring is 
 obtained, of peach-blossom red, varying in tint from a faint rose 
 to a pronounced brick color. 
 
 If urobilin is prpsent a color ring like the above will be seen but 
 the tint is mahogany. 
 
 If indican is present, a more or less violet-colored ring is seen 
 above the peach blossom ring of normal color. The color of the 
 indican ring varies from light blue to deep indigo according to the 
 amount of indican present. 
 
 If bile be suspected, add a little nitrous acid to the nitric and a 
 series of colors will he noticed from above downward, yellow, 
 green, blue, violet, and red, of which the green is characteristic. 
 Bile absent, no green. 
 
 Note:— Nitrons acid may tie readily made by boiling a piece of wood with 
 the nitric acid. 
 
 If albnmin and bile together are present the bile color-play is 
 beneath the albumin ring. 
 
 If albumin, globulin, and the albumoses are all present there 
 is a cloud at the zone of contact as in case of albumin. If no 
 cloud, probable absence of all three. 
 
 If albumoses alone are present, remove the cloudy urine (precip- 
 itated by the acid as above) with a pipette and heat. Urates are 
 dissolved by gentle heat, albumoses by a higher temperature, 
 reappearing on cooling while the urine turns yellow. 
 
 If albumin and albnmoses together are present, the yellow 
 color is noted as above, but the urine is only partially cleared by 
 heat. 
 
 If resins are present, the turbidity produced by nitric acid is 
 cleared by alcohol. 
 
 3. Alexander's Method. To distinguish albumin, nucleo-albu- 
 min (mucin), and resins Alexander proceeds as follows: Three 
 glasses are used and into each is poured 8 or 10 c.c. of uj-ine:— To 
 the first glass is added 8 or 3 drops of hydrochloric acid; if resins 
 are present a red-violet coloration is seen when the mixture is 
 heated. 'To the second glass is added strong acetic acid:- a precip- 
 itate insoluble in excess, indicates mucin. To the third glass 
 after heating is added half its volume of nitric acid: a turbidity 
 indicates albumin. 
 
 Practical advantages and disadvantages: — 
 
 1. Heller's test is a very convenient and simple one 
 for clinical purposes. 
 
TESTS FOR ALBUMIN. 173 
 
 2. It is said to preciptate s^irtli of one per cent of 
 albumin. 
 
 3. It precipitates various albuminous substances, 
 resins, urates, urea (excess), and oxidized chromogens, 
 but not phosphates, true peptones, or vegetable alka- 
 loids. 
 
 4. The chief practical objection to it is the corro- 
 sive character of the nitric acid. 
 
 B, THE NITKO-MAGNESIAN TEST 
 
 1. Preparation: — Saturate distilled water with 
 chemically pure magnesium sulphate, filter, and to the 
 clear filtered liquid add nitric acid. 
 
 Note: — The amount of nitric acid used varies according to those 
 who use this test. Dr. Roberts uses 1 volume of nitric acid to 
 5 of magnesium sulphate solution. Others use 1 of nitric acid to 
 3 of the magnesium sulphate. Some examiners prefer equal parts 
 of acid and magnesium solution. 
 
 2. Method of application: — The contact method as 
 in case of Heller's test. 
 
 3. Advantages and disadvantages: — The testis 
 said to be as delicate as Heller's while the liquid is less 
 corrosive. It is however, a more delicate test for 
 nucleo-albumin and the ring of the latter is nearer the 
 chemical fluid than in Heller's test. 
 
174 URINARY ANALYSIS. 
 
 CHAPTER XXVII. 
 
 LIFE INSURANCE TESTING FOR ALBUMIN— CONTINUED. 
 HEAT TESTS. 
 
 Among the most important tests for albumin we 
 find :— 
 
 C. THE HEAT AND NITEIO ACID TEST. 
 
 This test was the first ever used for albumin in the 
 urine by Cotugno in 1770. The urine is boiled and 
 nitric acid is added to it. It is performed in several 
 ways : — 
 
 Method I : — Fill a test-tube half full of clear urine, 
 hold it with a test-tube clamp, boil, and add one-tenth 
 its volume of nitric acid. 
 
 Results: — If any cloudiness, coagulum, or precipi- 
 tate is seen after boiling and addition of nitric acid, 
 albumin is present. 
 
 Method II : — Boil about an inch of the clear urine 
 in a test-tube and add 2 or 3 drops of ten-per-cent 
 nitric acid solution. If, after a few moments, there 
 is no cloudiness, coagulum, or precipitate, boil again, 
 add ten drops more of the dilute nitric acid and set 
 aside. A trace of albumin may become visible after 
 an hour or so, not seen at first. 
 
 Method III : — Clarify the urine by addition of a 
 few drops of potassium hydroxide solution, boiling, 
 and filtration. Fill a test-tube half full of it and add 
 15 to 18 drops of strong nitric acid. If the urine 
 contain albumin it will become somewhat cloudy. Boil 
 and let stand half an hour. There will be seen a 
 sediment of whitish flakes or granules. Boil again, 
 when if albumin be present, the flakes will not be 
 dissolved by the second boiling. 
 
 DISCUSSION. 
 
 Authorities are not agreed as to the best method of performing 
 the heat-and-nitrio-acid test. Those who employ method I. do so 
 
TESTS FOR ALBUMIN. 175 
 
 because (1) too small an amount of nitric acid may dissolve 
 coagulated albumin, hence add to the urine one-tenth its volume 
 of acid and not less; (2) too large an amount of the acid may also 
 dissolve the albuminous coagulum to a certain extent, hence use 
 not more than one-tenth its volume of acid. 
 
 Chances for error: — 1. While the urine is hot. 
 albumoses, urates, and vegetable alkaloids are not pre- 
 cipitated by this test. Urine rich in urates may on 
 cooling, precipitate a pinkish-red sandy precipitate of 
 uric acid. 
 
 2. The resins, thymol, etc., are precipitated by this 
 test, but the precipitate is soluble in alcohol. The 
 latter should not be added until the urine cools- for 
 fear of explosion. 
 
 3. When only a trace of albumin is present the 
 characteristic appearance is either the formation of a 
 few flakes of coagulated albumin or of a general 
 turbidity which finally results in a fine flooculent 
 separation, persisting when the solution is hot, and 
 rendered more pronounced by the addition of alcohol. 
 
 4. If albumoses are present, the urine turns dis- 
 tinctly yellow after addition of nitric acid, and, on 
 cooling, a whitish precipitate appears. 
 
 5. Faint hazes may be due to nucleo-albumin 
 (mucin). See differential testing further on. 
 
 D. HEAT AND AOBTIO ACID TEST. 
 
 The writer advises that this test be used as described 
 under the "Clinical Test," in Chapter XXV, namely, 
 boiling the upper third and adding acetic acid. 
 
 If the acetic acid be added drop ly drop after boil- 
 ing, there is little or no danger that the albumin will 
 be dissolved by excess. Eesins may be excluded by 
 use of alcohol. So far as the writer has been able to 
 observe the chief chance for error is due to precipita- 
 tion of what is probably nucleo-albumin (mucin). In 
 case a slight cloudiness is obtained, not by heating, 
 but only after addition of several drops of acid and 
 further boiling, it may be well to try the following : 
 
176 UEINARY ANALYSIS. 
 
 E. ACETIC ACID AND HEAT TESTS. 
 
 I. Purdy raises the specific gravity of tlie urine 10 or 15 degrees 
 by addition of a little saturated solution of common salt, filters 
 clear, and to a testrtube two-thirds full of urine add 1 or 2 drops 
 of 50 per cent acetic acid, and boils the upper third. He claims— 
 and with reason I think— that by this test mucin is not coagu- 
 lated, since this body is soluble in a strong solution of common 
 salt. 
 
 II. Heynsius acidulates the clear urine strongly with acetic 
 acid, then adds a few o.o. (about one fluidrachm) of saturated 
 solution of common salt. The urine is then boiled, when a floc- 
 culent precipitate indicates presence of albumin. 
 
 III. The clear urine may be treated with a few drops of acetic 
 acid until a distinctly acid reaction is obtained, and then one-sixth 
 its own volume of a saturated solution of sodium chloride, mag- 
 nesiuta sulphate, or sodium sulphate added. On boiling the urine 
 a precipitation of even minimal amounts of albumin will take 
 place. 
 
 CHEMICAL EXERCISE XII. 
 
 1. To one volunie of albuminous urine add six vol- 
 umes of water. Mix well, fill a test-tube half full of 
 the mixture, add a drop or two of nitric acid and shake : 
 album.in will he precipitated hut will redissolve on shak- 
 ing. Keep on adding nitric acid, drop by drop, until 
 finally the precipitated albumin is not dissolved. 
 
 This experiment shovfs that in dilute albuminous 
 solutions a small quantity of nitric acid does not com- 
 pletely precipitate the albumin. In urine the neutral 
 salts help small quantities of the acid to precipitate the 
 albumin, but it is not safe to rely on the use of two or 
 three drops. 
 
 2. Boil a sample of albuminous urine of aacZ reaction : 
 a cloudiness appears which is undissolved by either 
 acetic or nitric acid. 
 
 3. Boil a sample of albuminous urine to which 
 liquor potasses has been added : the urine becomes 
 turbid: filter; boil again. The urine remains clear. 
 Now add acetic or nitric acid in quantity sufficient to 
 overcome the alkalinity and an abundant whitish coag- 
 ulum of albumin appears. The first turbidity was due 
 to precipitation of the phosphates. After filtering, 
 although the urine was boiled, no coagulum of albumin 
 appeared because the liquor potassse had converted the 
 albumin into what is called alkali-alhwinin, not coag- 
 
TESTS FOB ALBUMIN. 177 
 
 ulated by heat. Addition of acid, however, broke up 
 the alkali-albumin and then the albumin was coagulated 
 by heat. 
 
 4. Let a sample of abundantly albuminous urine 
 grow stale and ammoniacal. It will then be seen on 
 boiling that only a slight turbidity due to phosphates 
 appears, but on addition of acid, albumin will be coag- 
 ulated and an abundant precipitate appear. 
 
 5. Filter a sample of acid urine containing but little 
 albumin, fill each of the two test-tubes f full of it and 
 boil the upper third of each. To one add 15 to 30 
 drops of nitric acid after boiling, and to the other 2 
 or 3 drops of acetic acid. Which shows the precipi- 
 tated albumin the plainer? 
 
 6. Compare either or both of these tests with the 
 cold nitric acid test, using (a) the Truax-Greene appar- 
 atus, (5) a test-tube and pipette and (c) conical glasses 
 and pipette. 
 
 7. To 10 c.c. of a sample of albuminous urine of 
 acid reaction add 5 c.o. of 20 per cent acetic acid, boil, 
 and compare with other samples to which acetic acid 
 is added after boiling in various amounts. 
 
178 URINARY ANALYSIS. 
 
 CHAPTER XXYIII. 
 
 LIFE INSURANCE TESTING FOE ALBUMIN.- ConMnwed. 
 
 THE FEKKOOYANIO AND TEICHLOEACETIO TESTS. 
 
 F. The ferrocyanic test: — There are several 
 methods of applyiug the ferrooyanide test, as follows : 
 
 Method I : — Make a solution of chemically pure 
 potassium ferrocyanide, 10 grammes in 200 o.c. of 
 distilled water (156 grains in 7 fl. oz.) Into the bottom 
 of a dean test-tube pour 15 to 30 drops of acetic acid 
 (30 per cent), then add two or three times that amount 
 of the ferrocyanide solution and shake. The mixture 
 should remain clear. JSTow add clear filtered urine, 
 and if albumin be present it will be precipitated 
 throughout the whole volume of the urine in the form 
 of a more or less milk-like flocculent cloud, according 
 to the quantity of albumin present. 
 
 Method II: — Pill an ordinary test-tube half full of clear filtered 
 urine and add 3 or 4 c.c. (a fluidrachm or so) of the ferrooyanide 
 solution. Mix thoroughly and add 10 or 15 drops of acetic acid, 
 and. if albumin is present, a cloudiness or coagulum will be 
 plainly seen. 
 
 Method III: — A few o.c. of urine are strongly acidulated with 
 acetic acid (sp. gr. 1064). If (a) there is no turbidity, further add 
 a few drops of a 10 per cent solution of potassium ferrooyanide, 
 when if albumin be present, either a faint turbidity or a precipi- 
 tate, according to quantity of albumin present, will be seen. 
 Compare with tube containing clear filtered urine, both tubes 
 being held against a dark background. 
 
 If (b) there is a turbidity seen on addition of the acetic acid 
 alone (urates or mucin), the urine to which the acetic acid has 
 been added should be filtered and diluted before the ferrocyanide 
 is added. 
 
 Method IV: — ^The test by contact is as follows: To five cubic 
 centimeters (one and a third fluidrachm) of 30 per cent acetic acid 
 add five drops of the ferrocyanide solution, and cause the mixture 
 to trickle down the side of a test-tube in which are 5 c.c. of clear 
 filtered urine. A white ring at the surface of contact between 
 the two fluids indicates the presence of albumin. 
 
TESTS FOR ALBUMIN. 179 
 
 CHANCES FOE EEEOB. 
 
 1. The ferrocyanide solution should be freshly made 
 in pure distilled water, filtered clear, kept in a clean 
 bottle, with a clean stopper, away from the light. 
 
 2. It is well to see that the acetic acid and the fer- 
 rocyanide solution when mixed together without urine 
 remain clear. 
 
 ■ 3. The writer has noticed that, if the acetic acid be 
 added from a pipette with a ruhber nipple., a cloudiness 
 or precipitate sometimes takes place. If pipettes are 
 used they should be all glass. 
 
 4. Heating will cause a precipitate in the mixture 
 without addition of urine. 
 
 5. When the amount of albumin is very small, cloudi- 
 ness is not seen immediately after adding the urine hut 
 only after a few minutes have elapsed. 
 
 6. The ferrocyanide test precipitates albumin, globu- 
 lin, acid and alkali-albumins, albumoses; nucleo- 
 albumin from bile is said to be precipitated by it. 
 
 7. Urines of high specific gravity should be diluted 
 with water lest albumin and albumoses be not pre- 
 cipitated. 
 
 8. Eemoving the coagulated substance with a pipette, 
 and boiling it, will tell whether it is albumin or albu- 
 moses, since the latter clears when boiled and reprecip- 
 itates on cooling. 
 
 Partial clearing on boiling indicates a mixture of 
 albumin with albumoses, but some care during the pro- 
 cess is necessary, since boiling decomposes the ferro- 
 cyanide solution and makes it cloudy. The best way 
 to manage it is to let the precipitate settle thoroughly, 
 decant supernatant liquid, add water, let settle again, 
 and remove with the pipette. • This can be done 
 rapidly by the use of the centrifugal machine. 
 
 G. The Trichloracetic Acid Test: — Trichloracetic 
 acid, CCli.COOH, is a substance derived from acetic 
 acid by treatment with chlorine in sunlight or by 
 oxidizing chloral with nitric acid. 
 
 It is a monobasic acid, HCaCl^Oa and occurs in 
 commerce in the form of crystals. 
 
180 UBINABY ANALYSIS. 
 
 Method of application: — Make a saturated solution 
 of the crystals, (half an ounce in an ounce of distilled 
 water) and by means of a pipette carry 1 or 2 c. c. 
 ( 16-32 minims) to the bottom of a test-tube contain- 
 ing the clear filtered urine so as to form a layer beneath 
 the urine. If albumin be present, a white ring will be 
 seen to form at the zone of contact between the two 
 fluids, varying in intensity with the amount of albu- 
 min present. 
 Chances for error: — 
 
 1. Albumoses are precipitated but disappear upon 
 boiling, to reappear on cooling. 
 
 2. Dilution of the urine prevents mistake which 
 may be due to precipitation of urates ; heat also serves 
 to distinguish these substances. 
 
 3. Alkaloids, if precipitated, are soluble either by 
 heat or by large excess of the reagent. 
 Advantages: — 
 
 1. This test will demonstrate albumin in urines in 
 which the more common tests yields negative results 
 but in which tube-oasts may nevertheless be found. 
 
 2. Although showing 1 part of albumin in 100,000 
 of urine, the test is not so delicate as to demonstrate 
 traces of nucleo-albumin in all urines. 
 
 3. Trichloracetic acid will detect albumin which has 
 escaped observation on account of being dissolved by 
 acetic acid, and not precipitated by picric acid or by 
 heat. 
 
 4. 'So color rings are formed in the urine when this 
 test is used. 
 
TUSTS FOR ALBUMIN. 181 
 
 CHAPTER XXIX. 
 
 MISCELLANEOUS TESTS FOR ALBUMIN 
 
 Inasmuch as different teachers prefer to teach medi- 
 cal students different tests I subjoin a list of a num- 
 ber of albumin tests with the hope that it will include 
 all in common use. 
 
 Acidulated brine test: — This test as performed by Roberts is as 
 follows: Make a saturated solution of sodium chloride and mix 
 one pint of it with one fluidounoe of strong hydrochloric acid (500 
 CO. with 30 CO.). Filter and apply by contact method, floating 
 the urine on the reagent. 
 
 Cliromic acid test: — Mix one part of a five per cent solution of 
 chromic acid with three parts of urine in a test-tube. If albumin 
 is present a cloudiness appears. If the mixture remain clear, boil 
 the upper portion and a slight trace of albumin will be thus 
 detected by cloudiness appearing in the heated portion. The 
 chromic acid must be chemically pure, and the distilled water 
 used for dissolving it also free from impurities. 
 
 Metaphosphoric acid, Hindenlang's test: — Into the clear filtered 
 urine drop a fragment of metaphosphoric acid and, if albumin be 
 present, a white precipitate is formed. 
 
 Picric acid test: — Make a saturated solution of picric acid, 6 or 
 7 grains to the ounce, of boiling distilled water. Float two inches 
 of the reagent on a column of urine four inches deep. As far as 
 the yellow color extends the coagulated albumin renders the 
 mixture turbid. Albumin, peptone, mucin, urates, albumose, 
 kreatinin, vegetable alkaloids, and piperazine are all precipitated. 
 Hence add solution of citric acid (20 gm. per liter) first filter to 
 eliminate mucin, then add picric acid, and carefully heat the pre- 
 cipitate formed. If albumin is present heat does not dissolve the 
 ooagulum as in the case of other bodies. The heat must not be 
 too great or other precipitates will be formed. 
 
 Piperazine picrate is crystalline and disappears on heating. 
 
 Potassio-mercuric iodide test:— This test is performed with 
 what is known as Tanr^-t's solution, potassium iodide, 3.33 
 grammes; mercuric chloride, 1.85 grammes; acetic acid, 30 cubic 
 centimeters; distilled water to make 100 cubic centimeters. Dis- 
 solve the two salts separately and then mix the solutions, add 
 the acetic acid, and make up the whole to 100 o.o. with distilled 
 water. Apply by contact method, floating the urine on the 
 reagent. Gentle heat distinguishes albumin, pine-acids, and 
 mucin from possible precipitates of albumoses and vegetable 
 alkaloids. 
 
 Phenic-acetic-acid test:— This test as used by the late Dr. 
 Millard of New York is performed with the following solution: 
 
183 URINARY ANALYSIS. 
 
 Glacial carbolic (phenic) acid, 95 per cent, 3 fluidrachms; acetlo 
 acid, C. P., 7 fluidrachms; liquor potaesse, 6 fluidrachms. Float 
 the urine on the reagent. Heat distinguishes albumin, mucin, 
 and pine-acids from albumoses and alkaloids. 
 
 Platinocyanide of potassiniu:— Same as the ferrocyanide test, 
 and has the advantage of being a colorless solution. 
 
 Sulphocyanide of potassium:— Take 100 c.c. of a ten per cent 
 solution of sulphocyanide of potassium and 20 c.c. of acetic acid, 
 and add a few drops to the urine to be examined. If it contains 
 the smallest quantity of albumin, a distinct cloudiness is at once 
 obtained; if the urine contain much albumin a thick white pre- 
 cipitate is obtained. Any excess of the reagent has no effect. 
 All normal urines, that is to say, such as are not affected by fer- 
 rocyanide of potassium and acetic acid, give negative re.sutts with 
 this reagent. By successive ddutions of urine containing albu- 
 min it is found that this reaction is more delicate than ferrocyan- 
 ide of potassium and acetic acid. It possesses the advantage of 
 being colorless, so that the least cloudiness is more manifest than 
 when ferrocyanide is used. Succinic acid may be substituted for 
 the acetic acid. If to albuminous urine sulphocyanide of potas- 
 sium and a little succinic acid be added, a distinct cloudiness is 
 obtained, while normal urine remains clear. 
 
 This reaction possesses the advantage of being easily carried 
 about, the sulphocyanide of potassium and the succinic acid being 
 solid. If these reagents be mixed in equal proportions, and a 
 small portion of the mixture be added to albuminous urine, an 
 immediate cloudiness results with the smallest quantity of 
 albumin. 
 
 Keaction of albumin with percliloride of mercury and acetic 
 acid: — If a few drops of a ten per cent solution of ijerchloride of 
 mercury be added to albuminous urine a distinct cloudiness is 
 obtained, while in normal urine the cloudiness is hardly visible, 
 except in very exceptional cases. If to the urine so rendered 
 cloudy by perchloride of mercury, a few drops of acetic acid be 
 added the precipitate disappears if it is not composed of albumin. 
 On the contrary, if the urine contains albumin, the precipitate 
 persists. A mixture of one part of acetic acid and a ten per cent 
 solution of perchloride causes only a cloudiness when there is 
 albumin in the urine; this appears immediately on the addition 
 of the reagents and does not form a deposit, while the addition of 
 the sublimate alone causes one. Peptones give no reaction with 
 these agents in the proportions above indicated. The same ap- 
 plies to uric acid, urea, phosphates, and sugar. Further, very 
 concentrated urine does not become cloudy on the addition of the 
 sublimate and acetic acid. 
 
 Spiegler's test for albumin:— Spiegler's very delicate test for 
 albumin in urine consists of a test solution composed as follows: 
 Perchloride of mercury, 8 grams; tartaric acid, 4 grams; sugar, 
 20 grams; distilled water, SOO grams. The sut?ar serves to raise 
 the specific gravity of the liquid to 1060, which is higher than 
 that of nearly all urines. It is used by placing some of it in a 
 test-tube, and gently adding some of the urine to be tested. If 
 albumin is present a ring will form at the junction of the two 
 liquids. The reaction will not take place in solutions of egg or 
 serum-albumin save in the presence of chlorides. 
 
 The sulpho-salicylic acid test:— This test was first described 
 by Eeoch, and used independently by Mac William. It is said to 
 
TESTS FOR ALBUMIN. 183 
 
 show traces of albumin in a dilution of 1 to 50000. Sulpho-sali- 
 cylio acid, C,HeSO. = C,H,.SOs.H(OH) COOH, is a white, crys- 
 talline substance, made by heating salicylic acid with concen- 
 trated sulphuric acid. It precipitates all proteids. It may be 
 used either in form of a saturated solution, or by adding some of 
 the crystals to a small quantity of filtered urine in a test-tube. In 
 the latter case the tube should be shaken. If albumin is present 
 in acid urine, a cloudiness or white homogeneous precipitate, 
 according to the amount of proteid present, appears. Uniform 
 opalescence is characteristic of this test. The test must be supple- 
 mented by heat to the boiling point, in order to distinguish the 
 the serines from the albumoses, the latter being dissolved by heat 
 as in the urine of the third stage of pneumonia, and the first 
 passed after ejaculation of semen. The urine must be acid, or the 
 test fails. Sulpho-salicylic acid gives no mucin reaction in normal 
 urine, but only when larger quantities of mucin are present. 
 
 Sodinm tnu^state (Oliver's Test): — Mix equal parts of a 1 to 4 
 solution of sodium tungstate and saturated solution of citric acid. 
 Apply by contact. Albumoses, mucin, and occasionally urates 
 are also precipitated, but heat clears all but mucin and albumin. 
 
 Jolles's test: — This is said to detect 1 part albumin in 120,000 
 of water. The constituents are mercuric chloride, 10 grams; suc- 
 cinic acid, 20 grams; sodium chloride, 10 grams; water 500 c.o. 
 
 Sharp's test:— Dr. Sharp substitutes glycerol for the sugar in 
 Spiegler's test. 
 
 Tanret's reagent: — Potassium iodide, 3.33 gm.; mercuric 
 chloride, 1.35 gm. ; acetic acid, 20 o.c; distilled water, q. s. 
 100 c.c. 
 Hillard's reagent: 
 
 95 per cent carbolic acid , ^'M 
 
 Glacial acetic acid 3 viq 
 
 Liquor potassse... Jxxij 
 
 Mix. 
 
 CHEMICAL EXERCISE XIIL 
 
 For five or six consecutive exercises the student 
 should test urines for albumin, using some one test, 
 until thoroughly familiar with it. The author advises 
 either the heat and acetic acid, or heat and nitric acid 
 tests to be used first. After familiarity with one or 
 the other of these is gained, try either the trichlora- 
 cetic acid test, the ferrocyanic test, or the sulpho-sali- 
 cylic acid test. 
 
181 
 
 URINARY ANALYSIS. 
 
 CHAPTER XXX. 
 
 THE QUANTITATIVE DETERMHSTATION OP ALBUMIN IN 
 THE URINE. 
 
 Clinical methods only will be considered in this 
 chapter. A favorite one involves use of the 
 Esbach tube (Fig. 41), which is a specially 
 constructed tube which has an upper mark E, 
 a second mark below it, U, and the figures 7, 
 6, 5, 4, 3, 2, 1, one above the other, indicat- 
 ing graduations of the tube, in parallel lines, 
 beginning just below U, and going down to 
 nearly the bottom of the tube. Between the 
 mark 1 and the curved bottom of the tube is 
 a short mark, not numbered, which is -J of 1. 
 In order to use the tube, first add eight or 
 ten drops of the 20 per cent acetic acid to, say, 
 half a fluid ounce (15 c.c.) of the urine to be 
 tested, mix well, and pour the mixture into the 
 tube until the latter is filled to the line indi- 
 cated by the letter U. Then fill to the mark 
 E with Esbach's reagent, a liquid made by 
 dissolving 165 grains (10 grams) of picric acid and 
 310 grains (20 grams) of citric acid in 30 fluid ounces 
 (900 c.c.) of distilled water and, after solution is 
 accomplished, adding enough distilled water to make 
 the total one litre (1.05 quart, or a little over 33 fluid 
 ounces). The solution should be made in cold water 
 and the chemicals powdered in a mortar before solution 
 is attempted. 
 
 After the yellow reagent fluid has been added, close 
 the mouth of the tube with the thumb, and invert a 
 dozen times without shaking. Then close with a 
 rubber cork and let settle for 24 hours. The precipi- 
 tated proteids, if present, settle down to the bottom 
 
 Fig. 41. 
 
 Esbach 
 
 tube. 
 
TESTS FOR ALBUMIN. 185 
 
 of the tube, and the height of the deposited mass may 
 be measured by the lines, 1, 2, 3, 4, etc., on the out- 
 side of the tube. The inventor, Dr. Esbach, claims 
 that these lines indicate percentages of albumin hy 
 weight, vis.: 1-10, £-10, 3-10, etc., of one per cent hy 
 weight. These figures must be carefully distinguished 
 from the old-fashioned method of reckoning albumin 
 roughly ly lulk, namely, 10 per cent, 20 per cent, 
 etc., after boiling with heat and nitric acid. One per 
 cent of albumin hy weight is a very large quantity, but 
 one per cent hy hulk is an exceedingly small quantity, 
 not much more than a plain trace. The Esbach tube 
 is graduated so as to express percentages by weight, 
 not bulk, and this must not be forgotten. I have, 
 however, for clinical purposes, discarded reckoning by 
 the Esbach tube save in the following way : 
 
 1. The precipitated proteids settle down below mark 
 1, albumin is small in quantity. 
 
 2. The precipitated proteids settle down below 3 
 but above 1, alhumin is moderate in quantity. 
 
 3. The precipitated proteids settle down to any 
 figure or letter above 3, alhumin is ahxindant, very 
 large in quantity if 5 to 7, enormous if much above 7. 
 In such cases dilute the urine with an equal volume of 
 water and multiply. In general it is better to dilute 
 the urine, so that its specific gravity does not exceed 
 1008. It is said that albumoses and kreatinin are pre- 
 cipitated by the Esbach liquid, and a crop of uric acid 
 crystals is often seen. 
 
 Separation of albumin and globulin: — First deter- 
 mine the total proteids by use of Esbach's albumin- 
 imeter, then saturate another portion of the urine 
 with magnesium sulphate, filter, and determine the 
 albumin in the filtrate with the Esbach tube again. 
 The difference in the two results represents the amount 
 of globulin precipitated by the magnesium sulphate, 
 but allowance must be made for increase in the volume 
 of the urine caused by saturation with the sulphate. 
 24 
 
186 
 
 URINARY ANALYSIS. 
 
 For a rack in which to set Esbaoh tubes the 
 writer finds the metallic one (Fig. 42), conveni- 
 ent, since the Esbach tubes are too large to fit 
 the apertures in many of the test-tube racks 
 used. 
 
 For the determination of small quantities of 
 albumin the original Esbach tube is not well 
 suited. Dr. Hayward, of Liverpool, has modi- 
 fied the tube so that the base is conical, instead 
 of round, by which means a small bulk of albu- 
 min may be measured. 
 
 Determination of albumin by use of per- 
 centage tubes:— Dr. C. W. Purdy, of Chicago, 
 has our thanks for devising percentage tubes 
 for the determination of albumin. They are 
 the same as those already spoken of under 
 chlorides (Fig. 35), and may be used either with 
 or without the centrifugal machine. When the electric centri- 
 fuge is used, the determinations may be made at a definite speed 
 for a definite time, for example, at 1000 revolutions per minute 
 for five minutes. Purdy directs that a percentage tube be filled 
 to the 10-c.c. mark with filtered urine, 3.^ c.c. of a 1 in 10 solu- 
 tion of potassium ferrocyanide added, and the mixture shaken, 
 then 1.5 c.c. of 30 per cent acetic acid solution poured in, and 
 the whole mixed thoroughly. Let stand 20 minutes and settle in 
 the centrifuge. Settle for fi^'e minutes at a speed of 1000 revolu- 
 tions, or till no further decrease in bulk of the precipitate occurs. 
 Results are expressed in terms of bulk, not weight. If the sedi- 
 ment, for example, settUs down to the mark 2 c.c, we have 30 
 per cent by bulk. If to the second small line, 3 per cent bulk. 
 These percentages do not correspond to percentages from boiling. 
 
 Back. 
 
 CHEMICAL EXERCISE XIV. 
 
 THB ■WEITEa'B EXPEKIMENTS IN DETERMINING BULK PBRCENTAGES 
 OF ALBUMIN. 
 
 Collect the twenty-four hours' urine of an albuminuric patient, 
 filter a few hundred cubic centimeters of it, and for all expeii- 
 ments use 10 c.c. of this filtered urine, and a speed of 1,000 
 revolutions per minute in the centrifuge for five minutes. To 
 different samples of the filtered urine add the following reagents 
 respectively: 
 
 I. Purdy's ferrocyanic mixture as previously described. 
 
 3. Five c.c. of the Esbach fluid, previously acidulating the urine 
 with 3 to 10 drops of 20 per cent acetic acid, according to reaction. 
 
 3. Boil the urine and then add 8 to 10 drops of 30 per cent acetic 
 acid. 
 
 4. Boil the urine and add 30 drops of nitric acid. 
 
 5. Add 0.2 gm. of trichloracetic acid. 
 
 6. Add 2 gm. of trichloracetic acid — (solubility in excess)i 
 
 7. Add 0.2 gm. of sulpho salicylic acid. 
 
 8. Add 2 gm. of sulpho- salicylic acid. 
 
 9. Add 0.2 gm. of metaphosphoric acid. 
 
 10. Add 2 gm. of metaphosphoric acid. 
 
 II. Add 5 c.c. of Oliver's sodium tungstate solution. 
 
TESTS FOR ALBUMIN. 187 
 
 IS. Add 5 c.c. of Jolles's test solution. 
 
 13. Add 5 c.c. of Tanret's reagent solution. 
 
 14 Add 5 c.c. of Millard's test solution. 
 
 15. Add 5 c.c. of Spiegler's test solution, or of the Spiegler- 
 Sharp test liquid, etc. 
 
 All sorts of variations may be tried, especially in the way of 
 adding small quantities of each reagent, and comparing results 
 with those obtained by using an excess of the reagent. The differ- 
 ence in bulk between coagulated and precipitated albumin may 
 be shown. The effect on the sediment of higher speed should 
 next be shown, each sediment being subjected to a speed of 1,700 
 revolutions a minute for five minutes. It will be found that no 
 two of the bulks will exactly agree, and that between the abund- 
 ant precipitated bulk where the Esbach fluid is used, and the 
 small coagulum obtained by heat and acetic acid, there is a 
 marked difiEerence in percentage. 
 
 The student will notice peculiarities of specific gravity and 
 density, for example, the precipitate obtained by the ferrocyanic 
 test is lighter apparently than that of some of the others. A 
 small percentage, say 3, obtained by the ferrocyanic test at 1,000 
 revolutions can be reduced one-half by a speed of 1,700. If the 
 quantity of proteids is very large, heat and acetic acid, or 0.2 gm. 
 of sulpho -salicylic acid produce a denser sediment of smaller bulk 
 than do the ferrocyanic, trichloracetic, or Esbach tests, at a speed 
 of 1,000. When the amount of albumen is large, a speed of 1,700 
 for 15 or 20 minutes may be required to settle the precipitate 
 properly. 
 
 Subject all the precipitates, settled at a speed of 1,000 per 
 minute, to one of 1,700 per minute for 5 minutes and note which 
 ones shrink in volume, and how much. Now pour off the super- 
 natant urine in every tube (which can readily be done without 
 losing any of the sediment), fill up to the 15 c.c. mark with cold, 
 distilled water, shake well until all the sediment is dislodged, 
 using a knitting needle or a small glass rod for stirring purposes, 
 and settle again at a speed of 1,700 for five minutes. It will be 
 found that this procedure reduces the percentage bulk of some of 
 the sediments. Pour off the supernatant cold water and add hoc 
 water (above 150° F.), shake and stir as before, and settle while 
 still warm at a speed of 1,700 revolutions. It wiU be seen that 
 hot water reduces the bulk percentages materially in some oases. 
 I«t cool and alter stirring and shaking, settle again at 1,700 and 
 it wiU be found that, in some cases the proteid is not reprecipi- 
 tated, on cooling, to its full previous bulk. 
 
 CLINICAL NOTES ON AUTHOR'S CASES. 
 
 1. In a case of persistent albuminuria without other symptoms, 
 and with but few casts in the urine, determination of the quantity 
 of albumin, by the different reagents mentioned above, showed 
 the following: Two. examinations of the 24 hours' urine, made 
 two weeks apart, showed about 4 per cent bulk of albumin by the 
 heat and acetic acid, and by the heat and nitric acid tests, respec- 
 tively, each time. On the other hand the ferrocyanic test showed 
 8 per cent the first time, and 14 per cent two weeks later; the tri- 
 chloracetic test, precisely the reverse, namely, about 15 per cent 
 the first time, and 8 per cent the second. In other words, the 
 results were identical when the methods involving heat and acid 
 
188 URINARY ANALYSIS. 
 
 were used, but contradictory between the ferrooyanic and tri- 
 chloracetic acid tests. 
 
 2. In a case of albuminuria, due to presence of pus and blood in 
 the urine, the small bulk percentages obtained by use of the vari- 
 ous reagents agreed quite closely. 
 
 3. In a case of chronic Bright's disease, ten days before death, 
 when albumin was very large in amount in the urine, heat and 30 
 drops of nitric acid gave bulk percentages, which agreed more 
 closely with those obtained by the precipitating reagents, than 
 was the case in other urines containing small bulks of albumin. 
 
 4. The writer suggests to all teachers, who have the electric 
 centrifuge, to encourage original work in the determination of 
 bulk percentages of albumin, in order to answer the following 
 questions: (a) Is the centrifugal method capable of yielding suflS- 
 ciently constunt results to be at all available for clinical purposes? 
 What reagent or method gives the most satisfaction, i. e. , is most 
 reliable? (b) Can the separation of albumin, globulin, and albu- 
 moses be made and the ratio of these substances to one another 
 approximately determined? 
 
 N. B — The influence of the speciflc gravity of the urine on the 
 bulk of the precipitates should be studied, and the size of the 
 flakes observed, when boiling is used. Serum-albumin can be 
 separated from globulin by rendering the urine amphoteric or 
 faintly alkaline with sodium hydrate, and then saturating with 
 magnesium sulphate in substance. Globulin is precipitated and 
 serum-albumin remains in the filtrate. Determine the bulk per- 
 centage of the serum-albumin, by means, say, of boiling and 
 addition of acetic acid, and by other reagents which do not react 
 with magnesium sulphate. 
 
 For the Gravimetric Determination of Albumin see 
 Appendix. 
 
SIQNIFICANCE OF ALBUMINURIA. 189 
 
 CHAPTER XXXI. 
 
 CLINICAL SIGNIFICANCE OF ALBUMINURIA. 
 
 Albumin occurs in the urine without serious signifi- 
 cance much oftener than was formerly supposed, but 
 at the same time the permanent presence of albumin in 
 the urine must on the whole always be regarded as 
 pathological. We may classify the various albuminu- 
 rias not due to pus or blood as follows : — 
 
 1. Functional Albnrainnrla: — This much -abused term describes 
 a number of albuminurias which in the past have been regarded 
 as physiological, to wit: transitory, intermittent, or cyolieal albu- 
 minurias. Albuminuria may follow severe muscular or mental 
 exercise, cold baths, hearty meals, etc., and disappear; or it may 
 continue several days or even weeks, disappear and reappear 
 again. In the latter case the albuminuria is called interviittent. 
 If it disappear and reappear with regularity, it is called cyclical. 
 Cyclical albuminuria is called postural when it disappears after 
 rest in bed. to appear again when the person stands on his feet. 
 
 These albuminurias may be observed in apparently healthy per- 
 sons, but the writer is skeptical about any physiological basis for 
 them. Among certain young men, whom the author has had 
 under observation for years, no death has as yet occurred, and no 
 disease of the kidneys can be demonstrated, but, as a rule, the 
 subjects are pallid or neurasthenic and, in some cases, sexually 
 weak. 
 
 Transitory albuminuria is noticed in anaemic children and mas- 
 turbating boys. It is also found in pregnancy and in parturition. 
 
 Urines containing abundant sediments of uric acid or oxalate of 
 lime are quite frequently found to contain albumin also. The 
 latter most always disappears, when the urine becomes normal in 
 other respects. 
 
 2. Albuminuria due to febrile disorders:— This in the experi- 
 ence of the general practitioner deserves second place. The albu- 
 min is seldom abundant, and disappears as the temperature 
 becomes normal. 
 
 3. Albuminuria due to renal disease itself:— Far more com- 
 mon than has hitherto been recognized. Should be placed second 
 in the list of any specialist who does not see many acute febrile 
 diseases. The essential diagnostic features are, (a) increase in the 
 quantity of night urine compared with the day, (b) decrease in the 
 excretion of phosphoric acid, (o) presence of albumin in both day 
 and night urine, (d) presence of casts, especially when in abund- 
 ance, and of various kinds, (e) and presence of renal epithelium 
 which, C. Heitzmann holds, is alone diagnostic of nephritis. 
 
190 URINARY ANALYSIS. 
 
 4. Albuminuria of yarious chronic diseases:— In these cases 
 the kidneys are perhaps free from anatomical lesions, but the 
 patient is himself suffering from some malady or other. The 
 patients are weak, nervous, or ansemic. They often have diarrhoea. 
 To this class belong pallid, ill-nourished young persons subject to 
 various complaints as headache, nervousness, dyspepsia and diar- 
 rhoea. The albuminuria may be chronic, but is curable. In the 
 virriters experience it is fairly common among medical students, 
 and especially among those vs^ho are either pallid in appearance, 
 or nervous. 
 
 Many maladies are attended by presence of albumin in the 
 urine, such as epilepsy, tetanus, mental diseases, painful paroxys- 
 mal affections of the abdominal organs (various colics), incarcer- 
 ated hernia, etc, etc. 
 
 The writer has found albumin quite constantly in the urine of 
 epileptics, even when seminal fluid is absent, not only after par- 
 oxysms but persistently. 
 
 5. Albuminuria from circulatory disturbances as in cardiac 
 insufficiency from valvular lesions, degenerations of the heart, 
 coronary disease, impeded pulmonary circulation affecting the 
 right heart, compression of renal veins by tumors, the pregnant 
 uterus, etc. It is probable that febrile albuminuria is circulatory 
 to a certain extent, due to renal hypersemia produced by increased 
 or diminished blood pressure. 
 
 The albuminuria of various choleras and in the simpler forms of 
 intestinal catarrhs are, according to Simon, doubtless dependent 
 upon such causes. 
 
 6. Hsemic albuminuria: — Albuminuria due to various diseases 
 of the blood as in purpura, scurvy, leukaemia, pernicious anaemia, 
 syphilis, jaundice, diabetes, oxaluria, uriceemia; in poisoning by 
 mercury and lead; after inhalations of ether and chloroform. 
 
 7. Albuminuria from mechanical pressure or interference:— 
 An impeded outflow of urine from the kidneys due to ureteral 
 stenosis, impaction of calculus, pressure of tumor on ureter, etc. , 
 may be followed by albuminuria. 
 
 8. Toxic albuminuria:— Albuminuria may follow direct irri- 
 tant action of poisons on the renal parenchyma. Substances like 
 iodine, phosphorus, arsenic, lead, antimony, mineral acids, nitre, 
 carbolic acid, oil of turpentine, oantharides, mustard, salicylic 
 acid, tar, petroleum, alcohol, balsam of copaiba, cubebs, etc., etc. 
 
 In acute febrile diseases the albuminuria may be partly due to 
 the direct irritant action of bacterial poisons. 
 
 CLINICAL NOTES. 
 
 1. Alburainaria due to presence of pus^ blood, or 
 lencorrhoeal fluid in the urine: — By far the most 
 common of all seen in routine practice. In the 
 urine of nearly all married women a trace of albumin 
 may be found, or at any rate traces of a substance 
 ■which responds both to the author's heat and acetic 
 acid test and to the ferrocyanio test. Albumin is 
 
SiaNIFIOANCE OF ALBUMINURIA. 191 
 
 found in greater or less quantity in the urine of most 
 all elderly men, due to pus from bladder or prostatic 
 troubles, also in the urine of young men who have 
 had gonorrhoea, and its complications. 
 
 Note:— This form of albuminuria is known as false, or adventi- 
 tious, 
 
 2. The -writer has found by observation of the mor- 
 tality among 500 patients with albuminuria, which 
 have been carefully traced up to 1896, that, when the 
 night urine unaccountaSly equals the day in quantity, 
 the chances are very great that the patient has Bright's 
 disease ; and when the night urine habitually exceeds 
 the day in quantity, the chances are three to one that 
 Bright's disease is present. 
 
 Again it has been found that when the quantity of 
 phosphoric acid falls below 20 grains (1.3 gm.) per 
 diem, the chances are great that the albuminuria is of 
 renal origin. When the phosphoric acid falls below 
 15 grains (1 gm.) the probabilities of rapidly fatal 
 renal disease are greater than those of recovery. 
 
 Furthermore, by the author's heat and acetic acid 
 test albumin unaccountably found in hoth day and 
 night urine is likely to be renal in origin. 
 
 3. In typical cases of contracting kidney, as those 
 with retinitis, soon terminating fatally, albumin may, 
 however, either not be found at all in the morning 
 urine, voided on rising, or may be present in traces 
 only. In a case of this kind which the writer saw 
 with Dr. C. Gurnee Fellows, a few months before 
 death of the patient, albumin and oasts were abseat 
 from the urine voided on rising, but present in the 
 urine voided during the day. 
 
 4r. Albuminuria not of renal origin occurs according 
 to Dr. J. Hubley Schall of E"ew York, as follows : 
 In 34 cases (out of 510 recorded analyses) in neuras- 
 thenia, epilepsy, dilatation of the stomach, morphine 
 habit, obesity, malassimilation in children, and after 
 laparotomy. Bouchard finds it in obesity, gout, and 
 diabetes. Schall finds intermittent albuminuria in 
 physicians due to mental and physical excesses. Phos- 
 phaturia was marked in four cases and there was slight 
 
192 URINARY ANALYSIS. 
 
 excess of sulphates. Hawkins of London, reports a 
 case of a physician who had albuminuria 43 years, 
 without other symptoms of Bright's disease. Inter- 
 mittent albuminuria, not of renal origin, may be due 
 to elaboration of certain albuminoids by the liver, to 
 excitation of the cutaneous nerves, to venous stasis from 
 paralysis of the veins, as in morphine habit, to malaria, 
 neurotic family history, prolapsus uteri, and, tempo- 
 rarily, as a result of over-study or powerful emotions 
 in neurasthenic individuals. 
 
 5. According to Schall, diet seems to have no appre- 
 ciable effect on the albumin in the cases just mentioned. 
 Milk increases it, but kumyss has a tendency to im- 
 prove the general condition and, in two cases, de- 
 creased the albumin. [This would seem to suggest an 
 intestinal cause for the disturbance in view of the 
 action of kumyss on aromatic sulphates See Ethereal 
 Sulphates]. 
 
 6 Dr A. W Stirling, of Atlanta Georgia, exam- 
 ined 369 boys between the ages of 12 and 16 on one 
 of the large training ships near London. Nearly 21 
 per cent had albumin in their urine three hours after 
 getting out of bed in the morning. Of the boys who 
 played in a band 60 per cent had albuminuria Albu- 
 min increases with age. In 92 cases between 5 and 94 
 years of age, from 20 to 30 years the percentage was 
 only 10; from 50 to 60, 66.6 per cent; 60 to 70, 75 
 per cent; 70 to 80, 75 per cent; 80 to 90, 83 per cent. 
 
PROTEIDS IN THE URINE. 193 
 
 CHAPTER XXXII. 
 
 PROTEIDS CONTINUED. GLOBULIN, ALBUM03ES, [PEP- 
 
 TONE], HEMOGLOBIN, FIBRIN, HISTON, 
 
 NUCLBO-ALBUMIN. 
 
 The proteids other than serum-albumin found in 
 urine do not possess the clinical interest which attaches 
 itself to albumin. A summary of our knowledge in 
 regard to them may be given as follows : 
 
 SERUM-GLOBULIN. PARAGLOBULIN. 
 
 Detection in urine: 
 
 Method 1. — Render the urine alkaline with ammonium hydrate, 
 so as to precipitate phosphates. Let settle for an hour, filter, and 
 to the filtrate add its own volume of a saturated solution of 
 ammonium sulphate. If globulin be present, a flocculent, white 
 precipitate occurs A yellowish or pinkish precipitate of ammo- 
 nium urate may also form, but is distinguishable by its color. 
 
 Method 3. — Render the urine alkaline with sodium hydrate, 
 filter, and carefully pour the filtrate down the side of a test-tube 
 containing a saturated solution of sodium sulphate, so as to form 
 a layer above this. If serum-globulin is present a white ring wilt 
 appear at the zone of contact. Baton's test. 
 
 Method 3. — Dilute 30 to 50 c.o. of clear filtered urine with 10 
 times its volume of water. Add dilute acetic acid and pass into 
 the solution a stream of carbonic acid gas. A turbidity, eventu- 
 ally becoming a precipitate, indicates the presence of globulin. 
 
 Method 4. — Drop albuminous urine, drop by drop, into a large 
 volume of water. Each drop as it falls is followed by a milky 
 streak if globulin is present. 
 
 Method 5. — Daiber separates globulin from albumin as follows: 
 The urine is poured into a vessel and mixed with an excess of abso- 
 lute alcohol, which precipitates all the albuminous substances. 
 This mixture is left to settle for some hours, then filtered and 
 washed with lukewarm, distilled water, then the deposit, together 
 with the filter paper on which it is collected, is deposited in an- 
 other vessel and distilled water at 30° 0. (86° F.) is added and, 
 drop by drop, diluted acetic acid up to complete dissolution of the 
 albuminoid substances. After filtration a solution of 1 part sodium 
 carbonate in 4 parts distilled water is added, until the solution 
 becomes perfectly neutral or slightly alkaline, and then a 50 per 
 cent solution of ammonium sulphate, which precipitates the glob- 
 ulin in the form of a flaky, white deposit. This latter may be dis- 
 solved in a 1 per cent solution of sodium chloride from which it is 
 again precipitated when the liquid is treated. The globulin 
 25 
 
194 URINARY ANALYSIS. 
 
 remaining in the ammonium sulphate solution may be extracted 
 as a precipitate by boiling the liquid. 
 Quantitative determination:— 
 
 1. In a rough way, Paton's test (method 3 above) will show by 
 the size of the ring, whether much or little serum-globulin is 
 present. 
 
 3. Collect on a dried and weighed filter the precipitate, obtained 
 by method 1 above, with ammonium sulphate after it has settled 
 for about an hour. "Wash thoroughly with a solution of ammo- 
 nium sulphate, one half saturated, until a sample of the washings 
 treated with acetic acid and potassium ferrocyanide no longer 
 gives a precipitate. Wash with alcohol and with ether to remove 
 any fats present, and dry at 130' to 130' C. (348° to 366' F.) until 
 it ceases to lose weight. The difference in weight, between the 
 dry filter without precipitate and with it, represents the quantity 
 of serum-globulin in the volume of urine used. 
 
 3. The Esbach tube may be used, as already described in the 
 Chapter on Quantitative Determination of Albumin. 
 
 Clinical Significance: — 
 
 1. Globulin is not found in normal urine. 
 
 2. Its occurrence without serum-albumin is very 
 rare, if it occurs at all without it. 
 
 3. The amount of globulin compared with that of 
 albumin is increased in albuminuria due to digestive 
 disorders, in chronic catarrhal cystitis, in acute 
 nephritis and especially in lardaceous disease (amyloid 
 degeneration of the kidney), and in the albuminuria 
 of pregnancy in which the globulin may exceed the 
 albumin. 
 
 4 The amount of globulm, compared with that of 
 albumin, is decreased in chronic nephritis 
 Clinical Notes: — 
 
 1. The lower the state of nutrition of the renal 
 epithelium, the more likely it is that globulin in 
 increased amount will pass through it. (Boyd). 
 
 2. The proportion in which globulin is usually asso- 
 ciated with albumin varies, so that it is not possible to 
 determine the variety of renal disease by it. Even in 
 lardaceous disease it may not be in excess. (Boyd). 
 
 3. In the albummuria of heart disease the globulin 
 is usually more abundant than m chronic interstitial 
 nephritis. (Boyd.) 
 
 4. Senator holds that an increase of the globuhn- 
 albumin ratio is a fairly constant symptom of lardace- 
 ous disease, and is of some diagnostic importance 
 
PROTEIDS IN THE URINE. 195 
 
 ALBUMOSES. 
 
 The first products of the hydration of the native 
 proteids are known as proto and hetero-albumose. 
 The product most resembling peptone is called deutero- 
 albumose. It is probable that there are a large num- 
 ber of albumoses, varying slightly according to the 
 particular native albumin from which they are derived 
 and the antecedents leading to their formation. 
 
 The albumoses, or proteoses as they are also called, 
 are products of the digestive action of proteolytic fer- 
 ments on all forms of proteid matter ; they are the 
 most important of the primary bodies resulting from 
 gastric and pancreatic digestion. They are also pro- 
 duced by the growth of bacterial organisms and many 
 of the toxic substances resulting from the growth of 
 pathogenic" bacteria, are peculiar albumoses. It is 
 probable that the albumoses found in urine owe their 
 origin to pyogenic micro-organisms, as the staphylo- 
 coccus pyogenes aureus, although it is equally prob- 
 able that the pneumococcus and streptococcus pyogenes 
 are, likewise, active agents in the same direction. 
 There is no question about pus containing albumose. 
 
 Albumoses thus formed under such different condi- 
 tions, while resembling each other in their chemical 
 properties, are not possessed of identically the same 
 physiological properties. 
 
 Serum-albumin and globulin by hydration, as possi- 
 bly from pepsin, frequently present in the kidneys 
 and urine, may frequently be accompanied in the urine 
 by traces of albumose. 
 
 Reactions:— The reactions characteristic of albumose according 
 to Munk are as follows: 
 
 1. Not precipitated by heat. 
 
 2. Careful addition of cold nitric acid produces a precipitate 
 which dissolves with a yellow color on boiling, to reappear again 
 on cooling. 
 
 3. Addition of acetic acid and double the volume of a concen- 
 trated sodium chloride solution, gives in the cold a cloudiness or 
 precipitate which clears on boiling to reappear on cooling. 
 
 4. The ferrocyanic test produces a cloudiness or complete pre- 
 cipitation. 
 
 5. Saturation with neutral ammonium sulphate precipitates 
 tham. 
 
196 URINARY ANALYSIS. 
 
 6. Addition of tannic and acetic acids, or phospho-tungstic acid 
 solution, produces a cloudiness or precipitate. 
 
 7. The biuret reaction is obtained when albumoses are present, 
 after removal of coagulable proteids by boiling with a little acetic 
 acid. 
 
 Detection in urine:— The above reactions do not permit us to 
 recognize small amounts of albumoses in urine either because they 
 are not sufficiently delicate or else because they are characteristic 
 of other albumins. Since in nearly all cases albumin or mucin or 
 both are present, together with albumoses, the following methods 
 must be tried. 
 
 1. When the albumoses are present in considerable quantity, 
 they may be readily detected by filtering the hot solution de- 
 scribed in reaction 2 above. Albumoses separate out in the fil- 
 trate on cooling. Or the hot filtrate will respond to the biuret 
 test. Or, boiled with Millon's reagent, a red color is obtained. 
 
 8. If the biuret test is obtained after removal of coagulable 
 proteids; test the filtrate for albumoses by first, nitric acid and 
 heat (note order), second, acetic acid and potassium ferrocyanide; 
 third, saturation with common salt and addition of a drop or two 
 of nitric acid. In the latter test, the precipitate resulting is espe- 
 cially sensitive to heat, disappearing quickly on warming, reap- 
 pearing on cooling. 
 
 3. For the detection of one part albumose or peptone in 50,000 
 parts of urine, M. L. Harris of Chicago, recommends the following: 
 
 The urine must first be freed from the last trace of all coagul- 
 able albuminoids before testing for albumose or peptone. 
 
 This is accomplished as follows: 
 
 To 20 c.c. of acid urine* in a test-tube are added six or eight 
 drops of a saturated solution of salicyl-sulphonic acid (sulpho-sali- 
 cylic acid) in distilled water, and 1 gm. of lead chloride. Shake 
 well and boil about thirty seconds. Cool by shaking in running 
 water from the cold water tap. 
 
 Filter through ordinary clean, white, filter paper until the urine 
 is clear. Now add a few drops of a clear saturated solution of 
 sodium sulphate in distilled water, in order to precipitate what 
 lead is held in solution; raise to the boiling point, and cool under 
 the cold water tap as before. 
 
 Filter again until clear. We should now nave a perfectly clear 
 urine, absolutely free of every trace of coagulable albuminoids, 
 including nucleo-albumin, in which we may search for albumose 
 or peptone. This clear filtrate is divided into three equal portions 
 and placed in test tubes, one of which is kept for comparison, the 
 other two for further analysis . 
 
 To one of these are now added three or four drops of a saturated 
 solution of salicyl-sulphotungstate of sodium in distilled water.f 
 
 *The urine must be fresh. If it must stand several hours before It can 
 be examined, it should be preserved from the growth of bacteria In It by 
 the addition of some antiseptic, preferably a few drops of formalin, which 
 will keep it several days, and does nit interfere witti subsequent tests. 
 
 t Salicyl-sulphotungstate of sodium is prepared as follows: To a boiling 
 saturated solution of tungstate of sodium in distilled water salicyl-sul- 
 phonic (sulpho-salioy lie) acid is gradually added, under constant stirring, 
 until the solution no longer turns red litmus blue; or m other words until 
 the alkaline tung&tate of sodium is completely neutralized. Upon cooling 
 the salicyl-sulphotungstate of sodiam crystallizes. A solution is now made 
 of this in cold distilled water and Altered. A perfectly clear colorless fluid 
 results. 
 
PROTEIDS IN THE URINE. 197 
 
 If albumose or peptone be present a cloudiness will appear, 
 varying in degree according to the amount of these proteids 
 present. 
 
 As the amount of albumose present is often very minute, it may 
 be necessary to compare the tube with the control tube in order 
 to detect the cloudiness. 
 
 The cloudiness disappears entirely on gently heating the test- 
 tube, to reappear on cooling. 
 
 In the third tube the test is varied by allowing about 5 c.c. of a 
 dilute solution of the salicyl-sulphotungstate of sodium, made by 
 adding about ten drops of the strong solution to 5 c.c. of distilled 
 water, to flow very gently down the side of the tube so as to rest 
 on the urine as a separate layer. 
 
 This should be very carefully done that the line of contact will 
 be sharp and clear-cut, not diffuse. A cloudy line appears at the 
 point of contact of the two liquids, if albumose or peptone be 
 present. 
 
 When the amount present is very small, it may take two or 
 three minutes for the line to develop and show best, the two 
 liquids being clear, when held in front of a dark background. 
 
 As before stated, this test is extremely delicate, one part in 
 50,000 being readily detected; it is simple and can be easily applied 
 in fifteen to twenty minutes. 
 
 Owing to the delicacy of the reactions it is necessary that all 
 test-tubes be absolutely clean and the test solutions pei-f ectly clear, 
 otherwise a slight reaction may be easily overlooked. 
 
 The sodium sulphate solution must be added in slight excess in 
 order to insure precipitation of all the lead, as any lead left in 
 solution would be precipitated by the salicyl-sulphotungstate of 
 sodium, and thus interfere with the test. This would be easily 
 recognized, as the cloudiness in that case would not disappear on 
 heating, but become more marked. The boiling during the appli- 
 cation of the test, while not absolutely necessary, facilitates the 
 reactions, and should always be done, the cooling, after boiling 
 and before filtering, must never be omitted. 
 
 3. Salkowski'H modification of Hof meister's test for what was 
 formerly called peptone is as follows: Albumin is first removed by 
 boiling and filtering (and testing of filtrate with acetic acid and 
 potassium ferrocyanide to see that the urine is sufliciently acid; if 
 albumin is found in the filtrate, acidulate the urine, drop by drop 
 with 30 per cent acetic acid, boiling after each drop, filtering and 
 testing with ferrocyanide). Fifty c.c. of the albumin-free urine 
 are acidified in a beaker with 5 c.c. of hydrochloric acid and pre- 
 cipitated with phospho-tungstio acid, the mixture being heated 
 over the free flarae when, in a few minutes, the precipitate will form 
 a resinous mass, which closoli' adheres to the bottom of the vessel. 
 The supernatant fluid is decanted off, and the mass at the bottom, 
 which now becomes granular, washed twice witli distilled water, 
 which is likewise removed by decantation. The precipitate is 
 then covered with about 8 c.c. of distilled water and treated with 
 0.5 0.0. of a sodium hydrate solution (specific gravity 1.16), Upon 
 shaking the beaker the mass will dissolve, the solution assuming 
 a dark blue color. This is heated on the free flame until the blue 
 color turns to a dirty greeiiibh-yellow. Tlie solution ac the same 
 time becomes turbid but, at times, may turn yellow and remain 
 clear. This decoloration may be hastened by the further addition 
 of a few drops of sodium hydrate solution. As soon iis tins point 
 
198 UBINARY ANALYSIS. 
 
 has been reached, some of the liquid is placed in a test-tube, 
 allowed to cool and then treated with a very dilute solution of 
 copper sulphate (1 to 3 per cent), drop by drop, when, in the pres- 
 ence of what were formerly called peptones, the solution assumes 
 a bright red color, which may be brought out still more strongly 
 if the specimen is now filtered. With this method which occupies 
 only about five minutes, 0.015 gram of peptone pro 100 c.c. of 
 urine may be demonstrated without diflSculty. The quantity of 
 urine used is so small that mucin may be disregarded. 
 
 Clinical significance of albumosuria: — Modern 
 observers have agreed that true peptone has never as 
 yet been found in urine. The products heretofore 
 considered peptones by Hofmeister and others were 
 not peptones at all, but albumoses. Hence the term 
 albumosuria must be substituted for the term pepto- 
 nuria, and the entire subject re-investigated. Harris's 
 conclusions from many hundred examinations of urine 
 are as follows : 
 
 As the albumose is due to the digestive action of 
 invading microbes on the albumins of the fluids and 
 tissues of the body, its presence in the urine simply 
 indicates that we have to do with an infective condi- 
 tion in a state of more or less activity A word or 
 two, however, in regard to the question of so-called 
 peptonuria and the presence of suppuration within the 
 body. 
 
 The digesting or peptonizing power of the ordinary 
 pus microbes is usually quite active, and, whenever 
 suppuration is taking place anywhere within the hody. 
 albumose is always present in the urine. 
 
 This albumosuria, however, can only be held indica- 
 tive of suppuration when all other infective conditions 
 can be excluded. The question may be stated thus : 
 Given a patient with a probable circumscribed inflam- 
 matory condition in which the infective diseases can 
 be excluded, the presence of albumose in the urine is 
 quite positive evidence that the condition is inflamma- 
 tory, and that suppuration has tahen place. 
 
 1. True peptone being very rarely, if ever found in 
 the urine, the term peptonuria should be substituted 
 by the term albumosuria. 
 
 2. The albumoses are produced by the digestive or 
 
PROTEIDS IN THE URINE. 199 
 
 peptonizing action of microbes on the albumins of the 
 body. 
 
 3. This digestive action is one common to all forms 
 of living organisms. 
 
 4. The albumoses are produced in quantities much 
 in excess of what are appropriated by the microbes 
 for their growth and development. 
 
 5. The albumoses being readily diffusible the excess 
 in production is quickly absorbed by the blood, where 
 being toxic and thus acting as foreign bodies they are 
 eliminated by the kidneys and appear in the urine. 
 
 6. Albumosuria may be present in any condition or 
 disease due to the action of micro-organisms within 
 the bod}'-, and is thus simply indicative of an infective 
 condition. 
 
 According to Harris, products corresponding to the 
 class, albumose or proteose, are found in the following 
 conditions : 
 
 All kinds of suppurative conditions, acute and 
 chronic, such as pelvic abscesses, appendicular ab- 
 scesses, peritonitis, suppurative lymphadenitis, subcu- 
 taneous suppuration, osteomyelitis, etc., and in- the 
 following infective diseases which he has had an 
 opportunity to examine : 
 
 Acute croupous pneumonia, la grippe, phthisis pul- 
 monalis, diphtheria, typhoid fever, syphilis, one case 
 secondary stage, and one case of septicsemia of un- 
 known origin. 
 
 Albumosuria very frequently accompanies albumin- 
 uria, in which case the condition is called mixed albu- 
 minuria. Albumosuria may alternate with albumin- 
 uria and precede as well as follow the latter, so that 
 in any case in which albumoses are demonstrable in 
 the urine, the appearance of albumin should be 
 expected. 
 
 Dr. Sidney Martin found in a case of empyema that 
 the amount of albumose in the urine varied inversely 
 with the purulent discharge. 
 
 Drs. Dickinson and Fyffe noticed a complete disap- 
 pearance of albumose from the urine when pus was 
 evacuated. 
 
200 URINARY ANALYSIS. 
 
 Albumose is not found in the wrine in many cases 
 where there is a large collection of pus in the_ abdomen 
 or in an hepatic abscess ; doubtless due to thickness of 
 the membrane surrounding the pus and interfering 
 with its absorption. 
 
 In a case of acute bronchitis with pleural pain a 
 peculiar albumose has been found in the urine most 
 closely related to protomyosiuose (a primary product 
 of the digestion of myosin, the latter a native proteid 
 of the globulin class, whose coagulation in muscle after 
 death causes rigor mortis). 
 
 In most virulent and fatal cases of pneumonia, with 
 extensive hepatization of the lung, albumoses are 
 absent, and their appearance is possibly a favorable 
 indication in this disease. 
 
 In many cases, however, of suppuration in the chest 
 cavity with albumoses in the urine the noticeable 
 features are severe character during primary fever, 
 high mortality, and occasional serious sequelae apart 
 from development of empyema. 
 
 Finally it is said by Dr. Saundby (the Interna- 
 tional Annual for 1897) that albumose is found by 
 delicate tests in the urine of the perfectly healthy. 
 
 NOTES ON PEPTONURIA, FORMERLY SO-CALLED. 
 
 (a) According to Maixner peptone is always present in urine 
 when pus is forming, the peptone constituent of leucocytes being 
 absorbed into the circulation, whence it is eliminated by the 
 kidneys. 
 
 (6) Again, extensive destruction of the corpuscular elements of 
 the blood is a cause of peptonuria. Hence we find peptonuria in 
 (a) the declining stages of pneumonia, in purulent pleuritis, sup- 
 purating tuberculosis, chronic bronchial catarrh, psoas abscess, 
 purulent meningitis, acute articular rheumatism, and (6) acute 
 infectious diseases and toxic conditions of the blood: — phosphorus 
 poisoning, croupous pneumonia, typhoid-fever, small-pox, scarlet- 
 ferer, mumps, erysipelas, empyema, visceral cancer, especially of 
 liver and intestines, catarrhal jaundice and apoplexy. 
 
 (c) Peptonuria (used in the former sense of the word) is almost 
 invariably associated with cancer of the liver. 
 
 (d) Peptone is said to be a normal constituent of urine in the 
 puerperal state. 
 
 (e) Ulcerative changes in the lungs being excluded, peptonuria 
 is significant of epidemic cerebro-spinal meningitis as distin- 
 guished from tubercular. (Jaksch.) 
 
 (/) Peptonuria, it is said, distinguishes septicaemia from latent 
 disseminated sarcoma. 
 
PBOTEIDS IN THE UBINE. 201 
 
 (gr) Peptonuria occurs in ulceration of the intestines, and when 
 peptone is injected into the blood. 
 
 It seems quite probable that many of these condi- 
 tions of so-called peptoniiria may be found to be 
 accompanied by presence <>i albumose 
 
 HEMOGLOBIN. 
 
 Haemoglobin, the red pigment of the blood, contains 
 iron, and gives the proteid reaction. Hsemoglobin- 
 uria occurs whenever the liver is for any reason, unable 
 to transform into bilirubin all the blood-coloring mat- 
 ter set free by destruction of red blood corpuscles. 
 In such a case the urine contains few red corpuscles or 
 none at all, but the coloring matter of the blood may 
 be recognized by the following : 
 
 1. Tests : — Ouaiacum test: —Mix equal parts of old 
 oil of turpentine, which has become ozonized by 
 exposure to the air and light, and tincture of guaiacum 
 which has been kept in a dark-glass bottle, and then 
 float carefully on the surface of the mixture an equal 
 volume of the urine to be tested If haemoglobin be 
 present, a bluish-green ring, becoming a beautiful 
 blue, appears when the two liquids meet, and, on 
 shaking, the mixture becomes blue. If the urine con- 
 tain pus, the latter will color the guaiacum alone with- 
 out the turpentine and the blue color will disappear, 
 when heated lo the boiling point, which is not the 
 case when the blue color is due to haemoglobin. The 
 urine tested should be fresh or made faintly acid. 
 
 2. Examine the urine spectroscopically as follows : 
 Render feebly acid by means of acetic acid, and place 
 before the open slit of the spectroscope in a test-tabe, 
 breaker, or similar vessel, when the two bands of oxy- 
 hsemoglobin (arterial blood), will be seen either at 
 once, or upon carefully diluting with distilled water. 
 If ammonium sulphide be now added, the spectrum of 
 reduced hemoglobin (venous blood) will be obtained. 
 More commonly, however, the spectrum of methas- 
 moglobin (a mixture of albumin, hfemoglobin, and 
 hematin), is seen in cases of haaraoglobinuria. 
 
 26 
 
203 URINARY ANALYSIS. 
 
 3. Heller's test: — Boil urine to which solution of 
 potassium hydroxide has been previously added to pre- 
 cipitate phosphates. The latter will present^ a bright- 
 red color, if haemoglobin is present. If it is difficult 
 to appreciate the color, filter, and dissolve in acetic 
 acid, when, if blood pigment be present, the solution 
 becomes red, and the color vanishes gradually on 
 exposure to the air. This test is quite as delicate as 
 the guaiacum one. 
 
 Clinical Significance: — 
 
 1. Haemoglobinuria is most frequently observed 
 after poisoning by potassium chlorate, arseniuretted 
 hydrogen, sulphuretted hydrogen, creasote, pyrogallic 
 acid, naphthol, hydrochloric acid, tincture of iodine, 
 carbolic acid, carbon monoxide, phosphorus, and also 
 by morels (Helvella esculenta). 
 
 2. Hsemoglobinuria follows injection into the blood 
 of solvents of the corpuscles as glycerin, solutions 
 of bile-salts, or distilled water ; also after transfusion 
 of the blood of animals into man. 
 
 3. Hsemoglobinuria may occur in the course of any 
 one of the specific infectious diseases, as scarlatina, 
 icterus gravis, variola hemorrhagica, yellow fever, 
 typhoid, typhus, and probably syphilis. 
 
 4. It occurs in pyaemia, scurvy, fat-embolism, some 
 oases of jaundice, after extensive burns, occasionally 
 in Raynaud's disease, and in leukaemia complicated by 
 icterus. 
 
 5. From unknown causes as an epidemic among new 
 born. 
 
 6. In the so-called paroxysmal haemoglobinuria the 
 attacks are frequently preceded by chills and fever 
 closely simulating malarial fever. It must be, how- 
 ever, distinguished from malarial hmmaturia. Simon 
 and others doubt the existence of malarial haemoglobi- 
 nuria while malarial haematuria is well-known. 
 
 Note:— Hsemoglobinuria is the voiding of urine containing the 
 coloring matter of blood, but few or no corpuscles; haematuria is 
 the voiding of urine containing both the coloring matter and 
 corpuscles. 
 
PROTEIDS TN THE URINE. 203 
 
 FIBEIN. 
 
 Fibrin in the urine may be either in solution or coagulated. In 
 the former case coagula separate or standing, covering the bottom 
 of the glass or changing the entire bulk of urine into a gelatinous 
 looking mass. In the coagulated state, fibrin is observed at times 
 in the form of blood-coagula in hsematuria. 
 
 Test:^Wash the clots thoroughly with water and dissolve by 
 boiling in a 1 per cent solution of sodium hydrate or a five per 
 cent solution of hydrochloric acid. On cooling, the solution is 
 tested as for serum-albumin. 
 
 Significance: — Colorless coagula of fibrin are seen only in cases 
 of chyluria or in diphtheritic inflammation of the urinary pass- 
 ages. In most cases of hsematuria with clots, the fibrin comes 
 from the kidneys, although it is often associated with haemor- 
 rhages into the urinary tract, and is seen frequently in cases of 
 villous tumors of the bladder. 
 
 NUCLEO-ALBTIMIN. 
 
 The term nucleo-albumin is given to the body occas- 
 ionally present in urine, which is precipitated by acetic 
 acid, and is insoluble in excess of this reagent, though 
 soluble in nitric acid. It has been also called mucin, 
 a mucinous bodj'', and a globulin, and the term muci- 
 nuria has been applied to the condition in which urine 
 contains it. Much contradiction exists in regard to 
 the nature of it. 
 
 Tests: — The carefully filtered urine is treated in a 
 test-tube, drop by drop, with an excess of concentrated 
 acetic acid, when the occurrence of a turbidity will 
 indicate presence of nucleo-albumin. Remove albu- 
 min first by simple boiling, and dilute the urine if 
 necessary before testing. 
 
 Albumin and nucleo-albumin: — E. E. Smith's 
 method of distinguishing albumin from nucleo-albu- 
 min is as follows : About an inch of clear filtered 
 urine in a test-tube is heated to boiling, after which 
 two or three drops of ten per cent nitric acid are added. 
 If, after a few moments, there is no reaction for albu- 
 min, the contents of the tube are again boiled, and 
 about ten drops of the nitric acid further added, and 
 the tube set aside. 
 
 A quarter of an inch of a clear five per cent solu- 
 tion of potassium ferrocyanide is placed in a test-tube, 
 an equal volume of dilute acetic acid is added, and the 
 
204 URINARY ANALYSIS. 
 
 whole poured into an inch of clear urine in another 
 test-tube, the liquids being well mixed by pouring 
 from one tube to the other several times. The test- 
 tube is then set aside. A comparison tube is prepared 
 as follows : An inch of the urine, clarified at the 
 same time as that previously used, is placed in a test- 
 tube, and two drops of dilute acetic acid are added. 
 This tube is likewise set aside. 
 
 If both tests react positively, either a trace of true 
 albumin or of mucus is present, to decide which, it is 
 necessary to observe the comparison tube, in which, if 
 mucus is present, there will be some turbidity from the 
 partial separation of nucleo-albumin. If the urine in 
 the comparison tube remains ferfectly clear, and the 
 reactions with heat and with ferrocyanide present the 
 appearance characteristic of the albumin tests, then it 
 is safe to conclude that a mere trace of true albumin is 
 present, but the appearance of even a slight cloudi- 
 ness in the comparison tube is to be taken as evidence 
 of the presence of mucus, to which then the delicate 
 heat and the ferrocyanide tests are to be attributed. 
 Since the separation of nucleo-albumin in the com- 
 parison tube is only partial, it is evident that no com- 
 parison can be made between the intensity of this 
 reaction and the heat and the ferrocyanide reactions. 
 
 The appearance characteristic of the heat and nitric- 
 acid reaction with a trace of albumin is either the 
 formation of a few flakes of coagulated albumin or the 
 formation of a general turbidity which finally results 
 in a fine flocoulent separation, persisting when the 
 solution is hot. The addition of one-third to one- half 
 the volume of alcohol causes the flocculent appearance 
 to become more pronounced, while any separated 
 resinous substances, thymol, etc., pass into solution. 
 
 When traces of 1Jrue alMimin are present, the ferro- 
 cyanide test gives a finely flocculent appearance, while 
 with nucleo-albumin a mere opacity is more common. 
 
 Finally, it is to be remembered that albumin is to 
 be considered absent from a urine till its presence is 
 demonstrated by methods which admit of its distinc- 
 tion from mucus. Undoubtedly the safest basis for 
 
PROTEIDS IN THE URINE. 205 
 
 interpretation, except perhaps in the hand of the 
 skilled analyst, is the requirement of three reactions. 
 (The two above, and Heller's test) ignoring such traces 
 as fail to respond to Heller's test. 
 
 Bladder mucus does not contain mucin but a proteid 
 probably identical with nucleo-albumin, and only 
 incompletely precipitated by acetic acid. To remove 
 it from urine, C. E. Simon recommends treating the 
 urine with neutral acetate of lead, carefully avoiding. 
 excess. 
 
 Significance: — Sarzin and Senator were unable to 
 find nucleo-albumin in 200 urines from almost the 
 entire list of hospital diseases, 
 
 0. E. Simon insists that an elimination of it from 
 the blood through the kidneys does not exist, and that, 
 when found, it is due to improper methods and refer- 
 able to disintegrating epithelia. 
 
 Eeissner, Obermeyer, and others claim to find it in 
 various diseases. Eeissner says it may precede albu- 
 min and continue longer than the latter. Obermeyer 
 finds it in icteric urine and in that of other diseases. 
 
 Purdy says that in catarrhal inflammations of the 
 urinary passages, mucin is much increased and may 
 form ropy, tenacious strings, or settle in jelly-like 
 mass. 
 
 Some author's allude to njicleo-albumin from bile, and it is said 
 that the mucin of bile diflfers from that of mucous membrane in 
 not being completely separated by acetic acid. The reader is 
 referred to Eraser's Notes for January, 1895, and to Dr. Landon 
 Carter Gray's well-known paper in the American Journal of 
 Medical Sciences, for October, 1894, in which differential testing 
 is described. It should be noted, however, that clarification of the 
 urine by powdered French chalk, filtering through talc, etc., has 
 recently been said to remove albumin as well as mucin from the 
 urine. 
 
 Almost unsurmountable difficulties seem to beset us in the study 
 of the albuminoid of mucus, and great difference of opinion 
 exists as to its origin, nature, and properties. 
 
 HISTON. 
 
 This albuminous body was first found by Kossel in the red-blood 
 corpuscles of the goose. It has been shown to exist in the leuco- 
 cytes of human blood, in combination with the acid leuko-nuclein, 
 the so-called nucleo-histon of Lilienfeld. It has been found in 
 the urine in a case of leuksemia by Kolisch and Burion as follows; 
 Albumin being removed, the urine was precipitated with 94 per 
 
206 URINARY ANALYSIS. 
 
 cent alcohol, the precipitate washed with hot alcohol and dis- 
 solved in hoiling water. On cooling, the solution was acidified 
 with hydrochloric acid and let stand several hours, filtered, and 
 precipitated with ammonia. Histon, if present, is now thrown 
 down in addition to certain mineral constituents. . The precipitate 
 is collected on a small filter, and washed with ammoniacal water 
 until the washings no longer give the biuret reaction. It is then 
 dissolved in dilute acetic acid, and the solution tested with the 
 biuret test; if this yields a positive result, and, if coagulation 
 occurs, on application of heat, the coagulum being soluble in 
 mineral acids, the presence of histon may be inferred. 
 
SUOAB IN THE URINE. 807 
 
 CHAPTEE XXXIII. 
 
 SUGAR IN THE URINE. 
 
 Introductory. The sugar found in the urine in the 
 conditions known as glycosuria and diabetes mellitus 
 is not cane sugar, as many medical students think, but 
 a substance very like grape-sugar, which probably 
 occurs in minute quantities in normal urine, and in 
 greatly increased quantity in diabetes mellitus. 
 
 Synonyms: — Sugar : — German, Zuoher ; French, 
 Sucre. Grape-sugar, dextrose, glucose : — German, 
 TraubensucJcer ; Olyoose, Dextrose, Harmucker; 
 French, Olycose, Dextrose. 
 
 Chemical constitution: — OaHi206, a carbohydrate 
 containing 6 atoms of carbon ; is one of the class of 
 monosaccharides, group hexoses, sub-group aldoses. 
 
 Reactions: 
 
 1. Absorbs oxygen when heated with strong alkali solution, 
 giving rise to characteristic color and odor. 
 
 2. Heated with alkaline solution of cupric salts, reduces them 
 with (red) precipitate of cuprous oxide. 
 
 3. Reduces bismuth subnitrate to the metallic condition, when 
 heated with it in presence of an alkaline solution. 
 
 4. Warmed with a solution of phenylhydrazin hydrochloride in 
 water, to which a little sodium acetate is added, forms a yellow 
 crystalline precipitate of phenylgluoosazon. 
 
 5 Fermented by yeast splits into alcohol, carbon dioxide, and 
 a number of other substances. 
 
 6. Boiled in faintly alkaline solution colored blue by indigo 
 exhibits a beautiful color reaction. 
 
 7. Gives color reactions with various substances, as with alpha- 
 naphthol and thymol in presence of sulphuric acid. 
 
 The method of application of these tests will be shown further 
 on. 
 
 A. CLINICAL TEST FOE SUGAR IN URINE. 
 
 One of the most satisfactory and reliable tests for 
 sugar, if performed with care, is that made by use of 
 Professor "Walter Haines' test-liquid. 
 
 Haines' test-liquid made by the metric system: — 
 
 2 grams of copper sulphate, 15 c.c. of water and 
 
238 URINARY ANALYSIS. 
 
 glycerine each, and 150 c.o. of liquor potassae. Use 
 3.75 CO. of the liquid in making the test. 
 
 Haines' sugar-test liquid (American measures) : — 
 A permanent, transparent, dark-blue solution contain- 
 ing cupric sulphate, and potassic hydroxide, dissolved 
 in glycerine and water. It is made as follows:* 
 Make a perfect solution of cupric sulphate ("free from 
 iron,") 30 grains, in one-half fluidounce of distilled 
 water : to this add one-half fluidounce of pure glycer- 
 ine; mix thoroughly, and add liquor potassse five 
 fluidounces. Owing to the fact that even the best 
 grade of cupric sulphate contains traces of tha ferric 
 salt, Haines' test-liquid will usually deposit, on stand- 
 ing, a slight reddish sediment. To avoid mistakes it 
 is wise to let the solution settle before it is used and 
 then decant from the sediment. 
 
 Testing the quality of Haines' liquid : — In order 
 to be sure that the solution has been properly made, 
 proceed as follows : Take one fluidrachm of the liq- 
 uid (which quantity will fill a five-inch test-tube to the 
 depth of about one inch), and boil it in a clean test- 
 tube for thirty seconds or more. Now let it cool. 
 Neither before cooling nor after should it show any 
 change of color. Compare it after boiling with a 
 fluidrachm which has not been boiled. The two should 
 look exactl}^ ahke. Now take the second fluidrachm 
 which has not yet been boiled and bring it to the boil- 
 ing point, also in a clean test-tube. Add a drop of 
 normal urine to it and bring to the boiling point again ; 
 repeat the process adding drop by drop till eight drops 
 of urine have been added Then boil thirty seconds. 
 Now let cool and see that no change in the color takes 
 place, though perhaps whitish flocks of phosphates can 
 be seen, suspended in the liquid, which in a short 
 time settle, forming a dirty-white sediment in the tube. 
 Compare with a third fluidrachm of the liquid which 
 has not been boiled and the only difference seen will 
 be due to the deposit of phosphates. There should he 
 
 *See Writer's "Biseases of the Kidneys" 2 Ed. p. 369. 
 
SUGAR IN THE URINE. 309 
 
 no reddish, greenish, nor yellowish tinge to the liquid 
 after it is hailed with normal urine. 
 
 Detection of sugar with Haines' test-liquid: — 
 Having ascertained that the test-liquid is of good 
 quality take a fluidrachm of it, boil it, and add one 
 drop of the suspected urine to it. If much sugar is 
 present in the urine, a change at once takes place ; 
 the whole liquid becomes turbid and changes color to 
 yellow, reddish-yellow, or brown-yellow. If no such 
 change takes place after adding a drop of urine, add 
 another drop and bring to a boil again, and so on 
 until the turbidity and discoloration are seen ; urine 
 which contains but a moderate quantity of sugar may 
 require four drops to be added, boiling after each drop. 
 Or it may be necessary in case but a small quantity of 
 sugar be present, to add eight drops of urine, boiling 
 after each drop, and after the eight drops are added 
 to boil for thirty seconds, before any change be seen. 
 If, however, no change is seen even then, let the tube 
 cool, when, provided but a small quantity of sugar be 
 present, the liquid becomes greenish and turbid. 
 But if no sugar is present, the brilliant blue transpar- 
 ency is unaffected on cooling. 
 
 Precautions: 
 
 1. The test depends on the reduction of the cuprio sulphate to 
 cuprous oxide. Normal urine has a slight reducing power on the 
 solution in case of prolonged boiling, therefore do not boil too 
 long, thirty seconds being enough. 
 
 3. Do not forget to set the tube aside after the test has been 
 made and let it cool. A small quantity of sugar causes a turbidity 
 only on cooling. A dirty test-tube is more often responsible for 
 the change on cooling. 
 
 3. Do not use a sample of the liquid which contains a reddish 
 sediment, lest the latter appear in the test-tube, and be mistaken 
 for a reduction. Decant or filter the liquid before using, 
 
 4. Do not mistake the whitish flocks of phosphates precipitated 
 in all urine, by this test, for sugar. 
 
 5. Do not use a dirty test-tube, since Haines' liquid is exceed- 
 ingly sensitive to the presence of numerous organic substances. 
 The test-tube must be thoroughly cleaned beforehand. 
 
 6. Do not use more than 8 or 10 drops of urine; a larger quan- 
 tity of even normal urine may cause reduction, 
 
 7. Do not add any chemicals whatever before or after the test. 
 
 8. Use a clamp for holding the test-tube and not too great heat. 
 An alcohol lamp is better than a Bunsen burner, unless the latter 
 be turned low, 
 
 27 
 
310 URINARY ANALYSIS. 
 
 9. Point the mouth of the test-tube away from everybody when 
 boiling, as the liquid sometimes "bumps."' 
 
 NOTES. 
 
 ] . Haines' test-liquid is affected by numerous organic substances 
 even in small quantities: For example, 1 or 2 drops of 20 per cent 
 acetic acid make it turbid and green on cooling; 2 drops of carbolic 
 acid cause a precipitate, but the blue color is not entirely lost. 
 The writer has found that a number of substances, left as samples 
 by enterprising agents of various chemical manufacturers, either 
 give copious characteristic precipitates, as in case of Panopeptone, 
 Forbes' diastase, Sabalol balsam, or else a precipitate of some sort 
 not typical, as in the case of a "non -saccharine solution of the 
 hypophosphites." which gave a grayish- white precipitate, without 
 changing the blue of the liquid. Chloral hydrate, chloroform, and 
 sulfonal have a reducing power on the cupric tests, a fact which 
 must be borne in mind, when these substances are added to urine 
 for antiseptic purposes, or when taken internally. 
 
 8. The question then comes up as to the possibility of a reaction 
 with Haines' test, when such substances are taken internally. So 
 far as grape-sugar itself goes, the writer has proved in his own 
 case that copious ingestion of solutions rich in glucose fails to 
 render the urine saccharine, that is, no reaction with Haines' test 
 has been obtained. 
 
 3. On the other hand there are those persons who, though free 
 from diabetes, void, when taking strongly saccharine solutions, 
 glucose in the urine. The writer published in the Hdhnemannian 
 of 1892 his observations on the reaction with Haines' test of the 
 urine of a certain person, who was drinking freely of champagne, 
 rich in glucose. It is thought by v. Noorden that such a condi- 
 tion is significant of a tendency to diabetes, and he tests the urine 
 of his patients after administering 100 grams of grape-sugar to 
 them. 
 
 4. In consequence of the above the writer is in the habit, when 
 testmg urine for sugar, to specify that the patient shall eat freely 
 of saccharme articles and to test the urine of each micturition 
 separately. It has been found that the urine voided in the after- 
 noon, about 3 or 4 o'clock, is most likely to aflfect Haines' solution. 
 When a marked reaction occurs at this time, the writer subjects 
 the urine of this particular hour to fermentation so as to avoid 
 error from possible presence of various organic substances includ- 
 ing those of the urine, as glycurouic acid. 
 
 It goes without saying that all glasses used shall be rigorously 
 cleaned, before any conclusions as to presence of a trace of sugar 
 can be arrived at. 
 
 5. Some curious facts as to this afternoon reaction with Haines' 
 liquid have come under the writer's observation: One patient 
 would ma,nifest it in the urine voided after eating bananas: 
 another whenever he drank ordinary tap beer, but not when he 
 drank bottled imported beer. 
 
 \ .5?,?^'^®*?! cases where this doubtful reaction has been found 
 prohibition of saccharine articles of food together with reduction 
 in starchy foods has been followed by an improvement in the gen- 
 eral health of the patient anji disappearance of the reaction 
 
SUGAR IN THE URINE. 311 
 
 ADVANTAGES OF THE HAINBS' TEST-LIQUID. 
 
 1. The solution is stable being known to keep fifteen years when 
 properly made from pure materials. The writer keeps it in a 
 dark place. 
 
 3. By adding the urine, drop by drop, the chances of reduction 
 by the other substances than sugar are lessened. 
 
 3. An idea as to the amount of sugar present may be had 
 approximately as follows: — If one or two drops of urine give an 
 immediate yellow or red precipitate, sugar is abundant, 4 per cent 
 or more; if several drops are necessary to produce the yellow pre- 
 cipitate, sugar is moderately abundant; if eight drops of urine 
 are required before any change occurs, sugar is in small amount; 
 if no change occurs until after cooling mere traces are present. 
 It is understood, however, that the tube is not allowed to cool 
 while the urine is being added. 
 
218 URINARY ANALYSIS. 
 
 CHAPTEE XXXIV. 
 
 USUAL LIFE INSURANCE TESTS FOR SUGAB. 
 
 One of the most commonly used test solutions is 
 Fehling''s, whicli is made as follows : — (1) Dissolve 
 69.28 grams of pure reorystallized copper sulphate 
 in enough distilled water to mak« one liter ; (2) Dis- 
 solve 100 grams of sodium hydroxide, "by alcohol," 
 in sticks, in 500 c.c. of distilled water. Heat to boil- 
 ing, and add gradually 350 grams of pure reorystal- 
 lized Kochelle salt. Stir until all is dissolved. Allow 
 the solution to stand 24 hours in a covered vessel, then 
 filter through asbestos into a liter flask, and add water 
 to make 1 liter. Keep each of these solutions in a 
 separate bottle. There are several methods of apply- 
 ing the test : 
 
 Method I : — Mix equal parts of the two solutions 
 described above using about a fluidrachm.(4 c.c.) of 
 each-. Pour 4 c.c. (one fluidraohm) of the blue solu- 
 tion thus made into a test-tube and test its stability 
 by boiling. If no change occurs on boiling, add 3 or 
 4 drops of the urine to be tested and boil again. If 
 much sugar be present, after a short time there results 
 a dense, opaque, yellow color, and a yellow-red preci- 
 pitate soon settles to the bottom of the tube. In case 
 of no change of color with 3 or 4, drops, continue add- 
 ing urine until an amount equal to the amount of the 
 solution has been added ; that is, if the amount of 
 solution used is 4 c.c, add in all 4 c.c. of urine but 
 no more. If no precipitate or change occurs, sugar is 
 absent. 
 
 Method II. — Pour 4 c.c. of the solution into a 
 test-tube, and add an equal amount of water. Boil 
 and the solution must remain clear. Then add ^ c.c. 
 of urine and boil, when, if sugar is present in amount 
 greater than one-tenth of one per cent, the yellow 
 
SUGAR IN THE URINE. 218 
 
 color appears. If not, add more urine and boil again, 
 and so on until an equal amount of urine has been 
 added. 
 
 Method III : — Mix equal parts of the two solutions, 
 dilute with four times as much water, boil, add a 
 small amount of urine and warm, not boil. 
 
 PEECAUTIONS. 
 
 1. it is important not to mix the two solutions until just before 
 the test is made, as the blue liquid formed does not keep well. 
 
 3. Even when the solutions are kept separately, it is said that 
 the tartrate used is likely to decompose, raoemio acid being 
 formed, which reduces cupric salts. 
 
 3. A greenish flocculent precipitate always occuring in greater 
 or less quantity when the urine is added, is due to precipitated 
 phosphates. 
 
 4. A clear dark green solution sometimes formed, when the 
 urine is heated with Fehling's solution, is not significant of sugar, 
 but is due to partial reduction by normal constituents of the urine 
 as uric acid, kreatinin, etc. A colorless mixture is indicative of 
 the same partial reduction. Drugs taken internally may cause 
 the same reaction. 
 
 5. If, however, with this change of color a red precipitate takes 
 place, the urine must be tested with the bismuth test or by fer- 
 mentation. Occasionally uric acid is so abundant as not only to 
 discharge the color of the mixture, but also to cause precipitation 
 of the red oxide of copper, and hence cause doubt. 
 
 6. The same precautions in regard to cleansing the tubes are 
 necessary as in case of Haines' liquid. i 
 
 7. It is also advised to remove albumin before applying the test. 
 This is done by boiling and filtering. 
 
 8. Some companies recommend their examiners to neutralize 
 the urine before applying Fehling's test. 
 
 9. Morphine, tannin, sdlioylio acid, salol, cubebs, copaiba, rhu- 
 barb, senna, sulfonal and antipyrin reduce Fehling's solution. 
 Internal administration of chloral, camphor, etc, produce gly- 
 curonic acid in the urine, which affects Fehling's test. Glycosuric 
 acid gives a positive reaction, but is rare in urine. 
 
 10. When the quantity of sugar is small and there is a fear 
 that the reduction of Fehling's solution has resulted from uric 
 acid or from kreatinin, some advise to filter the urine first three 
 times through animal charcoal. If Pavy's ammoniated cupric 
 test is used instead of Fehling's, a larger quantity must be 
 employed and the urine added to the depth of two inches in the 
 tube. Boil the upper portion of the mixture, which loses its blue 
 color, if sugar be present. Fermentation over mercury is prob- 
 ably safest In such cases. 
 
 NOTES. 
 
 1. Fehling's solution made as above is used for quantitative 
 determinations. 
 
 2. Fehling's solution is said to detect even traces of sugar, and 
 to be more delicate than Trommer's test. 
 
214 URINARY ANALYSIS. 
 
 3. A very convenient arrangement for keeping the two solutions 
 separately, is described by J. H. Long as follows :— Two bottles, each 
 holding about 300 c.c, are fitted with perforated rubber stoppers. 
 Through the opening in each stopper the stem of a 2 c.c. pipette 
 with very short tip is passed, and left in such a position that, when 
 the bottles are half filled, the bulbs and stems to the mark will be 
 covered with the liquid. One bottle contains the standard copper 
 sulphate solution, the other the mixture of alkali and tartrate 
 solution. The rubber stoppers should be covered with vaseline so 
 that they will permit the pipette stems to slide easily in the per- 
 forations, and also close the bottles perfectly. When the stoppers 
 are inserted, the pipettes should stand full to the mark, ready for 
 use. 
 
 On withdrawing the stoppers with forefinger closing the pip- 
 ettes, exactly Sec. of each liquid can be taken out without delay, 
 and on mixing in a test-tube yield the Fehling solution, fresh 
 and ready for use, directly, or after dilution with distilled water, 
 as thought necessary. As the solutions are used the pipette stems 
 are pushed farther through the stoppers so as to leave the marks 
 always at the surface of the liquids. The solutions may be kept 
 in this manner for years, and their use is not attended with any 
 inconvenience. The open ends of the pipette stems should be 
 kept closed with small rubber caps, or a bit of soft parafiSn wax. 
 
 THE BISMUTH TEST. 
 
 The bismuth test is used for the reason that bismuth salts are 
 not reduced by uric acid. 
 
 Principle: — Bismuth oxide in alkaline solution is reduced by 
 glucose, a precipitate of lower oxides of bismuth taking place. 
 
 Method of Preparation: — Nylander's modifioatioo of Almen's 
 test is pi^pared by dissolving 4 grams (62 grains) of potassium 
 sodium tartrate in 100 grams of an 8 per cent solution of caustic 
 soda, warming the fluid and adding as much subnitrate of bis- 
 muth as will remain in solution, namely, about 2 grams Filter, 
 on cooling, and keep in a colored glass bottle. 
 
 Method of Application:— Add 1 c.c. of the bismuth solution to 
 11 of the urine and boil for a few minutes. If sugar is present, 
 the solution becomes first yellow, then yellowish-brown, and 
 lastly nearly black, due to formation of lower oxides of bismuth. 
 
 Chances for Error:^ 
 
 1. When abundance of albumin, pus, or blood is present, sul- 
 phide of bisruuth is precipitated, which is a black deposit similar 
 to that caused by presence of sug ir. 
 
 3. The reaction occurs in urines containing melanin or melano- 
 gen. 
 
 3. When the urine contains a large proportion of reducing sub- 
 stances without sugar, the reaction occurs; but uric acid and 
 kreatinin do not reduce the bismuth test. The substances which 
 reduce the bismuth oxide are glycuronic acid combinations, and 
 substances formed after use of kairin, rhubarb, eucalyptus tinc- 
 ture, large doses of quinine, turpentine, and other drugs. 
 
 4. Glyoosuric acid gives a blackish discoloration. 
 
 5. In the presence of but very little sugar the solution is not 
 black or dark brown but only deeper colored, and after some little 
 time we see merely a dark or black edge on the upper layer of the 
 phosphatic precipitate. 
 
SUGAR IN THE URINE. 315 
 
 6. After standing for a time it is natural tliat a black deposit 
 should be found in the tube, the supernatant liquid becoming 
 clearer but still colored. 
 
 7. It is said that urines containing less than 0.3 per cent of 
 sugar do not react with Nylander's test. 
 
 Since a small amount of albumin does not interfere with this 
 test, it is easier to boil the urine and filter it before applying the 
 bismuth teat than to use Brticke's test, which requires some little 
 time and skill for performing it. 
 
 In the writer's opinion the ouprio test and the bismuth tests are 
 all that are necessary for life insurance purposes. 
 
 THE FERMENTATION TEST. 
 
 This test may be used to confirm the bismuth test. It should 
 be performed as follows: — Fill three test-tubes each half full of 
 mercury. To the first add the urine to be tested, to the second 
 add water, and to the third add a 1 per cent solution of grape- 
 sugar. Into each of the tubes drop a piece of compressed yeast, 
 of the same size in each. Cover the mouth of each tube in turn 
 with the thumb, invert over a small vessel of mercury, and set the 
 whole aside for several hours. If sugar is present, the urine in 
 the first tube should be displaced by the carbonic acid gas formed 
 to a greater extent than in the second. If the yeast is active, the 
 displacement in the third tube should be more noticeable than 
 that in the second. 
 
 Chances for Error: 
 
 1. The urine, if not acid, should be made faintly acid by addi- 
 tion of a little tartaric acid. 
 
 2. Less than one per cent of sugar may not be detected, since 
 the carbonic acid gas formed, is somewhat soluble in the urine. 
 
 fiemarks: 
 
 The fermentation method may be used in conjijnction with the 
 bismuth test as follows: — When the bismuth test gives only a 
 faint reduction, treat the acid urine with yeast whose activity has 
 been tested by the solution known to contain sugar, and allow it 
 to stand 84 to 48 hours in a warm place. Again test with the bis- 
 muth test, and if the reaction now gives negative results, sugar 
 was previously present. But if the reaction continues to give 
 positive results, other reducing bodies than sugar or perhaps sugar 
 with other reducing bodies is present. 
 
 CHEMICAL EXERCISE XV, 
 
 A. 1. Make up a four per cent solution of glucose or 
 grape-sugar and note the change which takes place 
 when a single drop of this solution is added to 4 c.c. 
 (one fluidrachm) of Haines' solution heated to boiling. 
 
 2. Dilute the glucose solution with equal parts 
 water, and add several drops successively to the 
 Haines' solution heated to boiling. 
 
 3. Dilute the glucose solution with two and four 
 parts of water respectively, and add 8 drops of each 
 
816 URINARY ANALYSIS. 
 
 to the boiling Haines' solution. If no change occurs 
 in either case, let the tube cool and note change if any 
 
 4. Dilute the glucose solution until no change occurs 
 until after the tube cools. Note carefully the char- 
 acter of the change. 
 
 B. 1. For several successive exercises test urines 
 containing different quantities of sugar with Haines' 
 test. 
 
 2. Kepeat the operation with Fehling's test. 
 
 8. Eepeat the operation with the bismuth test. 
 
SUGAR IN THE URINE. 817 
 
 CHAPTER XXXV. 
 
 DELICATE TESTS FOR SUGAR. 
 
 Foe clinical purposes the tests already given viz. 
 preferably by Haines' test-liquid, or Fehling's, Almen's 
 (Nylander's), and the fermentation method are all 
 sufficient. The remaining tests are, however, exceed- 
 ingly delicate and hence will be included : — 
 
 trommer's test. 
 
 To about one fluidrachm (4 c.c.) of urine in a test-tube add 
 enough cupric sulphate solution to make the urine light-green in 
 color; then add an equal volume of liquor potassss. A blue pre- 
 cipitate of hydrated cupric protoxide occurs at first, which, on 
 shaking the tube, dissolves, forming a beautiful, clear, blue solu- 
 tion. If allowed to stand half an hour or so, reduction gradually 
 takes place, especially if much sugar be present, a yellow or yel- 
 lowish-red precipitate of suboxide of copper being formed. If 
 instead of letting stand half an hour gentle heat'be applied, the 
 test becomes more delicate and reduction occurs at once. The 
 objections to the test are that, if it be not boiled it is not very 
 sensitive, and when it is boiled, especially if long, other sub- 
 stances than sugar may reduce the copper salt. (See notes in next 
 Chapter). 
 
 MODIFICATIONS OF FEELING'S TEST. 
 
 Boll 8 CO. of urine with 5 c.c. of cupric sulphate solution of the 
 strength used in Fehling's test. Let cool and add 1 to 2 c.c. of a 
 saturated sodium acetate solution. Filter, add 5 c.c. of alkaline 
 tartrate of the usual strength, and boil 15 to 30 seconds. The test, 
 when hot, shows as little as one-quarter of one per cent of sugar 
 and less still on cooling. (Allen's test). 
 
 Another modification is to remove alkaloids by filtering through 
 animal charcoal, make alkaline with mercuramin, and then any 
 reduction of an alkaline copper tartrate solution is due to dextrose. 
 
 THE PHENTLHYDRAZIN TEST. 
 
 Phenylhydrazin, C.Hs.NH — NHj is a derivative of hydrazin, 
 NHj — NHj, formed by the replacement of a hydrogen atom by 
 the aromatic radical phenyl, C«Ht. Hydrazin or diamin, NjH4, 
 is a substance in many ways resembliug ammonia gas. Phenyl- 
 hydrazin itself is a colorless oil of powerful reducing properties 
 which forms crystallizable salts with acids, of which the hydro- 
 chloride is used as a test for small quantities of sugar. 
 
218 
 
 URINARY ANALYSIS. 
 
 Principle:— Phenylhydrazin has the property of forming with 
 grape-sugar a highly characteristic crystalline compouad known 
 as phenylgluco'?azon. ... 
 
 Methods of application:— There is difference of opinion as to 
 how the phenylhydrazin test should be applied; one method is as 
 follows: Treat 6 or 8 c.c. of urine with two points of-a-kmfeful 
 of phenyl hydrazin hydrochlorate and 3 parts of acetate of sodium 
 and warm until the salts have been dissolved, a little water being 
 added if necessary. Plunge the tube in boiling water for twenty 
 to thirty minutes, and then suddenly plunge into cold water. If 
 sugar be present in moderate amounts, a bright yellow crystalline 
 deposit will at once be thrown down, partly adhering to the sides 
 of the tube. Traces of sugar will be revealed by the presence of 
 crystals of phenyl glucosazon, very delicate, bright yellow needles, 
 singly or in bundles and sheaves, insoluble in water. Fig. 43. 
 
 Fig. 43. Crystals of phenylglucosazoa. 
 
 Jolles uses the test by boiling the test-tube in a water bath for 
 one hour, and then letting stand for 13 to 14 hours. The method 
 by use of the water bath is generally given as follows: 
 
 To 25 c.c. (fii fluidrachms) of the urine to be tested add 1 gram 
 (15 grains) of phenylhydrazin hydrochloride, 0.75 gram (11 grains) 
 of sodium acetate and 10 c.c. (3f fluidrachms) of distilled water. 
 Place the whole, contained for convenience in a porcelain capsule, 
 on the water bath, and warm for at least an hour. Remove, let 
 cool, and if sugar be present, even in minute quantity, a yellow 
 precipitate settles out, which under the microscope is seen to con- 
 sist of minute needles, generally arranged in rosettes, which melt 
 at 304° C. (399° F.). (See notes below). 
 
 Precautions: 
 
 1. The mixture must not be warmed for less than an hour, or a 
 glycuronic-acid crystalline compound is formed, melting at 150' 
 C. (803° F.). {See notes below). 
 
 3. Phenylhydrazin is poisonous and, moreover, the hydro- 
 chloride causes a troublesome eczema, so that caution must be 
 observed not to get it on the hands. 
 
 3. To determine the melting point of the crystals pour off the 
 supernatant liquid, add water, let settle, pour off again and repeat 
 
SUGAR IN THE URINE. 219 
 
 this process several times. Transfer the crystals to a watch-glass, 
 dry them over sulphuric acid in a desiccator, place a small 
 amount in a thin, narrow tube, fasten the latter to a thermometer 
 in such a way that the substance in the bottom of the tube is 
 near the bulb of the thermometer, then immerse both in a vessel 
 containing oil and gradually heat until the crystals begin to fuse, 
 noting the temperature indicated by the thermometer. 
 
 Remarks: — This test is applicable in the presence of albumin 
 and gives no reaction with urates, uric acid, kreatin, or kreatinin; 
 nor with oxybutyria acid, urochloralic acid, uroxanthic acid, tan- 
 nin, morphine, salicylic acid, or carbolic acid. Glycuronio acid 
 and pentose are the only things likely to cause confusion. The 
 microscopic appearance of the osazon from maltose is different 
 from that of the glucose and the melting point of the latter is 
 higher. 
 
 THE INDIGO-CABMINE TEST. 
 
 This test, known as Mulder's may be employed for the detection 
 of small quantities of sugar but apparently possesses no advant- 
 ages over the preceding. 
 
 Preparation:— Make a solution of 0.2 per cent of sodium-indigo 
 sulphate in acidulated distilled water, and a 25 per cent solution 
 of crystallized sodium carbonate in distilled water. Add 5 drops 
 of the indigo solution to 3.75 c.c. (one fluidrachm) of the sodium 
 carbonate' solution and heat to boiling. A green color results. 
 
 Method of application:— Add 10 drops of the urine to the above 
 prepared green solution, heat again to boiling, and keep the fluid 
 as near boiling as possible without ebullition, by holding the tube 
 in the flame, withdrawing and replacing at short intervals. If sugar 
 is present, the color will pass from green to violet, purple, red and 
 finally straw-color without further change, the latter indicating 
 presence of sugar. Urine containing 0.01 per cent of sugar will 
 change the test to a red, while 0.02 per cent changes it slowly to 
 the straw-color. On shaking the tube to admit oxygen of the air 
 and cooling, the colors will return in the inverse order to that by 
 which they appeared. The greater the proportion of BUgar the 
 more rapid the change to yellow. 
 
 DELICACY OP THE TESTS. 
 
 Trommer's test - 0.0025 per cent. 
 
 Fehling's test. - 0.0008 ;; ;^' 
 
 Nylander's test 0.025 
 
 Fermentation test - 0.1-0.05 percent. 
 
 Phenvlhydrazin test 0.05 0.001" " 
 
 Polarimetric test - 0.025-0.05 •' " 
 
 It must be remembered, however, that testimony as to the 
 delicacy of these tests in urine is conflicting, some saying, for 
 example, that Nylander's test does not reveal less than 0. 3 per cent 
 of sugar. Williamson says that the phsnylhydrazin test gives a 
 reaction in dilute urine with 0.015 per cent of sugar, and that it 
 is too delicate for prolonged boiling in the water bath. 
 
230 VBli^ABY ANALYSIS. 
 
 CHAPTER XXXVI. 
 
 QUANTITATIVE DETERMINATION OF SUGAR. 
 
 The easiest method of determining the quantity 
 of sugar is that by fermentation with yeast, but it 
 requires 24 hours' time for its performance. Eesults 
 are approximate, but, if certain precautions be taken, 
 sufficiently accurate for clinical purposes. 
 
 Quantitative fermentation method* : — Collect the 
 whole urine for 24 hours, warm some of it to 77° F. 
 (25° C.) and take the specific gravity with an urino- 
 meter, standardized at 77° F. Make a note of the 
 specific gravity obtained. Measure off 120 c.c. (4 
 fluidounces) of the urine into a bottle, add half a cake 
 of compressed yeast, crumbled into small bits, cork 
 loosely, or with a nicked cork, and set aside in a warm 
 place for 24 hours. Filter, warm or cool to 77° F. 
 (25° C.) again, take specific gravity again. The 
 specific gravity is now less than before and each 
 degree lost indicates one grain of sugar per fluidounce 
 of urine, or about 2. 1 grams to the liter of urine. 
 Hence if the specific gravity before fermentation was 
 1040 and after fermentation was 1020, this urine con- 
 tains 20 grains to the ounce of urine or 42 grams to 
 the liter. 
 
 Calculation of results: — The percentage of sugar 
 in the urine may be calculated by multiplying degrees 
 of specific gravity lost, by 0.23. Thus in the above 
 example 20 times 0.23 equals 4.6 per cent, approxim- 
 ately. 
 
 Example for practice : — Urine of 24 hours measures 
 900 c.c. Specific gravity before fermentation 1030, 
 after fermentation 1025. Required percentage of 
 sugar and total sugar voided in 24 hours. Solution: — 
 1030 minus 1025 equals 5, hence the urine contains 5 
 grains of sugar per ounce, or 10.5 grams per liter. 
 
 * The writer greatly prefers this method to all those given on 
 pp. 231-225. 
 
SUGAR IN THE URINE. 331 
 
 Degrees lost, 5, multiplied by 0.23 equals 1.15 per 
 cent of sugar present. Total urine 900 c.c, or 30 
 fluidounces, therefore total sugar equals 900 times 10.5 
 divided by 1,000, or 9.45 grams in 24 hours; or 30 
 times 5 equals 150 grains in 24 hours. 
 
 Precautions necessai'y: — Do not set the urine 
 to be fermented in a hot place or it will evaporate 
 measurably in 24 hours, and an error, due to conden- 
 sation of volume, vrill affect the specific gravity. A 
 Jaksch fermentation flask is best for this purpose. 
 
 NOTES. 
 
 The process may be hastened, if to every 100 c.c. of 
 urine 2 grammes of sodium potassium tartrate and 2 
 grammes of sodium dihydrophosphate be added with 10 
 grammes of compressed yeast, and the mixture allowed 
 to stand at a temperature of from 30° to 34° C. Add 
 0.022 to the specific gravity taken before fermentation 
 to allow for addition of salts to the fermented sample. 
 
 Qnantitatlre determination by cupric solutions:— Fehling's 
 teat-liquid may be used as follows: — Measure off 10 c.c. of Fehling's 
 solution in a glass flask and dilute with 40 o.o. water. Dilute the • 
 urine with ten parts of water, unless the quantity of sugar is very 
 small when five are to be used. Into the boiling Feliling's solu- 
 tion add the diluted urine from a burette, \ c.c. at a time, until 
 the solution is almost colorless, then add, drop by drop, until 
 decolorization is complete. The degree of dilution of the urine 
 multiplied by 5, and the result divided by the number of c.c. of 
 diluted urine employed, will then indicate the per cent of sugar. 
 
 Cause's modification of this process is to dilute 10 c.c. of Feh- 
 ling's solution with 30 c.c. of distilled water, and treat with 4 c.c. 
 of a 1 to 30 solution of potassium ferrocyauide. While boiling, 
 the diluted urine is now added, drop by drop, until the blue color 
 has entirely disappeared, a precipitate not appearing at all with 
 this method. 
 
 The objections to this method are first, the great care necessary 
 in preparing Fehling's solution, and second the difiiculty of deter- 
 mining the end reaction. It should be used only by experts. 
 
 Purdy uses a solution and method as follows: — Cupric sulphate 
 (C. P.) 4.743 grams, potassium hydroxide, (C. P.) 23.50 grams, 
 strong ammonia water (8p. Gr. 0.9) 450 c.c, glycerin (C. P.) 38 
 CO., distilled water to make 1,000 c.c. The cupric sulphate and 
 glycerin are dissolved in 200 c.c. of water with aid of gentle heat. 
 The potassium hydroxide is dissolved in another 200 c.c, and the 
 two solutions are mixed. "When cold the ammonia water is 
 added, and the whole diluted to one liter; 35 c.c. of the solution 
 are measured into a flask of 300 c.c capacity, diluted with about 
 3 volumes of distilled water, and the whole thoroughly boiled. A 
 graduated burette of 30 c.c. capacity is filled to the zero-mark 
 
322 URINARY ANALYSIS. 
 
 with the urine to be tested, and the urine slowly discharged into 
 the boiling solution, drop by drop, until the blue color begins to 
 fade; then still more slowly, three to five seconds elapsing after 
 each drop, until the blue color completely disappears, and leaves 
 the test solution perfectly transparent and colorless. If 2 c.c. 
 of urine reduce 35 c.c. of the solution, 1 per cent of sugar is pres- 
 ent; if 1 c.c. of urine, 3 per cent; | c.c, 3 per cent; i c.c. 4 per 
 cent; J c.c. 8 per cent 
 Carwardine's Saccharimeter: — By means of this apparatus 
 
 Fia. 44. Carwardine's Saccharimeter. 
 
 (Pig. 44) the percentage of sugar can be determined, it is said, at 
 the bedside without calculations as follows: 
 
 A. 1 — Fill measure to " F" with Fehling's solution. 
 3. — Dilute by adding water to ' D F. 
 
 3. — Pour this into test-tube. 
 
 B. 1.— Fill burette to " XT" with urine. 
 3.— Dilute by adding water to ' D U.' 
 3.— Mix. 
 
 To estimate: — Boil A, and whilst boiling gently, add B as in 
 figure. When blue color has gone quite from A, hold B upright, 
 and read off percentage of sugar. 
 
 Picric acid determination:— Dr. Johnson of England uses a 
 method by which the sugar in the urine reduces picric acid and 
 the color produced when compared with that of a standard solu- 
 tion of ferric acetate indicates the percentage of sugar present. 
 The apparatus, reagents, and directions for use can be obtained of 
 MuUer & Co., 405 W. 59th St., New York, who are also agents 
 for Carwardine's Saccharimeter. 
 
 Polarimetric method:— The saccharimeter of Soleil-Ventzke 
 (Fig. 45) is convenient for determining sugar in urine. It is con- 
 structed in such a way that, if a solution of glucose be employed, 
 every entire line of division on the scale will indicate 1 per cent 
 of sugar. In every case the filtered urine should be free from 
 albumin, and if markedly colored, previously treated with neu- 
 tral acetate of lead in substance and filtered. If it be desired to 
 demonstrate the presence of sugar only, the compensators are first 
 brought to the zero position. If now, upon the interposition of 
 
sua AH IN THE URINE. 
 
 233 
 
 Fig. 45. Soleil-Ventzke Saccharimeter. 
 
 the tube filled with urine, a difference in the color of the two 
 halves of the field of vision be noted, the presence of an optically 
 active substance in the urine may be assumed and, if at the same 
 time the deviation be to the right, the presence of glucose is highly 
 probable. 
 
 Ultzmann's polarizing saccharimeter has advantag^es in that 
 it may be adjusted to a microscope stand. The arc or fixed scale 
 is so divided that one division of it represents 1 per cent of grape- 
 sugar at 20° 0. Results are uncertain, according to Purdy, when 
 the quantity of sugar is less than 1 per cent. 
 
 Maltose is a source of error in the polarimetric test, so that this 
 substance must be tested for by the phenylhydrazin test before- 
 hand. Large quantities of B-oxybutyric acid may neutralize or 
 overcome any rotation to the right due to glucose. In such cases 
 the fermented urine will turn the plane of polarization still more 
 strongly to the left, indicating the presence of a dextro-rotatory 
 substance, in all probability glucose. 
 
 Williamson's Method:— A test-tube of ordinary size is filled for 
 about half an inch with powdered phenylhydrazin hydrochloride; 
 powdered sodium acetate is added for another half inch. The 
 test-tube is next half filled with urine and boiled over a spirit 
 lamp. By shaking, the salts soon dissolve, and after the liquid has 
 reached the boiling point the boiling is continued for two minutes. 
 The tube is then allowed to stand and is finally examined for 
 sugar, which is indicated by a yellowish deposit of needle-shaped 
 crystals at the bottom of the tube. A urine which gives no reac- 
 tion may be declared quite free from sugar for all practical 
 purposes. 
 
 Wliitney's Tolumetric method: — F. Waldo Whitney of New 
 York uses a solution and method as follows; 
 
 The formula of the standard solution (parts by weight) is: 
 
 QBAMMES. 
 
 Ammonil Salphatia (C. P.) 1.2'38 
 
 Cnpri Salphitis (0. P.) ''•5587 
 
 Potaesii Hydroxid. (C. P ) - - „1^ l^S 
 
 AgnsB Ammon. (8p. gr. O.bO) 812.2222 
 
 eiycerini (C P.) 6U. 
 
 Aqnee (deec.) QS. 
 
224 
 
 URINARY ANALYSIS. 
 
 One cubic centimeter of the reagent is the equivalent of: 
 
 Cnpro-diammoniam Sniphate (NjHeCnlSO* 0.03S32 
 
 Cnpric Hydroxide, (^nOHjO - 0'"'6J 
 
 Grape Sngar, anhydronB, C'eHijOa U.OOSiB 
 
 The sulphates of ammonium and copper are chemically com- 
 bined as a double salt. It is best prepared for this reagent by 
 adding chemically pure ammonium hydrate to a solution of cupric 
 sulphate; a bluish precipitate falls, which redissolves in excess of 
 the alkali, to form a deep blue solution. Strong alcohol floated 
 on the surface of the solution separates long right rhombic prisms, 
 which are very soluble in water; this solution constitutes aqua 
 sapphirina. (Witthaus). The crystals should be dried on bibulous 
 paper in vacuo and used immediately, for if they are exposed to 
 the air they part with their ammonia and are converted into a 
 mixture of basic sulphates. In Fehling's, Pavy's and Purdy's 
 solutions the solution of ouprio sulphate is added to the solution 
 of caustic potash, which forms cupric hydroxide. If added to the 
 ammonia, it throws down the cupric hydroxide unless added to 
 excess, yielding a deep purplish-blue solution that will only keep 
 a longer or shorter period, according to the purity of chemicals 
 used and care employed. A permanent reagent can only be pre- 
 pared by chemical combination of these salts before adding to the 
 caustic potash solution. 
 
 The official potassium hydroxide contains (other than fifteen to 
 twenty-eight per cent of water), from five to ten per cent of im- 
 purities—viz., oxide of iron, chloride, sulphate, and carbonate of 
 potassium, silica, lime, and alumina— and should be purified by 
 the alcohol process. Digest the caustic potash in alcohol, which 
 only takes up the alkaline hydrate, decant the solution from the 
 precipitate, evaporate to dryness, and fuse the dry mass obtained. 
 
 Prepare the reagent with the chemicals as described, and add 
 sufficient distilled water, so that 3.696 cubic centimeters (one 
 drachm) are decolorized by 0.00526 gramme (one thirtieth of a 
 grain) of anhydrous grape sugar.* 
 
 The following tables will give the amounts of sugar in analytical 
 testing: 
 
 to KEDUOED BY 
 
 It contains to the ocnoe, 
 
 Pkeoentaqe. 
 
 1 miDloi. 
 
 16. gra'ns or more. 
 
 3.33 
 
 2 mlDims. 
 
 8. graiQb. 
 
 1.67 
 
 3 
 
 5.83 
 
 1.11 
 
 4 '• 
 
 4. 
 
 0.83 
 
 5 " 
 
 3.20 " 
 
 0.67 
 
 6 " 
 
 2.67 " 
 
 0..'i6 
 
 7 " 
 
 2.29 " 
 
 0.48 
 
 8 " 
 
 2. 
 
 0.42 
 
 9 " 
 
 1.78 grain. 
 
 0.37 
 
 10 " 
 
 1.60 
 
 0.33 
 
 *PhyeiciaQB caa procnre the reagent, accnratelr compoanded as described, 
 from the Lewis Chemical Company, No. 1300 Broadway, New York. 
 
SUGAR IN THE URINE. 235 
 
 The Method of Procedure:— Heat one drachm of the reagent in a 
 test-tube to boiling; add the urine slowly, drop by drop, until the 
 blue color begins to fade; then more slowly, boiling three to five 
 seconds after each drop, until the reagent be perfectly colorless, 
 like water, or until ten drops only are added. 
 
 It will be noted after reduction that the reagent, on cooling, 
 resumes the blue color again. This change is due to the absorp- 
 tion of oxygen from the atmosphere, changing the reduced sub- 
 oxide held in solution to the blue protoxide again. This should 
 not be mistaken for imperfect reduction or defect in the reagent. 
 The change takes place quickly by sha;king the tube, and the 
 reduction can be repeated, if done immediately, before the evap- 
 oration of the ammonia by the addition of the saccharine urine as 
 before, though not with the same degree of accuracy. 
 
 If albumin is present or a large amount of coloring matter, 
 more or less of a yellow tint will be noticed. 
 
 In samples of urine loaded with sugar, dilution with water is 
 necessary, for example, if one niinim of undiluted urine reduces 
 the reagent there is no telling how great a percentage of sugar 
 above 3.33 is present. Therefore, dilute the urine with, say, four 
 paris of water and multiply the amount found by the table by the 
 amount of dilution. That is if three minims of urine diluted 
 with four parts of water reduce the reagent then 5.33 (see table), 
 multiplied by 6 (number of volumes of urine plus water, or 1 + 4) 
 equals 36.65 grains per ounce. To find percentage multiply 1.11 
 (table) by 5, equals 5.55 per cent. 
 
 Dilution also serves to yield more accurate results, for example, 
 if 7 minims of undiluted urine reduce the reagent the urine may 
 contain anywhere from 3.39 to 3.67 grains per ounce. More pre- 
 cise figures may be obtained by diluting the urine, say, with one 
 part water, when, if 14 minims of this diluted urine are necessary 
 then the undiluted urine contains 3.29 grains to the ounce; 18 
 minims, 3.46 grains; dUution with 8 parts water would show 3.39, 
 2.43, and 3.54 grains. 
 
 To determine small amounts of sugar add lead acetate to the 
 urine in proportions of one-third of a grain for each degree of 
 specific gravity above 1,000 up to 1,034, if pale, or 1,030 if high- 
 colored; the lead salt precipitates all albumin, phosphates, sul- 
 phates, chlorides, and coloring matter, but does not affect the dex- 
 trose; filter until perfectly transparent and colorless, and examine. 
 This treatment should be given all dense urine loaded with uric 
 acid, urates, and abnormal coloring matters, even when less than 
 ten minims are required, if any doubt exists in the mind of the 
 examiner about the reduetion of the reagent. 
 
 Any shade of blue or green remaining in the reagent does not 
 indicate sugar. The reduction with urine, thus treated, leaves the 
 reagent colorless or a light amber tint, according to the amount 
 required. If no sugar be present, the blue or green tint is not 
 wholly dissipated, even if the dilution be carried much higher 
 than in the tables given. 
 39 
 
236 
 
 URINARY ANALYSIS. 
 
 For experimental use with prepared urine, or with distilled 
 water with a known trace of glucose added, a continuation of the 
 table is appended: 
 
 If beduoed by 
 
 It oontaiks to the ounce, 
 
 Feboentaoe. 
 
 11 minimB. 
 
 1.155 graiDB. 
 
 0.303 
 
 12 
 
 1.333 " 
 
 0.278 
 
 13 " 
 
 1.231 " 
 
 0.256 
 
 U " 
 
 1.144 " 
 
 0.238 
 
 15 " 
 
 1.067 " 
 
 0.222 
 
 18 " 
 
 1.000 " 
 
 0.208 
 
 17 " 
 
 0.941 " 
 
 0.196 
 
 18 " 
 
 0.889 " 
 
 0.186 
 
 19 " 
 
 0.842 '• 
 
 0.175 
 
 ao " 
 
 0.800 " 
 
 0.167 
 
 Experiments with the small traces, as shown in the above table, 
 are of no particular clinical importance, for small traces of sugar, 
 not continuous, would not indicate pathological changes, but 
 show the delicate and sensitive nature of the reagent, and require 
 the utmost care and precision in performing the analysis. 
 
 In some urines a white or grayish cloud due to cuprous urate 
 may be noticed or the blue color may fade to greenish but this 
 has no significance. There is no reduction as long as any blue or 
 green tint remains. 
 
 MISCELLANEOUS NOTES ON SUGAR TESTING. 
 
 Trommer's test.— According to Charles Piatt, of Philadelphia, 
 the best way to apply this test is as follows: To urine in a test- 
 tube add one-fourth its volume of 30 per cent sodium hydroxide, 
 and then 10 per cent cupric sulphate solution, drop by drop, until 
 a slight permanent precipitate is formed. Heat to boiling and, in 
 presence of glucose, a reddish-yellow precipitate of cuprous oxide 
 separates. If glucose be present it will be noticed that the cuprio 
 sulphate will form a greenish-blue precipitate on coming in con- 
 tact with the urine, but that on agitation this precipitate will dis- 
 solve, forming a dark-blue solution, itself a satisfactory test for 
 glucose in absence of sucrose and of glycogen. As most of the 
 reducing substances other than sugar, which are apt to be present 
 in the urine, react only at the boiling temperature, a second test 
 may be prepared as described, and, without heating, allowed to 
 stand twelve to twenty-four hours. If Efficient sugar be present 
 a red precipitate of cuprous oxide will be obtained. The test so 
 performed is practically free from the objection of other reducing 
 substances, but requires a somewhat larger amount of sugar to be 
 present; in other words, it is less delicate. A decolorization of 
 the solution without separation of cuprous oxide is not necessarily 
 indicative of sugar, nor is a precipitate forming only on cooling 
 of the test. In the former case the smallest amount of cuprous 
 oxide may be detected by Hoppe-Seyler's reaction with hydro- 
 chloric acid. 
 
 As an introduction to Trommer's, or, for that matter, to any 
 sugar test, filtration through charcoal may be resorted to. By 
 continued filtration a highly-colored urine may be reduced to a 
 colorless solution practically free from reducing substances, sugar 
 
TESTS FOB SUGAR IN THE URINE. 827 
 
 Included, unless the latter be in large amount. Seegen proposed 
 to filter repeatedly through charcoal, to reject the filtered urine, 
 to wash the charcoal carefully with distilled water, and to apply 
 the tests to the washings. Charcoal filtration is, however, by no 
 means so perfect a process as is Briicke's method with lead acetate. 
 In this the phosphates, carbonates, sulphates, coloring-matter, 
 etc., are removed by precipitation with neutral lead acetate, or 
 boiling saturated solution of lead chloride. To the filtrate am- 
 monium hydroxide is added in excess, the precipitated plumbic 
 glucosate is filtered off, washed carefully, suspended in water, 
 decomposed by passing hydrogen sulphide, and the hydrogen sul- 
 phide removed by boiling. The clear solution is then evaporated 
 to the original volume of urine, allowed to stand several hours, 
 again filtered, if necessary, and, finally, the filtrate is tested by 
 any reliable sugar test. 
 
 A less tedious manner of securing at least a partial separation 
 of other constituents of the urine from the sugar is by Allen's 
 method. (See above). 
 
 PuKdy's test.— Dr. Charles Piatt finds that in the case of 
 Purdy's solution many normal urines will show a reducing power 
 equivalent to from 0.3 to 0.3 per cent of glucose, this substance, 
 however, being entirely absent. Deduct, therefore, 0.2 per cent 
 for each 5 c.c. of undiluted urine. 
 
 Haines' solution. — Dr. Piatt says that small amounts of sugar 
 0.30 per cent, or less, are not detected by this reagent. Allen's 
 modification of Fehling's test, the phenylhydrazin teat, and the 
 fermentation tests are more delicate. 
 
 Briicke's modification of the bismuth test.— Dr. Piatt recom- 
 mends this as one of our most reliable methods. Make up 
 Frohn's reagent by dissolving 7 grammes of potassium iodide in 
 20 c.c. of water. Heat and add 1.5 grammes of freshly precipi- 
 tated bismuth subnitrate and about 1 c.c. of strong hydrochloric 
 acid. Add a few drops of this to 10 c.c. of water in a test-tube, 
 then add hydrochloric acid, drop by drop, until the precipitate 
 which has formed just disappears. To 10 c.c. of urine add the 
 same amount of reagent and of acid as in the preliminary trial 
 test. Filter, make the filtrate strongly alkaline with sodium 
 hydroxide, and boil. A black precipitate will indicate glucose. 
 
 The Phenylhydrazin test. — Dr. Piatt performs this test as 
 described above in the second method, but uses 2 grammes of 
 sodium acetate. In case the crystals are not clearly revealed, the 
 yellow precipitate may be separated and dissolved in hot alcohol, 
 the alcoholic solution added to water in a beaker, the alcohol 
 removed by evaporation and the deposit again examined. This 
 test is exceedingly delicate, responding to 0.001 per cent of glucose 
 in aqueous solution and to 0.05 per cent in the urine. 
 
 The fermentation method. — Dr. Piatt says that rather better 
 results may be obtained by Antweiler's and Breitenbend's method 
 of fermentation in presence of Eochelle salts and determination 
 of the loss in weight due to evolution of carbon dioxide. This loss 
 in weight multiplied by 2.045 gives the amount of glucose in the 
 sample taken (3.0454 parts of glucose producing one part of caxbon j 
 dioxide on fermentation). 
 
228 URINARY ANALYSIS. 
 
 CHAPTER XXXYII. 
 
 CLINICAL SIGNIFICANCE OF GLYCOSURIA. 
 
 Gltjcose is found in the urine under the following 
 sircumstances : 
 
 1. In traces in normal urine, but not recognized by 
 the tests usually employed. Patients who view glyco- 
 suria calmly are in the habit of asking the writer 
 whether "sugar" is not found in all urine. To. such 
 the answer "No," should be given, especially since 
 JTolles denies that even traces are present. 
 
 2. Transitory and due to alimentary causes: — If 
 a person have glycosuria from ingestion of so small an 
 amount as 100 grams (about 3 ounces) of chemically 
 pure glucose the condition is to be regarded as patho- 
 logic, showing a diminished power of utilizing carbo- 
 hydrates in the system. Diffuse cerebral lesions refer- 
 able to alcohol and syphilis are likely to give rise to 
 this digestive glycosuria, which may follow the inges- 
 tion of 100 grams of glucose. In lead colic this glyco- 
 suria has been observed and as a constant symptom of 
 functional neuroses (grand hysteria and traumatism) ; 
 also in phosphorus poisoning. 
 
 3. Transitory in many nervous diseases : — Lesions 
 affecting the central as well as the peripheral nervous 
 system, such as tumors and hemorrhages at the base 
 of the brain, lesions of the floor of the fourth ventricle, 
 tetanus, sciatica, cerebral and spinal meningitis, con- 
 cussion of the brain, in about 10 per cent of cases of 
 head injury, fracture of the cervical vertebrae ; follow- 
 ing epileptic, hystero-epileptic, and apoplectic seizures, 
 mental shock produced by railroad accidents, etc., 
 (traumatic neuroses), mental strain and worry, fatigue, 
 and anxiety. (Probably due to distinct or reflex influ- 
 ence affecting the floor of the fourth ventricle). 
 
 Transitory also in certain acute febrile diseases, par- 
 
SUGAR IN THE UBINE. 229 
 
 ticularly during convalescence, namely, typhoid fever, 
 scarlatina, measles, cholera, diphtheria, influenza, and 
 especially malaria. (Due possibly to action of pto- 
 mains or leukomains on the floor of the fourth 
 ventricle). 
 
 Transitory also in cases of poisoning by a number 
 of substances : — Curare, chloral hydrate, sulphuric 
 acid, alcohol, carbon monoxide, morphine, etc., and 
 even after simple transfusion of normal salt-solution 
 into the blood. 
 
 Phloridzin (a gluooside from the bark of the root of 
 the apple tree), will likewise cause sugar to appear 
 temporarily in the urine, ceasing with the withdrawal 
 of the drug. 
 
 4. Persistent in connection with certain brain 
 lesions, particularly those affecting the floor of the 
 fourth ventricle. 
 
 5. Persistent in the disease known as diabetes mel- 
 litus, together with more or less polyuria, and increased 
 elimination of solids, except uric acid, and associated 
 in advanced cases with acetonuria, lipuria, and lipa- 
 eiduria. (See further on). 
 
 FLUCTUATIONS IN THE QUANTITY OF SUGAK IN DIABETES MELLITUS. 
 
 According to Simon the following is true: 
 
 1. Cases have been known in which 360 grams (5,580 grains, or 
 about one pound) of sugar in 34 hours have been passed. 
 
 2. The severity of the pathologic process cannot be measured 
 by the amount of sugar eliminated. The total amount of sugar 
 may not exceed a few grams daily, and yet the disease rapidly 
 tend toward fatal termination. 
 
 3. Absence of sugar from the urine In one or even more urinary 
 examinations does not exclude diabetes. In such a case give the 
 patient 100 grams of glucose, and test the urine three or four 
 hours afterward. 
 
 4. A light case of diabetes in which the sugar has disappeared 
 under dietetic treatment may suddenly become severe, and appar- 
 ently severe cases may suddenly assume a more benign type. 
 
 5. In a type described by Hirschfeld a specific gravity of 1013 
 smA. greatly diminished elimination of solids is noticed. 
 
 THE BEGINNING OP DIABETES MELLITUS. 
 
 According to Loeb the following is true: 
 
 1. Little is known with respect to the earliest stage of diabetes. 
 
 3. The temporary occurrence of a small quantity of sugar in the 
 urine ousht not to be regarded lightly; severe diabetes sometimes 
 follows. 
 
S30 URINARY ANALYSIS. 
 
 8. Soma oaaes of diabetes are acute from the first. 
 
 4. Some cases of slight and temporary diabetes recover com- 
 pletely. 
 
 5. In a great number of cases of diabetes before a large quantity 
 of sugar is excreted, small quantities are excreted temporarily, 
 often for years. 
 
 NOTES ON THE WKITER'S CASES. 
 
 In the writer's experience the urine of all persons should be 
 tested in the afternoon, about two hours following the noonday 
 meal. Traces of sugar discoverable by Haines' test may be pres- 
 ent at that time but absent at other hours of the day. 
 
 In the writer's experience polyuria is not a constant symptom 
 among well-cared for Americans with diabetes. Not over 50 per 
 cent of 70 cases seen by the writer had noteworthy polyuria, and 
 in his private practice the largest amount ever collected and accu- 
 rately measured was 18 pints. The mortality among all the 
 polyuric cases seen in 7 years was 42 per cent, but no typical case 
 of glycosuria without polyuria and other marked syttiptoms 
 proved fatal in that time. Half the writer's patients voided 20 to 
 40 grams of urea per 24 hours. The mortality was directly pro- 
 portioned to the quantity of urea, the safest excretion being 20 to 
 30 grams. The mortality in thosa voiding over 60 grams of urea 
 was very great. 
 
 The author has had several cases in which the patient although 
 intelligent, was not aware of having any disease, even whpu there 
 was considerable polyuria and over 1,000 grains of sugar daily. 
 
 The thirst is greatest in cases where the percentage of sugar 
 rises above 4 per cent. In a case in which there was 6 per cent of 
 sugar, thirst was intense, but when, under the writer's mineral 
 water treatment, the sugar fell to 4 per cent, the patient declared 
 that he drank no more water than was prescribed for him. namely 
 8 glasses per 24 hours, and was no more thirsty than usual. 
 
 KEDTJCING SUBSTANCES OCCASIONALLY FOUND IN UEINB. 
 
 . Besides glucose there are found in the urine the fol- 
 lowing carbohydrates : Lactose, levulose, maltose, 
 dextrin, laiose, pentose, inosite, and animal gum ; cane 
 sugar, and glycogen may also occur. In addition to 
 these, certain acids are found which have reducing 
 properties, viz., glycuronic acid and glycosuria acid. 
 
 Levulose:— The usual tests show presence of a reducing sub- 
 stance, and polarimetric examination shows a deviation to the left 
 or none at all. Occasionally present in diabetic urine. 
 
 Lactose. See Chapter XIX. 
 
 Maltose: — The phenylhydrazin test gives crystals differing in 
 appearance from those of glucose, and they melt at a temperature 
 about 16° C. lower than that of the glucososazon crystals. Found 
 in the urine of a person supposedly with pancreatic disease, asso- 
 ciated with acholic stools. 
 
 Dextrin: — On application of Fehling's test the blue liquid 
 becomes first green, then yellow, and sometimes dark brown. 
 Has been found in diabetic urine. 
 
SUGAR IN THE URINE. 331 
 
 Lalose: — Titration with Fehling's solution shows from l.S te 
 1.8 per cent more sugar than the polarimetric method. 
 
 Pentose: — This sugar occurs in milk, tea, coflfee, and wines, in 
 normal urine and in diabetic urine. Salkowski says that in order 
 to test for pentose take 200 to 500 o.c. (6^ to 16 fiuidounces) of 
 urine, and for each 100 c.c. (3i fiuidounces) add 3i grams (39 
 grains) of phenylhydrazin dissolved in a quantity of acetic acid, 
 sufficient to render the solution acid. Heat the mixture in a Bo- 
 hemian-glass vessel until it begins to boil, then place in a water 
 bath for an hour and a quarter. When cooled, the crystals of 
 phenylpentosazon will be obtained. The crystals melt at 158" C. 
 (316.4" F.), and are dissolved by water of 60° C. (140° F.) temper- 
 ature. Fermentation by ordinary yeast destroys pentose. Tollen's 
 test (heating the urine with a saturated solution of phloroglucin 
 in hydrochloric acid), shows pentose to be present in mest diabetic 
 urines, and in the urine of dogs rendered diabetic by ablation of 
 the pancreas or by ingestion of phloridzin. 
 
 Inosite and animal gum have already been eonsidered. See 
 Chapter XIX. 
 
 Cane sugar may occur in traces in the urine. If containing 
 other sugars as impurities it may reduce copper tests, otherwise 
 not Glycogen has been found in some diabetic urines. 
 
 ACIDS WITH REDUCING POWKE. 
 
 CHycnronic acid: — This substance, CHioO,, occurs in the urine 
 abundantly after administration of such drugs as chloral, butyl- 
 chloral, morphine, chloroform, camphor, curare, nitrobenzol, etc. 
 It is occasionally found in the urine of apparently healthy people. 
 Detection: — Urine containing glyouronic acid reduces Haines' 
 and Fehling's solutions, giving a yellow or even, red precipitate, 
 and rotates the plane of polarized light to the right, but fermen- 
 tation with yeast shows no glucose present. Phenylhydrazin 
 forms crystals, with glyouronic acid, but they differ from those 
 of phenylglucosazon, being in the form of rosettes, while the 
 needles are thick and plump, the whole resembling crystals of 
 ammonium urate. They melt at 150° C. (302° F.) 
 
 Glycosuric acid: — This substance, called also uroleuoinio acid, 
 urrhodinic acid, and alkapton, occurs very rarely in urine. 
 Urines which contain it are normal in color, when voided, but 
 turn dark on standing. Glycosuria acid is more frequently found 
 in the urine of children than in adults, the condition at times 
 occurring in families, and persisting for years. Its significance is 
 not known, though Dr. Marshall, of Philadelphia, noticed a grad- 
 ually increasing weakness in a case coming under his observation. 
 Glycosuric acid reduces Fehling's solution, but merely causes a 
 blackish discoloration when the bismuth test is used. Fermenta- 
 tion is negative. When Ehrlich's test is applied, a dark-brown 
 color develops on standing for fifteen minutes, while at the end of 
 an hour the urine has turned almost black. The first person to 
 isolate glycosuric acid was Marshall of Philadelphia. 
 
333 URINARY ANALYSIS, 
 
 CHAPTER XXXVIII. 
 
 ACETONE AND ALLIED SUBSTANCES. 
 
 Acetone has already been alluded to in describ- 
 ing diabetes mellitus, as it frequently occurs in the 
 urine of that disease. This substance, a thin, color- 
 less liquid of peculiar fruit-like odor, dimethyl-ketone, 
 CHg — 00 — OH3, occurs in small amount in normal 
 urine, blood, and secretions; the amount is notably 
 increased in diseases. A purely albuminous diet 
 increases it after 48 hours and, in general, acetonuria 
 is always due to increased albuminous decomposition. 
 Oontinuous administration of white of eggs causes its 
 appearance. It has been found in febrile diseases of 
 long duration, in certain nervous diseases, as in general 
 paresis, melancholia, tabes, and after epileptic seizures ; 
 also in Addison's disease, general carcinomatosis, 
 eclampsia, and other conditions where there is in- 
 creased albuminous decomposition. 
 
 Detection: — Distill 500 to 1,000 c.c. of urine adding 
 1 gram phosphoric acid pro liter and employ the first 
 10 to 30 0.0. for the following tests : 
 
 1. Luben'stest: — Treat a few c.o. of the distillate 
 with several drops of a dilute solution of iodo-potassio 
 iodide and sodium hydrate ; iodoform is formed, recog- 
 nized by its odor. Lactic acid and alcohol, if present, 
 also form iodoform. 
 
 2. Baeyer's indigo test : — This test may be applied 
 to the urine directly. Dissolve, by aid of heat, a few 
 crystals of nitro-benzaldehyde in the urine ; on cooling 
 the aldehyde separates in the form of a white cloud. 
 Make the solution alkaline with dilute solution of 
 sodium hydroxide and, if acetone be present, first 
 yellow, then green, and lastly an indigo-blue color 
 will appear within ten minutes. 
 
ACETONE IN URINE. 233 
 
 3. Keynold'§ testr — A few c.o. of the distillate are 
 treated with a small amount of freshly precipitated 
 yellow oxide of mercury. (The latter is made by pre- 
 cipitating solution of mercuric chloride with an alco- 
 holic solution of sodium hydrate). Shake the mixture, 
 filter, and add a few drops of ammonium sulphide to 
 the clear filtrate. If acetone be present, a black color 
 due to formation' of mercuric sulphide is seen. 
 
 Inasmuch as few physicians have the facilities for 
 distilling urine, it is easier in diabetes mellitus to test 
 for the next constituent to be considered, namely, 
 
 DIAOETIO AOID. 
 
 This substance, a colorless, strongly acid liquid, also 
 known as ethyl-diacetio acid, CH3.CO.OH2-CO^H, 
 when found in urine, is always of pathologic signifi- 
 cance. It is found especially in diabetes, in various 
 forms of digestive disturbance, and in the high and 
 continued fevers of children and others. It strikes a 
 Bordeaux-red with solution of ferric chloride and is 
 tested for as follows: To a few c.o. of urine add a 
 strong solution of ferric chloride (perchloride of iron), 
 drop by drop, until the precipitation of phosphates 
 ceases. This may be readily observed by letting the 
 precipitate settle, after a few drops of the iron solu- 
 tion have been added, which it will do in about ten 
 minutes. Filter, and to the filtered urine add more 
 of the iron solution. If now a Bordeaux-red color 
 is seen, another portion of the urine is boiled and 
 similarly treated, and if this second sample give no 
 reaction, suspect presence of diacetic acid. Confirm 
 by treating a third portion of the urine with sulphuric 
 acid, shake the mixture with ether, and draw off the 
 ether. Test the ethereal extract with the iron solu- 
 tion as above, and if the Bordeaux-red color be ob- 
 tained, which disappears on standing for 24 to 48 
 hours, diacetic acid is present, especially if acetone 
 can be detected in the distillate. 
 
 It is necessary to boil the urine, as in the second 
 case above, since this procedure prevents the reaction 
 30 
 
234 URINARY ANALYSIS. 
 
 with diacetic acid but not the reaction with the urine 
 of those who have taken various drugs, (thallin, anti- 
 pyrin, salicylic acid, and phenol), also fatty acids and 
 other compounds. If then, after boiling, the Bor- 
 deaux-red appear, it is due to something else besides 
 diacetic acid. 
 
 CLINICAL NOTES ON ACETONE AND DIACETIC ACID. 
 
 1. The writer deems the test for diacetic acid an 
 important one, as he has found it in the urine • of 
 several diabetics who speedily died, and has not found 
 it in cases which have been apparently cured by his 
 mineral-water treatment. (See ifaknemannian, Janu- 
 ary and April, 1897). 
 
 2. Jaksch proposes to substitute the term diacetic 
 coma for diabetic coma, deeming the coma due to dia- 
 cetic acid in the blood. 
 
 3. Diaceturia is least significant and not uncommon 
 in febrile conditions in children. 
 
 4. Diaceturia is especially common in the diabetes 
 of children and the writer finds it an ominous sign. 
 Its appearance is often preceded by diminution in the 
 quantity of sugar. 
 
 5. Diaceturia in the height of acute fevers in adults 
 is of grave significance. 
 
 6. Diaceturia is sometimes a sign of anto-intoxica 
 tion, so-called diacetcemia, accompanied by vomiting, 
 dyspnoea, and jactitation, soon ending, in case of 
 adults, in coma and death without other discoverable 
 disease or lesion. Children may recover from it. 
 When acetone without diacetic acid is present, such 
 cases may recover whether adults or children. 
 
 7. The breath gives the odor of acetone (chloroform 
 and acetic acid) in diabetic coma, and also, in case of 
 children suffering from various febrile affections. 
 
 8. The urine, also, in long continued fevers may 
 have the odor of acetone. 
 
 9. In the gastric crises of diabetes, now well recog- 
 nized, especially in cases serious from the beginning, 
 acetone may be present in the urine, and the odor of 
 it may be noticed in the breath. 
 
ACETONE IN VBINE. 235 
 
 10. AlthoTigh acetone, diacetic acid, and oxybutyric 
 acid appear to be connected with the phenomena of 
 diabetic coma yet it is possible that they are a result 
 rather than a cause of it. The presence of toxins cir- 
 culating in the blood, causing an increased tissue- 
 destruction, with simultaneous formation of abnormal 
 acids, may possibly be the cause of the coma. (0. E. 
 Simon). 
 
 OXTBTJTYBIO ACID. 
 
 There is no easy method of detecting this substance in urine 
 though its occurrence is of great clinical interest. It is an odor- 
 less syrup, B-oxybutyric, or hydroxy butyric acid, CsH.OH.COOH, 
 optically active, Isevo-rotatory, and its presence may be inferred 
 If, after fermentation, the urine rotate the plane of polarized light 
 to the left 
 
336 URINARY ANALYSIS. 
 
 CHAPTEE XXXIX. 
 
 ABNORMAL COLORING MATTERS IN URINE. 
 
 Xhb following abnormal coloring matters will now 
 be considered : Blood-pigments, biliary pigments, 
 pathologic urobilin, melanin, the chromogen giving 
 Ehrlich's reaction, and some others of less importance. 
 
 Blood-pigments: — The tests for these have already 
 been given. (See Hsemoglobinuria). McBmalin is a 
 rare pigment which is identified by the spectroscope. 
 UroruhrohoBmatin and urofuscohcBinatin are two rare 
 pigments observed by Baumstark in the urine of a case 
 of pemphigus leprosus complicated with visceral lepra. 
 
 Haematoporphyrin is attracting some attention now, 
 as it is found in the urine during long continued ad- 
 ministration of sulfonal. Urines rich in this pigment 
 present an abnormal color, varying from a sherry or 
 port-wine tint to Bordeaux-red. Clinically it does not 
 appear to be of any special significance. Its formula 
 is Ci6Hj8]S'20s, and it is probably closely related to the 
 haematoporphyrin resulting from action of sulphuric 
 acid on hsematin. 
 
 BILE IN THE UEINB. 
 
 Oholuria shows itself by presence of the bile pig- 
 ments in urine. Of these bilirubin alone occurs in 
 freshly voided urine, the others forming on standing. 
 Whenever the outflow of bile into the intestines be- 
 comes impeded, bilirubin is absorbed by the lym- 
 phatics and eliminated in the urine, icterus at the same 
 time resulting. 
 
 Color of urine containing bile: — This varies from 
 a bright yellow to a greenish- brown, sometimes almost 
 black. After bile has been abundant in the urine and 
 has diminished to small quantities, the urine has an 
 intense yellow color, resembling somewhat dilute 
 potassium chromate solutions. 
 
COLORINa MATTERS IN URINE. 337 
 
 Odor of urine containing bile: — The odor strongly 
 suggests ox-gall, and those who are familiar with this 
 substance can detect bile in the urine without chemical 
 tests. 
 
 Foam of urine containing Mle: — The foam of bili- 
 ary urines is increased and may show, if held in the 
 right light, a peculiar color, usually greenish-yellow. 
 
 The sediment of biliary urines: — One of the easi- 
 est ways to detect bile is to examine the sediment witn 
 the microscope. Epithelia are stained an intense 
 golden-yellow, tube-casts also. Granular oasts show 
 a peculiarity in this respect, certain parts of them 
 being darker and more opaque than others. Filter- 
 paper is also stained by biliary urine. 
 
 Chemical tests: — Of the legion of tests for bile only 
 two will be considered. 
 
 1. Sosenhaok^s: — This, according to Jolles, is the 
 most delicate and is a modification of Gmelin's. The 
 urine is filtered through thick Swedish paper, the 
 latter removed, and, on the inner surface of it, is placed 
 a drop of concentrated nitric acid, which has been 
 allowed to stand exposed to the air for a short time. 
 In the presence of bilirubin rings presenting the colors 
 of the rainbow will form around the nitric acid. 
 
 2. JIupperfs test: — This is a favorite among chem- 
 ists; 10 to 20 c.c. of urine are precipitated with milk 
 of lime, or a solution of barium chloride, and the pre- 
 cipitate, after filtering, brought into a beaker by per- 
 forating the filter and washing its contents into the 
 latter with a small amount of alcohol acidulated with 
 sulphuric acid. The mixture is boiled, when, in pres- 
 ence of bilirubin, the solution assumes an emerald- 
 green oolor. Urine tested for bile should be freshly, 
 voided. 
 
 CLINICAL NOTES. 
 
 1. The bile pigments in urine may appear several 
 days before icterus is perceptible. 
 
 2. They are found in urme in numerous diseases of 
 the liver, in which icterus may or may not be present. 
 
 3. The diseases in which bile is most often seen in 
 
238 URINARY ANALYSIS. 
 
 the urine are, besides catarrhal jaundice, biliary calcu- 
 lus, parasites, compression of the duct by tumors of 
 the liver, of the gall-bladder, the duct itself, and of 
 neighboring structures, namely, the pancreas, stomach, 
 and omentum. In diseases in which the blood pres- 
 sure in the liver is lowered. In cases in which degen- 
 erative processes are affecting the glandular epithelium, 
 as in acute yellow atrophy or where the destruction of 
 red corpuscles is going on rapidly so that the liver 
 cannot transform into bilirubin all the blood pigment 
 carried to it, as in pernicious anaemia, malarial intoxi- 
 cation, typhoid fever, poisoning with arseniuretted 
 hydrogen, etc. 
 
 BILIARY ACIDS. 
 
 These occur together with bile pigment and their significance 
 is essentially the same. Dr. Oliver's method of detection is sim- 
 ple, and as follows: 
 
 To 20 minims of clear filtered urine reduced to 1,008 in specific 
 gravity add 60 minims of test-fluid prepared as follows: 
 
 Pulverized peptone gr. xxx; 
 
 Salicylic acid gr. iv; 
 
 Acetic acid (B. P.) m. xxx; 
 
 Distilled water to fl. oz. viii. 
 
 To be filtered repeatedly until transparent. 
 
 If bile salts are present in quantity greater than normal, a dis- 
 tinct milkiness promptly appears, becoming more intense in a 
 moment or so. If the bile salts are in normal or less than normal 
 quantity, there is no immediate turbidity, but in a short time a 
 slight tinge of milkiness is seen. 
 
 For Cholesterin see Sediments. 
 
 PATHOLOaiC UEOBILIN. 
 
 This substance must not be confounded with normal urobilin 
 (urochrome). It may be obtained, according to Gautier, from 
 urochrome by submitting the latter to the action of reducing 
 agents. It represents a lower form of oxidation than normal 
 urobilin, and, like it, is derived from the coloring-matter of the 
 blood and bilirubin. 
 
 Color of urine containing pathologic urobilin:— This is usu- 
 ally dark yellow, resembling that due to bile, and even the foam 
 may be colored. 
 Tests:— 
 
 1. Huppert's test for bile (see above) gives a brownish-red pre- 
 cipitate where urobilin is abundant, disappearing upon boiling 
 with acidulated alcohol, the liquid at the same time becoming 
 colored a brownish or pomegranate red. If but a small amount 
 of the pigment is present, the liquid is colored only a light reddish 
 tinge. (Jaksch's test). 
 
COLORING MATTERS IN URINE. 239 
 
 3. Gerhardt's test:— Shake 10 to 30 c.c. of the urine with chloro- 
 form and treat the extract with a few drops of a dilute solution of 
 iodo-potassic iodide. On the further addition of a dilute solution 
 of sodium hydrate the chloroform extract is colored a yellow or 
 yellowish-brown, and exhibits a beautiful green fluorescence 
 which is even more intense than in the case of normal urobilin. 
 
 3. If these tests fail, recourse must be had to the spectroscope. 
 In acid urines or solutions urobilin presents a distinct band of 
 absorption between "b" and "F," extending beyond "F" to the 
 right, while in alkaline solutions a band is likewise seen between 
 "b" and "F" which does not extend beyond "F," and is less 
 intense. 
 
 OLINIOAL NOTES ON PATHOLOGIC UROBILIN. 
 
 1. In 12 cases of atrophic and hypertrophic cir- 
 rhosis Jaksch was able to find urobilin in the urine in 
 every instance. 
 
 2. Simon has found it in a few cases of hepatic cir- 
 rhosis, chronic malaria, and pernicious antemia, in all 
 of which the skin showed a light icteric hue, but bile 
 pigment was absent from the urine. 
 
 3. Urobilinuria accurs most commonly in the course 
 of extensive cutaneous hemorrhages due to scars, car- 
 cinoma, the hemorrhagic diathesis, etc. Individuals 
 in whom this process is going on exhibit a yellowness 
 of skin, but there is no bile in the urine and no 
 obstruction of the bile ducts. (Jaksch). 
 
 4. Binet has found urobilin increased in digestive 
 disturbances, infectious diseases, measles, scarlatina, 
 typhoid fever, and pneumonia, but scants/ in uncom- 
 plicated diphtheria. 
 
 5. Eiva believes that the greater part of urobilin 
 and its chromogen is of intestinal origin, but under the 
 influence of modifications in the biochemical function 
 of the liver not yet understood. 
 
 6. According to Hayem urobilinuria is an early sign 
 of hepatic incompetence, as in the beginning of cir- 
 rhosis of the liver, in cardiac cases where hepatic 
 lesions are imminent, and in numerous acute affections 
 in alcoholics. He thinks it a bad sign in typhoid 
 fever. He finds it in newly-delivered and in nursing 
 women ; also in most forms of cachexia. Kelatively 
 pale urines may contain it. , 
 
 7. Mya thinks urobilinuria a sign of destruction of 
 the red blood corpuscles; he finds it in pneumonia, 
 
240 URINARY ANALYSIS. 
 
 febrile polyarthritis, typhoid fever, and anemias, in 
 poisoning by pyridin, antipyrin, acetanilid, and other 
 similar substances ; also in grave hepatic lesions. 
 
 MELANIN. 
 
 In cases of melanotic disease the urine, normal in color when 
 voided, gradually darkens on exposure and finally becomes black. 
 Such urines generally contain melanin and its chromogen in solu- 
 tion. Deposits of melanin are not by themselves at all character- 
 istic of melanotic tumors, being found in malarial conditions. 
 Moreover melanin itself may be absent in cases of melanotic 
 tumors and present in wasting and inflammatory conditions. Its 
 occurrence is merely confirmatory of other symptoms of melan- 
 otic tumor. 
 
 Tests:— 
 
 1. A few 0.0. of urine are treated with bromine- water, when, in 
 presence of melanin or melanogen, a precipitate will be obtained, 
 which is yellow at first, and then gradually turns black. 
 
 2. The "addition to melanotic urine of a few drops of a strong 
 solution of perchloride of iron will cause the appearance of a gray 
 color, which is imparted to the precipitate of phosphates occurring 
 at the time if more of the reagent be added, and which dissolves 
 again in an excess. 
 
 VARIOTJS COLORS IN TTMNB. 
 
 Phenol urines: — Certain urines darken on standing when 
 melanin is absent. The color may be due to presence of various 
 oxidation products of hydrochinon, as in cases of poisoning by 
 carbolic acid or following the ingestion of pyrooatechin, salol, 
 hydrochinon, salicylic acid and its compounds in large doses. 
 
 Tests:— 
 
 1. Ferric chloride solution develops a marked violet color which 
 does not disappear on standing, when salol and salicylic acid have 
 been taken. 
 
 2. In suspected carbolic acid poisoning, if the ratio of mineral 
 to conjugate sulphates, normally 10 to 1, becomes greatly dimin- 
 ished, without other cause, the diagnosis of poisoning by carbolic 
 acid may be inferred. 
 
 3. Tests for melanin are negative. 
 
 Alkapton: — This substance has already been described under 
 the name glycosuria acid. Urines containing it, though normal 
 in color when voided, darken on standing. 
 
 Bine urines, etc.:.— These are usually referable to internal use 
 of methyl blue, which is administered in the treatment of ma- 
 laria, chyluria, cystitis, and other diseases. Sometimes, however, 
 indican is formed within the urinary passages and colors the 
 urine blue, but the occurrence is of unknown significance. Indigo 
 taken internally will also color urine blue. 
 
 Oreen urines occur, but the cause of the color is not definitely 
 known. See Chapter IV. 
 
 Urines containing copaiba turn red on addition of hydrochloric 
 acid, and the ^ed color is changed to violet on application of heat. 
 
 During administration of iodine or the iodides, nitric acid turns 
 urine dark mahogany and the StokvisJafle indican test developa 
 a beautiful rose-red color in the chloroform. 
 
COLORING MATTERS IN URINE. 241 
 
 INFLUENCE OF DRUGS, ETC., ON THE COLOR OF URINE. 
 
 The drug substances, named below, when taken internally, 
 influence the color of the urine as follows: 
 
 Aloes, reddish. 
 
 Alizarin, reddish. 
 
 Analgen, blood-red after large doses or continued use. 
 
 Anilin chlorhydrate, external use, may cause dark red color in 
 urine. 
 
 Antipyrin, urine darker than normal. 
 
 Arseniuretted hydrogen, poisoning by this agent, black urine. 
 
 Bilberries, reddish. 
 
 Blackberries, darker than normal. 
 
 Carbolic acid, in time the urine assumes a dark to olive-green 
 color, changing to blackish. 
 
 Carrots, reddish-yellow. 
 
 Chelidonium, brownish yellow or red; blood-red in alkaline urine. 
 
 Casoara, yellow or reddish-yellow. 
 
 Chryaophanic acid, yellow or orange-color. 
 
 CoflEee, strong coffee darkens the urine. 
 
 Creosote, darkens the urine. 
 
 Frangula (Buckthorn), yellow or reddish-yellow. 
 
 Fuchsin, reddish. 
 
 GalUc acid, may darken the urine. 
 
 Gamboge, yellow more intense than normal. 
 
 Hydrochinon, darkens the urine. 
 
 Indigo, blue color. 
 
 Kairin, urine darker than normal or greenish-brown. 
 
 Logwood, darkens the urine. 
 
 Madder, reddish. 
 
 Methyl-blue, imparts blue color to urine. 
 
 Mulberries, red. 
 
 Naphtol, dark to blackish-brown color. 
 
 PhenocoU, brown-red to blackish brown. 
 
 Picrotoxin, yellow. 
 
 Potassium chlorate, poisoning by this agent, black. 
 
 Pyrocatechin, darkens the urine. 
 
 Pyrogallic acid, external use may give urine a brown tint. 
 
 Quinine, urine darker than normal. 
 
 Eesin, grayish-yeUow, 
 
 Eesorcin, darkens the urine. 
 
 Rhamnus, see Cascara. 
 
 Rheum, bright-yellow, deep-yellow or greenish; alkaline urine, 
 intense red. 
 
 Salicylic acid, in large doses, smoky hue. 
 
 Salol, dark-brown color. 
 
 Santonin, yellow, more intense than normal; alkaline urine, 
 intense red or orange-red. 
 
 Senna, like Rheum. 
 
 Sulphuric acid, poisoning by this agent, black urine. 
 
 Sulphonal, at times clear dark-red, due to haematoporphyrin. 
 
 Tannic acid, may darken the urine. 
 
 Tar, darkens the urine, when applied by inunction to the body. 
 
 Thallin, yellow to brownish with a greenish tint. 
 
 Trional, see sulphonal. 
 
 Turpentine, often darkens the urine. 
 
 XJva Ursi, color darker than normal. 
 31 
 
243 URINARY ANALYSIS. 
 
 ehelioh's diazo reaction. 
 
 This reaction has been called the typhoid fever reao- 
 Hon, due to presence of a chromogen in urine, which, 
 when treated with a solution of diazo- benzene-sul- 
 phuric acid and ammonia imparts a color to uring 
 varying from eosin to deep garnet-red. 
 
 Method of application: — Simon advises the test to 
 be made in the following way : A few c.c. of urine 
 are poured into a small test-tube, an equal quantity of 
 the sulphanilic-acid mixture (see (c) below), is added 
 and the whole thoroughly shaken: 1 c.c. of ammonia 
 water is then allowed to run carefully down the side 
 of the tube, forming a colorless zone above the yellow 
 urine containing the acid. At the junction of the two, 
 a more or less deeply colored ring will be seen, the 
 color of which is readily distinguished, the slightest 
 carmine tinge being shown readily by contrast with 
 the colorless zone above and the yellow below. If, 
 now, the mixture be poured into a porcelain basin 
 containing water, % salmon-red color will be obtained 
 if the chromogen in question is present, but a yellow 
 or orange-red when it is absent. 
 
 Note: — The solutions required are made as follows: (a) 50 c.c. 
 of hydrochloric acid are diluted to 1,000 c.c. with distilled water, 
 then saturated with sulphanilic acid; (5) 5 grams of sodium 
 nitrite are dissolved inf95 c.c. of distilled water; (c) a mixture is 
 then made of 40 c.c. of the sulphanilic acid mixture mada as in (a) 
 with 1 CO. of the sodium nitrite mixture made as in (b) and this 
 mixture (e) is used in performance of the tests. 
 
 Ehrlich's original method was to add the mixture (c) to the urine 
 in equal parts with ammonia in excess. His modified method was 
 to add about 50 c.c. of absolute alcohol to 10 c.c. of urine, filter, 
 and add to the alcoholic urine the mixture (c) from a burette, 20 
 c.c. of the mixture to 30 c.c. of the alcoholic urine, adding the 
 mixture in small quantities at a time and shaking thoroughly. 
 Then on addition to the whole of a few drops of ammonia the 
 characteristic color appears, which disappears on shaking and 
 becomes permanent only after adding excess of ammonia. 
 
 Colors obtained: — The characteristic color is cwr- 
 mine-red ; it may vary from eosin to deep garnet-red. 
 An orange color may be obtained in normal urine. 
 Urines containing bile may exhibit a dark cloudy dis- 
 coloration changed to reddish-violet on boiling. Urine 
 containing alkapton may exhibit a dark-brown color on 
 
COLORING MATTERS IN URINE. 243 
 
 standing. In rare instances of diseases associated with 
 well marked chills, Ehrlich's original method (see 
 above) develops an intensely yolk-yellow color, even 
 imparted to the foam. 
 
 CLINICAL NOTES ON THE DIAZO EBAOTION. 
 
 1. The reaction when found between the 5th and 
 13th day of a disease, the diagnosis of which is in 
 doubt, disappearing later, points to typhoid fever. 
 
 2. The reaction may occur in other acute febrile 
 diseases, as scarlatina, measles, small-pox, malaria, 
 pneumonia, etc. 
 
 3. The reaction is found in phthisis pulmonalis, and 
 its presence for any length of time is of bad omen. 
 
 4. Differentiation between acute miliar}' tubercu- 
 losis and typhoid fever may be made as follows : In 
 typhoid fever the reaction is usually present as early 
 as the 5th or 6th day, and disappears not later than 
 the 22d day; in acute tuberculosis it does not appear 
 earlier than the beginning of the 3d week and then 
 persists almost to the end. 
 
 6. Absence of the reaction from the 6th to 9th day 
 in typhoid usually indicates a mild case, except in 
 children. Exceptions are, however, occasionally noted 
 as when in severe cases the reaction is not obtained 
 before the third week, and lasts only a few days. 
 
 6. EOtheln is distinguished from measles by absence 
 of it. 
 
 7. Tubercular phthisis is differentiated from chronic 
 pulmonary disease by presence of it. 
 
 8. The reaction is occasionally obtained in the 
 healthy ; invariably in typhoid fever and pneumonia ; 
 generally in pleurisy; frequently in measles, perito- 
 nitis, suppurative inflammations, erysipelas, and 
 phthisis; occasionally in rhachitis and diabetes 
 mellitus. 
 
 9. It is absent in malignant and chronic non-tuber- 
 cular lesions. 
 
 10. Its absence is very valuable testimony in show- 
 ing that an affection is not typhoid fever. 
 
244 URINARY ANALYSIS. 
 
 11. Morphine, even in dilute solution, yields the 
 diazo reaction according to Hewlett. 
 
 CHEMICAL EXERCISE XVI. 
 
 1. Obtain some urine containing bile; note the 
 color, odor, and color of the foam. 
 
 2. Examine the sediment with the microscope, and 
 note that epithelia and various elements are stained by 
 the pigments. 
 
 3. Try Eosenbach's test and Huppert's test on 
 freshly voided biliary urine. 
 
 4. Note that the filtered urine will in most cases 
 show a trace of albumin. 
 
 5. Obtain the urine of a patient with typhoid fever 
 after the fifth day and demonstrate Ehrlich's reaction 
 in it. 
 
ANIMAL BASES IN URINE. 245 
 
 CHAPTER XL. 
 
 ANIMAL RASES IN URINE. TOXICITY OF URINE. 
 
 Animal substances of a basic nature occur in urine, 
 in small quantities in normal urine, but in larger quan- 
 tities during certain pathological conditions. They 
 are called ptomains or putrefactive bases, transition 
 products of decomposition, that is, temporary forms 
 through which matter is being transformed from the 
 organic to the inorganic state by agency of bacteria 
 and leucomains, products either of fermentative 
 changes other than those of bacteria, or of retrograde 
 metamorphoses. These compounds are of the greatest 
 interest and importance in modern medical study since 
 they may be regarded as the chemical causes which 
 he at the bottom of all infectious diseases, but as yet 
 it must be admitted that the whole subject is wrapped 
 in the deepest obscurity 
 
 Chemical properties of the animal bases: — 
 
 1. They resemble alkaloids, containing nitrogen, are all alkaline 
 in reaction, insoluble in water, but soluble in acids forming com- 
 pounds with the latter, from which compounds they are precipi- 
 tated by ammonia. 
 
 2. They are energetic reducing agents decomposing chromic 
 acid, iodic acid, and silver nitrate; they give Prussian-blue with 
 potassium ferrocyanide and ferric chloride. 
 
 3. They are all oxidizable and unstable, especially under the 
 influence of an excess of mineral acid, which colors them red and 
 then converts them to a resinous mass. 
 
 4. They are precipitated by numerous reagents, as picric acid, 
 iodine and potassium iodide, potassio-mercuric iodide, phospho- 
 molybdic acid, metatungstic and phosphotungstic acid, tannin, 
 auric chloride, and iodide of potassium and bismuth in dilute 
 solutions acidulated with sulphuric acid. 
 
 Detection: — Methods for detection are tedious. The Gautier, 
 Stas-Otto, or Brieger methods are usually employed. That of 
 Brieger is perhaps best suited for urinary work as follows: — 
 Suflacient hydrochloric acid is first added to render the urine acid, 
 and the mixture is then boiled for a few minutes and filtered. 
 Thefllterate is concentrated at first over aflame, and subsequently 
 over a water bath, to a syrupy consistence. If the urine is foul, 
 it is especially advisable to evaporate in vacuo and at the lowest 
 
346 URINARY ANALYSIS. 
 
 possible temperature, and as a general thing this procedure is 
 useful on account of the instability of the bodies sought. 
 
 The thick fluid is next mixed with 96-per cent alcohol, filtered, 
 and the filtrate treated with a warm alcoholic solution of lead 
 acetate. The resulting lead precipitate is removed by filtration 
 and the filtrate concentrated — preferably in vacuo — to a syrup, 
 and again taken up in 96-per cent alcohol. The alcohol is next 
 evaporated, and the residue, disolved in water, is freed from lead 
 by the addition of sulphuretted hydrogen and filtration. The 
 filtrate is acidified with hydrochloric acid and evaporated to a 
 syrupy consistence. It is then diluted with alcohol, and alcoholic 
 solution of mercuric chloride is added. The resulting precipitate 
 is boiled in water, and certain ptomains may separate at this stage 
 in consequence of different solubilities of the double salts of mer- 
 cury. The better to secure this, the precipitate may be treated 
 successively with water at various temperatures. Should it be 
 thought that the lead precipitate may have retained some of the 
 ptomains, it may be suspended in water, the lead converted into 
 sulphide, and the fluid treated in the manner just described. 
 
 The solution obtained as above is flltered, freed from mercury, 
 and evaporated; the excess of hydrochloric acid is carefully neu- 
 tralized with sodium carbonate (the reaction is kept feebly acid), 
 then it is again extracted with alcohol to free it from inorganic 
 salts. The alcohol is evaporated, the residue dissolved in water, 
 the remaining traces of hydrochloric acid neutralized with alkali, 
 the whole acidified with nitric acid and treated with phosphomo- 
 lybdio acid. The phosphomolybdate double compound is separa- 
 ted by filtration and decomposed by neutral lead acetate or, 
 more readily, by heating over a water bath. The lead is next 
 removed by means of sulphuretted hydrogen (hydrogen sulphide); 
 the filtrate is evaporated to a syrupy consistence and taken up 
 with alcohol. Several ptomains are thus separated as hydrochlor- 
 ates, and may be obtained in the form of double salts of gold, 
 or platinic chloride, and of picric acid. The chloride of the 
 base is obtained by removing the metallic base by precipitation 
 with sulphuretted hydrogen, while the picrate is taken up with 
 water, acidified with hydrochloric acid, and repeatedly extracted 
 with ether to remove the picric acid. The last step is to ascertain 
 if any ptomains remain in the phosphomolybdic acid filtrate after 
 precipitation of the phosphomolybdic acid. 
 
 Brieger has obtained some of his ptomains by a simpler modifi- 
 cation of his above complete method. Thus he has obtained 
 neurodinhy treating the aqueous extract of the organic matter, 
 after boiling and filtration, with mercuric chloride, collecting the 
 precipitate, decomposing it with sulphuretted hydrogen, evapor- 
 ating the filtrate over a water bath, and extracting the base with 
 alcohol. 
 
 Character of the bases:— Most of the members of the uric acid 
 leucomains have been found in urine, namely, xanthin, paraxan- 
 thin, heteroxanthin, the alloxuric bodies and bases, hypoxanthin, 
 methyl-xanthin, carnin, episarkin, epiguanin, etc. These bases 
 are commonly spoken of as xanthin bases or nucleiu bases since 
 they are derived from the nucleins. [Kossel suggested that the 
 nuclein bases be divided into two groups: Xanthin bases includ- 
 ing guanin, xanthin, and its methyl derivatives, and sarhin bases 
 including adenin, hypoxanthin, and their methyl derivatives. 
 Uric acid constitutes a third group. Kossel and Krilger have 
 
ANIMAL BASES IN URINE. 247 
 
 lately used the term alloxuric bodies to include uric acid and 
 the xanthin bases, since these contain alloxan and urea-residues. 
 On the other hand, alloxurio bases include xanthin, guanin, 
 adenin, hypoxanthin, heteroxanthin, paraxanthin, also theo- 
 bromin, theophyllin, caflfein, and carnin. Episarkin would not be 
 included in this group, as it probably has only an alloxan residue]. 
 
 Other bases which have been found are reducin, parareducin, 
 and a base containing an aromatic nucleus and giving a com- 
 pound with platinum chloride. Thudichum thinks urochrome 
 and kreatinin basic. Pouchet has found carnin and another base 
 of the composition C7HUN4O1, or CtHuNjOj; also abase which 
 he called extractive matter of urine, CsHnNOa. He regards urine 
 as containing small quantities of certain pyridin bases like those 
 from decomposing fish. Baumstark isolated a compound having 
 the composition CiHsNaO, which cotdd just be detected in forty 
 liters of urine. Selmi succeeded in obtaining from pathological 
 urines various bases which he calls pathoamins. The term uro- 
 toxin is likewise sometimes used to designate the urine poison. 
 Bouchard, Villiers, Lepine, Gautier, and others have apparently 
 found basic substances in pathological urine. 
 
 In general, however, it may be said that ic is comparatively 
 easy to find alkaloids by the so-called alkaloidal tests in urine but 
 much more difBcult to isolate them in a chemically pure condi- 
 tion, such that their exact constitution can be determined. 
 
 The diamins, cadaverin, and putresoin have been isolated in a 
 perfectly pure condition. 
 
 SPECIAIi METHODS OF DETECTION AND ESTIMATION. 
 
 Luff's method: — The urine of infectious diseases is examined as 
 follows: Render a large quantity of the urine alkaline with 
 sodium carbonate, and agitate with half its volume of ether. Let 
 stand, remove ether, filter, shake with solution of tartaric acid. 
 The alkaloids are removed as tartrates. Render the aqueous acid 
 solution alkaline with sodium carbonate, shake with half its vol- 
 ume of ether, remove ether, evaporate spontaneously, dry residue 
 over sulphuric acid, and test for alkaloids by dissolving in hydro- 
 chloric acid and precipitating with phosphomolybdic acid, potas- 
 sio-mercuric iodide, etc. 
 
 The alloxuric bodies and bases: — Krtlger and 
 Wulff use a copper method as follows : 100 c.c. of the 
 urine freed from albumin are placed in a beaker and 
 boiled; then 10 c.c. of a 1 in 2 sodium bisulphite solu- 
 tion and 10 c.c. of a 13 per cent solution of copper 
 sulphate are added and the whole raised to boiling. 
 Finally 5 c.c. of a 10 per cent solution of barium 
 chloride are added. This causes the precipitate to 
 settle rapidly and permits washing. The precipitate 
 is allowed to stand two hours, then filtered through a 
 10-12 cm. Swedish plaited filter and washed about 
 five times with warm water (60° C). The filter and 
 
348 URINARY ANALYSIS. 
 
 its moist contents are placed in a Kjeldahl round diges 
 tion flask (150 o.c), and 16 c.c. of concentrated sul- 
 phuric acid added, together with 10 gm. of potassium 
 sulphate and 0. 5 gm. copper sulphate. On boiling for 
 about one hour the solution becomes clear. The solu- 
 tion is then transferred to a flask, rendered alkaline 
 with sodium hydrate, and distilled. Talc can be 
 advantageously used to prevent bumping. The distil- 
 late is titrated with ^ oxalic acid, using rosolic acid 
 as an indicator. 
 
 By subtracting now from the nitrogen thus obtained, 
 the nitrogen calculated from the uric acid estimated by 
 the Salkowski-Ludwig method (see Appbitoix), the dif- 
 ference gives the nitrogen in the alloxuric bases in .100 
 c.c. of the urine. According to Baginsky, 2.8-3.8 
 mg. of xanthin bases are present in 100 c.c. of urine. 
 This corresponds to 0.042-0.057 gm. per day. Krtiger 
 and Wulff found by the method just given that on an 
 average 0.1325 gm. of alloxuric bases was excreted in 
 the urine per day. The proportion of uric acid nitro- 
 gen to the nitrogen of the alloxuric bases was, on an 
 average, 3.82 :1. 
 
 In a case of leukaemia, Bondzynski and Gottlieb 
 found this proportion to vary from 1.06:1 to 3.22:1. 
 The daily excretion of alloxuric bases was 0.5-0.6 gm. 
 
 OLmiOAL SIGNIFICANCE OF THE BASES. 
 
 1. In acute febrile diseases, as typhoid fever, pneu- 
 monia, pleurisy, and acute yellow atrophy, large 
 amounts of the bases are found. Bouchard points out 
 that these substances are probably formed in the lower 
 portion of the intestinal tract. 
 
 2. The diamins, putrescin and oadaverin, have been 
 found in cases of cholera, pernicious anaemia, and in 
 connection with cystinuria. 
 
 3. Ptomains in notable amounts have been found in 
 the urine of maniacs. 
 
 4. In cases of extensive skin-burns, a basic substance, 
 presumably peptotoxin, has been found. 
 
 5. Toxins which in animals produce (a), convulsions ; 
 
ANIMAL BASES IN URINE. 349 
 
 (5), anemia; (c), effects similar to those of Basedow's 
 disease, have been extracted from urine. 
 
 6. A base behaving like cholin has been found in 
 the urine of Addison's disease, and a base has been 
 found by Hunter in pernicious anemia. 
 
 7. Interest in the alloxuric bodies has been stimu- 
 lated of late by investigations which go to show that 
 aseptic surgical fever is due to increase of these sub- 
 stances. 
 
 8 Xanthin is said to be increased ten fold in acute 
 nephritis. Yaughan finds xanthin in the sediment of 
 urine in cases of enlarged spleen. 
 
 9. Xanthin and hypoxanthin are increased in leuco- 
 cythsemia owing to the increase in nucleated white 
 blood corpuscles. 
 
 Hypoxanthin is 'thought to be the substance once 
 observed as a deposit by Bence Jones in the sediment, 
 and called xanthin by him (see Sediments). 
 
 10. Paraxanthin is thought by Eachford to be the 
 cause of migraine and other troubles. Its physiological 
 action is to produce an almost rigor mortis-like condi- 
 tion when injected into the muscles. 
 
 11. Modern investigators are seeking to show that 
 Bright's disease is due to irritation of the kidneys by 
 passage through them of toxins, in all probability 
 formed in the intestinal tract. 
 
 The work in this field of urinary toxins already done is enor- 
 mous. To describe it in full would be a volume in itself. But as 
 yet it has neither become sufficiently exact to be reliable nor is it 
 capable of being used for clinical purposes. It is safe to say, 
 however, that medicine of the future will achieve brilliant results 
 from research work in these substances. The reader is referred 
 to Vaughan and Novy (third edition), for much that is interesting 
 in connection with the subject. 
 
 THE TOXICITY OF UEINB. 
 
 Bouchard's book on auto-intoxication has recently 
 
 aroused much interest in this subject although Feltz 
 
 and Eitter, as long ago as 1881, demonstrated the 
 
 toxicity of normal urine by injecting it into the blood 
 
 32 
 
250 URINARY ANALYSIS. 
 
 of animals. Bocohi and Sohiffer, Dupard, L6pine, 
 Gu6rin, next investigated the subject, followed by 
 Bouchard, Lenoir, and Charrin. Bouchard finds seven 
 toxic agents in urine, namely, one diuretic, one nar- 
 cotic, one sialogenous, three convulsive {two organic, 
 one inorganic), and one reducing bodily heat. 
 
 Bouchard's intravenous injections on rabbits of nor- 
 mal urine show the following toxic symptoms : 
 
 A. Myosis (contraction of pupils), accelerated respi- 
 rations, somnolence and coma; also lowered body 
 temperature, diminished reflexes, death from convul- 
 sions or coma. 
 
 B. The toxicity varies under certain ciraumstances: 
 
 1. The urine is twofold as toxic during the day as 
 (luring the night. 
 
 2. The night urine is strongly convulsive. 
 
 3. The day urine is strongly narcotic. 
 
 4. Active muscular exercise diminishes the toxicity. 
 6. The toxicity increases the longer the urine stands. 
 
 6. If urine is decolorized, by filtering through char- 
 coal, its toxicity is diminished about one-third. 
 
 7. An aqueous extract (chiefly of the mineral ele- 
 ments) causes contraction of the pupil, convulsions, 
 lowered temperature, but no coma, diuresis, or saliva- 
 tion. 
 
 8. An alcoholic extract causes deep coma and diu- 
 resis, but no convulsions nor myosis. 
 
 C. In diseases the following is found : 
 
 1. In acute ursemia the urine is non-toxic. 
 
 2. In acute infectious diseases and fevers, if the 
 kidneys' remain unaffected, the urine is more toxic 
 than in health. 
 
 3. In kidney diseases, the urine is much less toxic 
 than in health. 
 
 4. In tetanus the urine is powerfully toxic. 
 
 5. In pneumonia it is strongly toxic, producing con- 
 vulsions similar to tetanic urine. 
 
 6. In typhoid fever it is then no more toxic than 
 normal urine. 
 
 7. In cholera it produces cyanosis, convulsions, 
 lowered temperature, albuminuria, and diarrhoea. 
 
IHE TOXICITY OF URINE. 251 
 
 8. In leucocythsemia the urine is highly toxic, caus- 
 ing convulsions and death. 
 
 In kidney diseases, if it require 80 o.o. of urine to 
 kill a rabbit of one kilogram weight, it may be assumed 
 that the capacity of the kidneys is crippled about one- 
 half ; if a week later only 60 c.c. are required the 
 condition of the kidneys is improved. 
 
 Apropos of this subject it may be of interest to 
 quote the following from Vaughan and ITovy : 
 
 "The chemical theory of so-called urtemia has 
 received support in recent researches, notwithstanding 
 the fact that the old idea that urea is the active poison 
 and the theory of Frerichs that ammonium carbonate 
 is the active agent, has been abandoned. 
 
 ' ' Landois laid bare the surface of the brain in dogs 
 and rabbits, and sprinkled the motor area with kreatin, 
 kreatinin, and other constituents of the urine. Urea, 
 ammonium carbonate, sodium chloride, and potassium 
 chloride had but slight effect ; but kreatin, kreatinin, 
 and acid sodium phosphate caused clonic convulsions 
 on the opposite side of the body, which later became 
 bilateral. The convulsions continued at intervals for 
 from two to three days, when, growing gradually 
 weaker, they disappeared. Landois concludes that 
 chorea gravidarum is a forerunner of eclampsia. These 
 experiments have been confirmed by Leubuscher and 
 Zeiohen. 
 
 "Falck injected into both sound and nephrotomized 
 animals fresh urine, urine and the ferment of Muscu- 
 lus and Lea, and urine which had undergone spontane- 
 ous decomposition, without producing any symptoms 
 which were comparable with those observed in uremia. 
 However, he did find that if a few drops of an infusion 
 of putrid flesh were added to the urine before injection, 
 all the typical symptoms of urasmia were induced. 
 That the infusion of putrid flesh alone had no effect 
 was also demonstrated. This would lead us to believe 
 that some ferment in the infusion converts some con- 
 stituent of the urine into a highly poisonous body. In 
 this connection attention may be called to the fact 
 that kreatin may be converted by the action of certain 
 
253 URINARY ANALYSIS. 
 
 germs into methyl-guanidin, which produces convul- 
 sions. "Whether such conversion occurs in uraemia or 
 not, and if it does what the cause of it is, are ques- 
 tions which must be left for future investigations to 
 decide. It would be well for some one to test the brain 
 and blood of a person, who had died in urasmic oon- 
 vulsioas, for methyl-guanidin." 
 
URINARY SEDIMENTS. 853 
 
 CHAPTEK XLI. 
 
 URINARY SEDIMENTS. 
 
 TTrtke on standing deposits a sediment which may- 
 be recognized as follows : 
 
 Chemical tests for sediments: — Let the glass con- 
 taining the urine settle for several hours. When the 
 sediment forms, remove it with a pipette. An ordinary 
 glass tube will serve as a pipette. Close the upper 
 orifice of the tube tightly with the finger, dip the 
 lower end into the sediment and remove the finger ; 
 urine rich in sediment runs up into the tube ; again 
 close the upper orifice of the tube with the forefinger and 
 remove the tube from the glass. The urine and sedi- 
 ment in the tube do not flow out as long as the finger 
 is tightly pressed over the upper orifice. Insert the 
 lower orifice into a test-tube, remove the finger, and 
 the sediment will now flow out into the test-tube 
 where it may be tested in various ways as provided 
 further on. In this book under the heading Chemical 
 Tests for Sediments it is always assumed that the sedi- 
 ment to be tested has been removed to a test-tube in 
 this way, unless the centrifugal machine is used. 
 When several chemical tests are to be tried, it is best 
 to use several samples of the sediment in different 
 test-tubes. 
 
 The centrifugal machine accelerates and simplifies 
 chemical tests for sediments. Instead of waiting sev- 
 eral hours for the urine to deposit its sediment, pour 
 well-shaken urine into the two or more tubes of the 
 centrifuge, revolve at moderate speed (say 1,700 revo- 
 lutions) for five minutes and the sediment has collected 
 in the bottom of the tubes. By a clever device of Dr. 
 Purdy the urine can be poured off from the sediment 
 in his tubes without loss of sediment. Chemical tests 
 
254 URINARY ANALYSIS. 
 
 may then be tried without necessity of transferring 
 the sediment to a test-tube. 
 
 The following figure shows a centrifuge of modern 
 make. The fore* exerted is anormously greater than 
 that of gravity. 
 
 FlO. 46. Piirdy's eleotrie centrifuge, used by the author. 
 
 The sediments easily recognized, either by chemical 
 means or by inspection are : 
 Urates, Blood, 
 
 Uric acid. Pus, 
 
 Phosphates, Calcium oxalate (less easily). 
 
 "We shall consider the sediments according to the 
 reaction of the urine, whether acid or alkaline. 
 Acid urine: — 
 
 1. Hold the tube containing sediment in water 
 heated to 60° 0. (140" to 150° F.). If it clears wholly 
 or partly, urates compose the sediment. 
 
 2. If it does not clear with heat, is of a brownish 
 or yellowish color, and consists of small grains looking 
 like "red-pepper grains," add a few drops of liquor 
 potassse 'to the sediment and shake ; if it dissolves, 
 uric acid is present. 
 
URINARY SEDIMENTS. 355 
 
 3. If the sediment is small in amount and colorless 
 divide into three portions, add acetic acid to one and 
 hydrochloric acid to the other, shake thoroughly. If 
 the second is dissolved and the first is not, calcium 
 oxalate is probably present. Confirm by adding a few- 
 drops of liquor potassae to third portion and notice 
 insolubility. 
 
 4. If the sediment is whitish and especially if it is 
 dense and creamy white, add a few drops of liquor 
 potassae to it. If it becomes greenish and gluey, per- 
 haps forming viscid strings when poured from the 
 tube, pus is present. The urine itself, if pus is pres- 
 ent, will always respond to the albumin test, showing 
 •from traces to ^ on Esbach tube. 
 
 5. If the sediment is reddish in tint and does not 
 respond to tests for urates nor appear as uric acid 
 crystals, test for Hood as follows : Mix equal parts of 
 freshly made tincture of guaiao and old spirit of tur- 
 pentine,* shake well, and cause a like amount of urine 
 containing the sediment to trickle down the side of the 
 tube into the guaiac-turpentine mixture. ' A dense .yel- 
 lowish precipitate (guaiac) is seen in all urines but, if 
 blood be present, at the juncture of the yellow precipi- 
 tate and fl.uid above it, is seen a blue color, slowly 
 appearing. 
 
 Use freshly voided urine in making this test. The 
 urine itself will always respond to the albumin test, 
 showing from traces up to the 2d mark on Esbach 
 tube according to amount of blood. 
 
 Feebly acid, neutral, or alkaline urine: — 
 
 1. Test a whitish sediment for phosphates by add- 
 ing acetic acid and shaking well. If phosphates alone 
 are present, the sediment is wholly dissolved. If the 
 sediment is only partly dissolved, seen by comparison 
 with some of the original sediment in another tube to 
 which nothing has been added, phosphates are present 
 together with other constituents, probably micro- 
 organisms, mucus, epithelia, and perhaps pus. 
 
 *The turpentine should be well ozonized by exposure to air and 
 light. 
 
256 URINARY ANALYSIS. 
 
 2. In alkaline urine a slimy, viscid sediment, which 
 sticks to the glass or is clotted and gelatinous, is pus 
 mixed with mucus and needs no chemical test. Acid 
 urine containing a whitish sediment, if set in a warm 
 place until alkaline, will then have this stringy sedi- 
 ment if pus is present. 
 Urine of any reaction: — 
 
 1. Sediments not readily recognized by any of the 
 above tests are probably composed of mucus, micro- 
 organisms, epithelia, and fungi. The urine of nearly all 
 women contains an abundant mucous sediment which 
 does not respond to the tests above. Excess of mucus 
 in the urine is recognized by the slowness with which 
 the urine filters. 
 
 2. Micro-organisms in urine are readily recognized 
 by the hazy appearance they give to the urine. No 
 matter how long the urine stands, the haze due to 
 micro-organisms will not settle. It requires a high 
 speed of the centrifugal machine to settle them, 2,000 
 revolutions or more. Stale urine of women with leu- 
 oorrhoea exhibits this haze due to countless micro- 
 organisms. 
 
 3. In urine containing sugar an abundant whitish 
 sediment forms as the urine grows stale, composed of 
 penicillium glaucum, a fungous growth not answering 
 to the tests above given. 
 
 In general, chemical tests for urinary sediments are 
 not as satisfactory as microscopical examination, and 
 are often wholVy negative unless more or less tedious 
 processes of separation are resorted to. 
 
 4. Urine, if containing albumin, in no matter how 
 small quantity, and depositing, if only a scanty sedi- 
 ment, should be carefully examined for' tube-casts with 
 the microscope. A sediment so slight as hardly to be 
 seen with the naked eye may contain a considerable 
 number of casts. In such cases the centrifugal ma- 
 chine is of great service in concentrating the scanty 
 sediment. 
 
EXAMINATION OF URINE. 857 
 
 CHAPTER XLII. 
 
 MICROSCOPICAL EXAMINATION OF URINE. 
 
 Let the urine settle six hours in a conical glass in 
 case the physician does not possess a centrifugal ma- 
 chine, but if the latter be at hand proceed as in chem- 
 ical testing, settling for five minutes at a speed of 1,700 
 revolutions, or higher if bacteria are to be examined. 
 Eemove a little of the sediment by means of a pipette 
 and place a small drop on a glass slide. Do not use 
 cover glass at first. Procure a Bausch & Lomb micro- 
 scope (Continental BB stand) with half-inch and one- 
 fifth inch objectives. Always use half-inch first, focus 
 by raising, not lowering the tube, and study the field. 
 
 In a general way consider whether the objects seen 
 are (a), crystalline, *'. e., of definite geometrical form 
 and strongly refractive of light, or (5), whether they 
 are shapeless and granular, or (e), whether they are 
 pale and more or less regular in form. 
 
 "We shall first suppose the objects seen are either 
 crystals, or amorphous granules, and take up those 
 occurring in acid urine first. 
 
 The sediments commonly found in acid urine are 
 uric acid, urates, calcium oxalate; less commonly, 
 cystin, hippuric acid, kreatinin, leuoin and tyrosin, 
 calcium sulphate. 
 
 SEDIMENTS OF UEIO ACID. 
 
 Occurrence: — In acid, usually sharply acid, urine, 
 especially when below 1020 in specific gravity. 
 
 Color and appearance: — Crystals visible to the 
 naked eye, looking like red-pepper grains, prone to 
 cling to the sides and bottom of the glass, very heavy, 
 falling quickly to the bottom of the glass when the 
 urine stands. Best seen by holding the glass above 
 33 
 
258 
 
 URINARY ANALYSIS. 
 
 the head and looking upwards. Of deep yellow or 
 orange -red color, in some urines pale-yellow. 
 
 Crystalline structure: — Primary form is a rhombic 
 prism, and the crystals occur in various combinations 
 or modifications of this form. 
 Solubility: — 
 
 1. Insoluble in acids, as hydrochloric or acetic. 
 
 2. Soluble in fixed caustic alkalies (potassium hyd- 
 roxide). 
 
 3. Converted into ammonium urate by ammonia. 
 Microscopical appearances: — Uric acid crystals 
 
 (Fig. 47) have a rich yellow or orange color, or at least 
 
 0^ «°&r ii. 
 
 FlO. 47. Various forms of uric acid crystals. (Finlayson.) 
 
 a pale yellow color. They occur as lozenge-shaped, 
 rounded, barrel-shaped, compound, twin, cross, or 
 rosette forms. In over-acid urines there are also seen 
 spear-shaped or comb-and-brush-shaped crystals. They 
 are easily seen with a low power (150 diameters) and 
 look large with a high power (500 diameters). They 
 may occur in enormous quantities, filling th« entire 
 field with beautiful forms of rich coloring. 
 
 In some urines the crystals are a pale lemon-yellow 
 color and must, if hexagonal, be differentiated from 
 cystin. (See Cystin). 
 
EXAMINATION OF URINE. 
 
 259 
 
 Physiology: — The uric acid sediment Is normally found in some 
 urines after standing ten hours or more. The tendency to sedi- 
 ments of this kind is increased by rich food, animal or vegetable, 
 and by bodily exercise. In the urine high acidity, poverty in 
 mineral salts, low pigmentation, and high percentage of uric acid 
 tend to accelerate the precipitation of uric acid in form of con- 
 cretions or sediment. 
 
 Pathology: — The sediment is probably pathological, if oocuring 
 in urines less than six hours old. The sooner it is deposited the 
 greater the danger of formation of gravel and calculi. The de- 
 posit is found: — 
 
 1. In acute febrile disorders, and convalescence from scarlatina. 
 
 3. When function of the heart, lungs, kidneys, and diaphragm 
 is impeded. 
 
 3. In the so-called "uric acid diathesis" (defective action of the 
 liver with errors in diet, and sedentary life). 
 
 4. In mental and physical strains (over-work, sleeplessness). 
 
 5. In early stages of contracting kidney (interstitial nephritis). 
 
 Diagnostic hints: 
 
 1. In chronic nephritis if uric acid sediments occur, 
 one kidney only is involved (Heitzmann). In later 
 stages of nephritis the sediments are not often seen. 
 
 2. Spear-shaped crystals indicate hyper-acid urine, 
 as in gout or rheumatism. 
 
 Fig. 48 Sharp-pointed crystals of uric acid. 
 
 3. Clusters of uric acid crystals found in fresh urine, 
 especially if spear-shaped, together with epithelia 
 from pelvis of the kidney and blood corpuscles, mean 
 
360 URINARY ANALYSIS. 
 
 hemorrhage in pelvis of the kidney due to deposition 
 there of sharp crystals. 
 
 4. Constant deposit of uric acid crystals in fresh 
 urine is to be regarded as a a sign of functional de- 
 rangement of the liver, and possibly of undue produc- 
 tion of uric acid in the body. 
 Clinical notes: — 
 
 1. Patients, in whose fresh urine uric acid crystals 
 are found, quite commonly complain of pain along the 
 course of the ureter and in the median line above the 
 symphysis pubis. Copious ingestion of fluids has sev- 
 eral times in my experience relieved such pains. 
 
 2. Patients who have inflammatory diseases of the 
 urinary organs are worse when they pass uric acid 
 crystals, the latter irritating sensitive mucous surfaces. 
 This should not be forgotten in the treatment. 
 
 3. Uric acid sediments in diabetic urine seem to be 
 related to the ' 'rheumatic' ' pains from which some 
 diabetics suffer ; at any rate in one or two instances 
 treatment based solely on the uric acid condition has. 
 resulted in marked alleviation of the pains. 
 
 SEDIMENTS OF MIXED URATES. 
 
 Composition: — ^Acid urates of sodium, potassium, 
 ammonium, and (rarely) calcium. 
 
 Occurrence: — In acid urine. (Ammonium urate in 
 alkaline urine). Especially in urines of high specific 
 gravity, above 1025. 
 
 Color and appearance: — Amorphous, reddish, 
 granular sediment, in color faint pinkish, fawn-color, 
 reddish, or brick-red, forming what is known as the 
 "brick-dust" sediment which adheres so closely to the 
 sides of containing vessels, especially at the surface 
 line of the urine. Scanty urines of high specific grav- 
 ity are frequently turbid from presence of suspended 
 urates. In the urine of children the mixed urate sedi- 
 ment frequently gives the urine a "milky" appear- 
 ance with but faint tint of color. 
 
 A pellicle of urates is frequently noticed on the sur- 
 face of urines containing this sediment. 
 
EXAMINATION OF URINE. 361 
 
 The sediment of urates is of different color from the 
 urine containing it, being deeper in hue. 
 
 Crystalline structure: — The acid urate of sodium 
 is usually amorphous, sometimes crystalline (various 
 forms). The acid potassium urate is amorphous, as is 
 the calcium urate. The ammonium urate is crystal- 
 line, and consists of dark spheres with fine sharp 
 spicula. 
 Chemical tests of the mixed urate sediment: — 
 
 1. Characteristic test : Dissolved by heat* (120° F. 
 or upwards), reappearing as the liquid cools. 
 
 2. Insoluble in 20 per cent acetic acid. 
 
 3. Soluble in caustic alkalies, as liquor potassae. 
 
 4. Eesponds to the murexide test (see uric acid). 
 
 5. Decomposed into uric acid on addition of hydro- 
 chloric acid, the former separating as brownish grains 
 (crystals). 
 
 6. Not readily soluble in water ; the sodium urate 
 soluble with difficulty (1150 parts cold, 124 parts 
 boiling) ; calcium urate very sparingly soluble. 
 Microscopical appearances: — 
 
 1. The mixed urates, when amorphous, appear 
 under the microscope with a low power (150 diame- 
 
 FiG. 49. Amorphous urates. 
 
 *The books say "gentle heat dissolves urates." If a bottle of 
 urine, turbid from urates, be set in water of temperature 140" F. 
 (60° C ) in about three minutes the sediment will dissolve, 
 when the urine is heated to 130° F. (50» C). 
 
268 URINARY ANALYSIS. 
 
 ters) as flocculent masses filling the entire fielt/. "With 
 a high power (500 diameters) thej'' appear (Fig. 49) as 
 brown granules in a moss-like arrangement. 
 
 2. Sodium urate, when crystalline (Fig. 50a), occurs 
 in a great variety of forms. In one of Dr. Heitzmann's 
 slides showing urate of sodium from a dermoid cyst of 
 the kidney some of the crystals are much smaller than 
 those in the figure. The crystals are more or less 
 colored, brown or pink, and appear as needle-like 
 clusters, in double fan-shape arrangement, or leaf- 
 shaped. 
 
 3. Ammonium urate appears with a low power (150 
 diameters) as dark-brown spheres which, with a high 
 power (500 diameters), are seen (Fig. 50) to be studded 
 
 
 p 
 
 Fig. 50. Sodium urate (a), and ammonium urate (ft). 
 
 with fine, sharp-pointed spicula, so-called thorn-apple 
 crystals. 
 
 Physiology: — Normal urine precipitates urates (a) in cold 
 weather; (6) when stale. Urine two or three days old may first, 
 when more acid, throw down a sediment of amorphous mixed 
 urates and uric acid; later, when four or five days old and am- 
 moniacal, the amorphous urate sediment becomes transformed 
 into ammonium urate. 
 
 The freshly voided urine of a healthy person shows no sediment 
 of urates at ordinary temperatures, except possibly after profuse 
 perspiration with diminution of amount of urine. 
 
 Pathology: — The sediment of mixed urates may occur tempor- 
 arily in: — . 
 
 1. Slight disturbances of health from over-eating or drinking 
 or prolonged abstinence from either, after great exertion, revelry 
 or excitement, hard study, or fright. 
 
 2 Temporarily in slight colds, digestive disturbances in child- 
 ren, and during attacks of gout. 
 
EXAMINATION OF URINE. 363 
 
 3. During fevers and inflammatory diseases; in febrile exacer- 
 bations of chronic diseases. 
 
 4. More constantly in visceral disorders attended by wasting; 
 in chronic affections of the heart, liver, and spleen; in functional 
 disorders of the stomach; in congestions of the kidneys. 
 
 5. In the scanty high-colored urine of dropsical patients. 
 
 Diagnosis: — 
 
 1. The presence of uric acid and of urates in the 
 urine in form of deposits is one of the most constant 
 signs of functional derangements of the liver. 
 
 2. If without errors of diet a patient under 40 hab- 
 itually passes urine which soon deposits a pinkish sed- 
 iment, or which thoHgh clear when voided soon becomes 
 thick and opaque, there is undoubtedly an undue ten- 
 dency to produce uric acid. 
 
 3. In such cases as the above, possibility of the 
 presence or formation of gravel or calculus is to be 
 borne in mind. 
 
 4. The richer the color of the urate sediment, the 
 more the evidence of functional derangement of the 
 organ in question. 
 
 5. In acute lung diseases the larger the amount of 
 the urate sediment, the more insufficient the respiration. 
 
 6. Eose-red urates are common in articular rheu- 
 matism, acute and chronic ; in acute articular rheuma- 
 tism the urates are more highly colored (by uroery- 
 thrin) on the advent of pericarditis. 
 
 7. The paler the color of the urate sediment the 
 worse, usually, the condition of cutaneous functions. 
 
 8. The sediment of urates is now thought to be 
 indicative of total absence or relative insufficiency of 
 disodic phosphate in the urine. 
 
 Clinical notes: — 
 
 1 . An occasional sediment of urates is not serious 
 since it occurs even in slight disturbances of health. 
 Eegulation of the digestion, avoidance of late hours 
 and irregular living, together with copious ingestion 
 of fluids will quickly cause it to disappear. 
 
 2. In eight or ten rapidly fatal cases from cardiac 
 or renal diseases I have noticed the urine to be con- 
 stantly cloudy from urates. But as in all these cases 
 the urine was scanty, 15 to 20 ounces (450-600 o.c.) 
 
264 URINARY ANALYSIS. 
 
 daily, I can assign no special prognostic significance 
 to the sediment. 
 
 3. In looking for tube-oasts in urine containing urate 
 sediments, be sure first to dissolve the sediment with 
 heat just short of boiling. (See Tube-Oasts). This is 
 done by immersing the bottle or tube in water heated 
 to 140° F. (60° C). The urate sediment will dissolve 
 when the urine containing it is of a temperature of 
 120° F. (50° 0.). 
 
 SEDIMENTS OF CALOIUM OXALATE (OXALATE OF LIME). 
 
 Chemical constitution and deriyatioii: — OaO.Oi. 
 
 Occurrence: — Usually in acid urine, sometimes in 
 alkaline.* "When occurring in profusion and in sev- 
 eral forms, urine usually hyper-acid. 
 
 Color and appearance: — Light, easily-moving sedi- 
 ment, usually of small bulk, and colorless. 
 
 Crystalline structure: — Octahedra, made up of 
 four-sided pyramids, situated base to base, as seen in 
 their long diameters ; or less commonly, ovoid or cir- 
 cular discs. 
 Chemical tests: 
 
 1. Soluble in hydrochloric acid, insoluble in acetic 
 acid. 
 
 2, Insoluble in alkalies, as liquor potassae. 
 Microscopical appearances: — 
 
 Common forms : — Small, colorless crystals (Fig. 51), 
 seen with diflficulty with a low power (160 diameters), 
 best studied with a power of 400 or 500 diameters 
 octahedral in form, highly refracting; have appear- 
 ance of rear of a letter envelope, i. e. , squares crossed 
 obliquely by two sharp lines. "When small, the two 
 lines form a bright spot at their crossing in the centre. 
 
 *I cannot understand the statement of certain authors that 
 oxalate of lime is a sediment characteristic of alkaline urine. 
 Between January 1, 1895, and June 1, 1896, I found sediments of 
 calcium oxalate in il6 samples of the 24 hours' urine. Of these 
 98 were urines acid in reaction, 1 neutral, and 17 alkaline. In 
 every case but two where there was great profusion and different 
 forms of crystals, the urine was hyper-acid in reaction. 
 
EXAMINATION OF UBINE. 
 
 865 
 
 Fig. 31. "Various forms of calcium oxalate crystals. (Peyer). 
 
 Edge view of the octahedra shows them as four-sided 
 pyramids, base to base. Concretions of these crystals 
 may occur as shown in the figure. 
 
 Calcium oxalate also occurs in small circular crystals, 
 sometimes smaller than blood corpuscles. 
 
 Kare forms : — Large octahedra, double octahedra 
 ("twins"), discs, and tablets with rounded corners. 
 The dumb-bell, according to Heitzmann and others, is 
 the disc seen in edge view. Uric acid sometimes crys- 
 tallizes as dumb-bells, but they are brownish in color. 
 
 Calcium oxalate crystals are more easily found after 
 any phosphates present have been dissolved by addi- 
 tion of acetic acid, or urates cleared up by heat. 
 
 Physiology: — Oxalate of lime, CapaOj, formed by the com- 
 bination of oxalic acid with calcium (lime) occurs in the urine as 
 sediment after eating heartily of apples especially those of the 
 Spitzbergen variety, bananas, and rhubarb. In the spring when 
 "pie-plant pie" is a favorite dish, oxalate sediments are common. 
 A case is on record where a boy ate so much "pie-plant" and 
 drank so much hard water that the oxalate crystals formed in his 
 body caused hsematurial Cabbage, carrots, spinach, asparagus, 
 
 34 
 
386 URINARY ANALYSIS. 
 
 Borrel, onions, tomatoes, turnips, gooseberries, cresses, parsnips and 
 saccharine articles of diet may also be responsible for the sedi- 
 ment, as also an excess of fat meat. Certain beverages may 
 cause a sediment of oxalate of lime; these are alkaline waters, 
 carbonated drinks, fermented liquors, and sparkling wines, 
 
 In cases when the sediment is due to food or drink it is tempor- 
 ary. Persistent presence of the sediment regardless of diet is 
 probably pathological, when the sediment occurs before the urine 
 is 34 hours old. 
 
 Pathology: — Insufficient activity of that stage of oxidation in 
 the body which changes oxalic acid into carbonic. Hence oxalate 
 of calcium sediments are found in a great variety of disorders. 
 
 1. Due to the action of certain drugs as gentian, rhubarb, 
 squill, valerian, and others. 
 
 3. In febrile disorders. 
 
 3. Pulmonary and cardiac affections in which respiration is 
 impeded. 
 
 4. Disorders of the hepatic system. 
 
 5. Depressed conditions of the nervous system. 
 
 The tendency to oxaluria is now regarded as indicating even 
 more defective oxidation than the condition known as lithiasis 
 (uric acid sediments). 
 
 According to Debout d' Estr^es oxaluria i» more common in 
 America, lithiasis more common in Europe. 
 
 Clinical hints: — 
 
 1. Oxalate sediments in urines of high specific 
 gravity, 1026 to 1040, are found in many cases of 
 nervous dyspepsia, hypochondria, or melancholia. 
 Symptoms suggesting locomotor-ataxia may occur 
 which, however, disappear when the digestive trouble 
 is remedied. 
 
 2. Patients with urine, as above, quite frequently 
 complain of pain in the region of one kidney or the 
 other, urinate frequently, and cannot retain their 
 urine at times. 
 
 3. Open air life especially in dry climates or in the 
 mountains is a sovereign remedy for this class of 
 patients. 
 
 4. The tendency to "oxaluria" lasts a long time. 
 I have one patient still suffering from recurrences of 
 the symptoms after 14 years. 
 
 5. Severe attacks of prostato-urethritis may occur 
 in protracted cases of oxaluria. 
 
 6. Stone formation is fairly common in chronic 
 cases of oxaluria. Stone may be present in the kidney 
 and yet oxalate crystals not always abundant, some- 
 times even absent from the urine. This I have 
 
EXAMINATION OF URINE. 267 
 
 observed in two cases in which calculus was subse- 
 quently passed, after renal colic. 
 
 CTSTIN IN THE SEDIMENT. 
 
 Chemical Composition and Synonyms:— Formula, CaH.NSOs, 
 amido-sulpho-pyruvic acid, an amide of the lactic acid series; 
 contains more than 35 per cent of sulphur. Cystine. German, 
 Cystin. French, Cystine. An organic substance. 
 
 Occurrence:— A sediment seldom occurring, especially in 
 strongly acid urine; when occurring is commonly in faintly acid, 
 pale urine which on standing gives off odor of sulphuretted hydro- 
 gen as well as that of ammonia. 
 
 Color and appearance: — Of pale-lemon, or dirty yellowish 
 gray color often changing to green on standing. 
 Solubility: — 
 
 1. Insoluble in cold and hot water, ether, alcohol. 
 
 2. Insoluble in acetic acid. 
 
 8. Soluble in ammonia, and in solutions of sodium and potassium 
 hydroxides, as liquor potassae, but insoluble in solution of am- 
 monium carbonate. 
 
 4. Soluble in hydrochloric acid. 
 
 5. Soluble in solutions of oxalic acid. 
 
 6. Soluble in large excess of hot water. 
 Characteristic test:— None. 
 
 Chemical recognition:*— Let urine settle, decant, filter sedi- 
 ment, wash latter with water, and (1) test on platinum foil. Cys- 
 tin does not fuse but bums with a bluish-green flame and without 
 melting, while a sharp, acid odor like hydrocyanic acid, is evolved. 
 (If in solution in the urine, it may be precipitated by acetic acid, 
 and its solubility ascertained in reagents mentioned under SolVf 
 bility above,) (2) Heated with nitric acid, it dissolves with 
 decomposition and, on evaporation, leaves a reddish-brown mass 
 which does not give a purplish color with ammonia. 
 Microscopical appearances: — Cystin may occur as hexagonal 
 
 tablets superimposed upon or 
 contiguous to one another and 
 which with a power of 5f'0 
 diameters are seen to have 
 radii, which are fine lines of 
 secondary crystallization. In 
 many the angles become worn 
 off, approximating a circular 
 form. The crystals may have 
 a faint greenish tinge, or pos- 
 sess an opalescent lustre sug- 
 gesting mother of pearl. Less 
 _ commonly cystine occurs as 
 
 TT. -n r^ ..■ /T^ T. \ highly refractive four-sided 
 FIG. o2. Cystm. (Daiber.) ^^^J^ ^^^^^^^ ^j^^^e si^g^ ^^e 
 
 dark, when out of the direct line of vision, but brilliant white 
 when presented vertically to the light. 
 
 * The value of the ferrooyanide of sodium test has been diepated bj Kraken- 
 berg. 
 
 <:^2D 
 
 o 
 
 o 
 
368 URINARY ANALYSIS. 
 
 Micro-chemical reactions:— Differentiate from uric acid by its 
 solubility in oxalic and hydrochloric acids; from triple phosphate 
 by its solubility in ammonia. 
 
 Physiology:— Cystin sediments may be noticed in the urine 
 for years, especially in young men, without impairment of the 
 health of the individual but they can hardly be called physiological. 
 
 Pathology:— Some families are prone to cystin sediments and 
 calculi as others are to uric acid, hence it is probably associated 
 with hepatic disorders. Cystin has been found in the urine of 
 Bright's disease, chlorosis, and acute articular rheumatism. Little 
 is known about it. 
 
 HIPPUEIC ACID IN THE SEDIMENT. 
 
 Microscopical Appearances: — Colorless four-sided prisms 
 (Fig. 53) whose sides, wlien seen with a power of 500 diameters, 
 sometimes show indentations. It also occurs in clusters of very 
 fine needles. 
 
 Fig. 53. Hippuric acid. 
 
 Note: — ^The writer having seen a slide of hippuric acid actually 
 deposited in urine, prefers to give a cut as above of a drawing of 
 it rather than to copy those more elegant but less typical ones 
 usually given in the books. 
 
 Micro-chemical tests:— Differentiate from uric acid by solu- 
 bility in alcohol; from triple phosphate by insolubility in acetic 
 acid. The crystals are soluble in ammonia, but insoluble in 
 hydrochloric acid. 
 
 Signiftcance:— Usually due to ingestion of certain berries as 
 cranberries or bilberries; also to administration of benzoic acid, 
 benzoates, and other drugs. Heitzmann says it is sometimes 
 found in the sediment of the urine of diabetes. 
 
 CALCIUM SULPHATE IN THE SEDIMENT. 
 
 Chemical constitution and synonyms:— Calcium sulphate, 
 CaS04. Formed by union of sulphuric acid or sulphates with 
 calcium or its compounds. Sulphate of lime, gypsum. German, 
 schwefehaiirer Kalk, Gyps. French, sulphate de chaux. 
 
 Occurrence: — A rare sediment in concentrated urines of highly 
 acid reaction. 
 
 Form: — Crystalline and sometimes amorphous. 
 
 Color and appearance of sediment:— A whitish, heavy, dense, 
 .sediment. 
 
EXAMINATION OF URINE. S69 
 
 Solubility:— 
 
 1. Sparing soluble (1-400) in cold water. 
 
 2. More soluble in large bulk of hot water. 
 
 8. Insoluble in ammonia and in strong hydroohlorio acid. 
 
 Characteristic te*t:— None. 
 
 Cliemical recognition:— Let urine settle, decant supernatant 
 urine from sediment, filter the sediment, wash latter with cold 
 water, dissolve in large bulk hot water, divide into two portions, 
 test one with barium chloride, the other with ammonium oxalate. 
 
 KREATININ IN THE SEDIMENT. 
 
 Microscopical appearances:— According to Heitzmann kreat- 
 inin sometimes appears in the sediment of acid urine. Tha 
 crystals (Fig. 54) are colorless or at most light greenish in shape 
 
 Fig. 54. Kreatinin. 
 
 somewhat like those of uric acid, but seen with a power of 500 
 diameters, have striations both concave and radiating. 
 
 Note: — The cut given above is from a drawing made of a slide 
 belonging to Dr. Charles Heitzmanu. None of the books on 
 urinary analysis in ordinary use give cuts resembling these forms. 
 
 Signiflcauce: — The crystals shown in the figure were found in 
 the urine in a case of ursemia, and are regarded by Heitzmann as 
 an unfavorable sign. Small crystals of it may be found after 
 excessive muscular exertion. 
 
 LEUCIN AND TYROSIN IN THE SEDIMENT. 
 
 Chemical constitution and ajnonjms:—Leucin, leucine) C. 
 HuNOa, or C6Hio(NH2)COOH, amido-caproic acid, and tyrosin, 
 (tyrosine) O.HnNOs, or C6H<OH.CHj.CH(NH3).COOH, also an 
 amido-fatty acid, a monobasic phenol acid. Both leucin and 
 tyrosin are decomposition products of the albuminoids. German, 
 Leucin, Tyrosin. French, Leucine, Tyrosine. 
 
 Occurrence:— In urine containing excess of biliary coloring mat- 
 ters. Possibly also in urine not containing bile. It is the opinion 
 of Jaksch that in some instances when these bodies were supposed 
 to have been in the urine that they were not sufficiently identified. 
 
 Form:— Crystalline.— Leucin, yellowish and of greasy feel. 
 Tyrosin, snow-white crystalline masses, tasteless and odorless. 
 Solubility of leucin:— 
 
 1. Insoluble in ether. 
 
 2. Insoluble in cold hydrochloric acid. 
 
 3. Soluble in caustic alkalies, as liquor potassse, and ammonia. 
 
270 URINARY ANALYSIS. 
 
 4. Partly soluble in water and in alcohol, more readily in hot 
 alcohol. 
 Solubility of tyrosin:— 
 
 1. Insoluble in alco Viol and ether. 
 
 2. Insoluble in acetic acid. 
 
 3. Soluble in hydrochloric acid. 
 
 4. Soluble in caustic alkalies. 
 
 5. Difficultly soluble in cold water. 
 
 6. Readily soluble in hot water. 
 
 Chemical recognition of leucin:— Concentrate the urine 
 slightly over the water bath, let settle, decant, collect sediment 
 on filter, wash with cold water, dissolve in ammonia with addi- 
 tion of ammonium carbonate, set aside, allow to evaporate, then 
 separate from tyrosin by treating with absolute alcohol, which 
 dissolves some of the leucin but not the tyrosin. Let the alcoholic 
 solution evaporate and test as follows: 
 
 (a) Scherer's test:— Place some of the residue on platinum foil, 
 add a few drops of nitric acid and heat until it is consumed. A 
 colorless residue is left. Now heat again with a drop or two of 
 caustic potash solution and, if leucin is present, drops of an oily 
 fluid will form, which does not adhere to the platinum, (b) Hof- 
 meister's test: — Dissolve another part of the original ammoniaoal 
 residue in hot water and further heat with some proto-nitrate of 
 mercury; a deposit of metallic mercury occurs on the tube, (c) 
 Heat cautiously some of the residue in a glass tube open at both 
 ends to about 170" 0. (338° F.), and if leucin is present it sublimes 
 without fusing inta woolly masses, and a smell of amyl-amin is 
 given off. 
 
 Chemical recognition of tyrosin;— Go back to the residue from 
 which leucin was separated by treatment with absolute alcohol 
 and test as follows: (a) Place a very small particle of it on a 
 watch-glass, moisten with a drop of sulphuric acid, cover over, 
 Ift stand half an hour, dilute with water, saturate while hot with 
 calcium carbonate, filter, and treat the colorless filtrate with a 
 very dilute solution of acid-free perchloride of iron (made by sub- 
 liming the perchloride and dissolving sublimate in water). A 
 violet color appears readily destroyed by excess of the iron solu- 
 tion. (Piria, Stadeler). (b) Dissolve another portion of the residue 
 in hot water, add a few drops of Millon's reagent (made by dis- 
 solving 1 part by weight of mercury in 2 of nitric acid, heating 
 gently, and adding 3 parts of water) and there arises a red pre- 
 cipitate, the supernatant fluid being colored red to purple-red. 
 (Hoffmann's test). 
 
 HoflEmann's test may be applied directly to an urinary sediment 
 supposed to contain tyrosin. 
 
 Microgcopical appearances: — Leucin (Fig. 55) appears as yel- 
 
 ®^ o 
 
 
 Fig. 55. Leucin (a) and tyrosin (b). 
 lowish, highly refracting spheres somewhat resembling fat gran- 
 ules, though not so highly refracting, and which, with a high 
 
EXAMINATION OF URINE. 371 
 
 power (500 diaraetersj, look large. Tyrosin appears as very fln« 
 needles in sheaf -like collections. Crystallized from an alkaline 
 solution it may occur in form of rosettes composed of fine needles 
 arranged radiately. 
 
 Micro-chemical tests: — Differentiate leucin from fat granules 
 by its insolubility in ether; from ammonium urate by no decom- 
 position nor separation of uric acid crystals when treated with 
 hydrochloric acid. 
 
 Physiology: — The amido-fatty acids being products of decom- 
 position of proteids are not found In normal urine. They are said 
 to occur physiologically in the axilla and between the toes. 
 
 Pathology: — When retrograde changes are rapid in the body, as 
 in extensive suppuration and gangrene, leucin and tyrosin are 
 formed in the body in large amounts, may pass into the urine, 
 and largely supplement or replace urea. 
 
 Significance: — Sediments of leucin and tyrosin are found in 
 acute yellow atrophy of the liver and in acute phosphorus poison- 
 ing. Whether they occur in other diseases, as infectious dis- 
 eases, is doubted. Prus has found abundance of leucin in a case 
 of leukasmia. 
 
 CALCIUM SULPHATE, 
 
 Microscopical appearances: — Long, colorless needles, (Pig. 56), 
 
 Fie. 56. Calcium Sulphate. {Daiber). 
 
 or elongated tables with abrupt extremities; sometimes also in 
 dumb-bell shaped amorphous masses. 
 
 Micro-cheinical tests:— The crystals and the amorphous masses 
 are both insoluble in ammonia and in strong hydrochloric acid. 
 
 Physiology: — Not found normally in urine. 
 
 Pathology:— Concentrated urine of highly acid reaction is 
 thought to be necessary for the presence of this sediment. 
 
 Clinical significance:— Unknown or none other than given 
 under Pathology. 
 
 XANTHIN (HYPOXANTHIN) IN THE SEDIMENT, 
 
 Occurrence: — A very rare sediment in acid urine. 
 Form: — Crystalline, 
 
272 URINARY ANALYSTS. 
 
 Microscopical appearances: — Lemon-shaped or whetstone- 
 shaped crystals somewhat like uric- 
 acid. (Fig. 57). 
 Micro-chemical tests:— viwi-n/T-- \/ n\i^ 
 
 1. Differentiate from uric acid by JloJwff f\ 
 
 mation of ammonium urate crystals, ^—^ O^^'^yfKflW.r-^A^ 
 and by solubility in hydrochloric /^'^^^TKn^WKN^^ v.S' 
 
 solubility in ammonia without for- '^^A^ 
 
 .«.-" - - '-^^.^ 
 
 2. Insoluble in acetic acid. ^ [N/yiVV^ 
 
 Significance:— Found by Benca 
 
 Jones in the sediment of urine in -"'Si."'' -^^FJ. ™' 
 
 case of a boy who passed a calculus (Hypoxanthm?) 
 
 composed of it. (Neubauer). 
 
 Note: — It is now thought that the substance is really hypoxan- 
 thin, not xanthia. 
 
SEDIMENTS IN URINE. 273 
 
 CHAPTEE XLIII. 
 
 SEDIMENTS FOUND USUALLY OR ALWAYS IN ALKA- 
 LINE URINE. 
 
 These are ammonium-magnesium phosphate, sim- 
 ple phosphates, and ammonium urate ; less commonly 
 calcium carbonate, magnesium phosphate, soaps, 
 indigo. 
 
 SEDIMBNTS OF AMMONIUM-MAGNESIUM PHOSPHATE OK 
 TRIPLE PHOSPHATE. 
 
 Occurrence: — Always in urine either alkaline or 
 verging on alkalinity. 
 
 Chemical composition : — (N H^) Mg PO4.6 Ha O. 
 Galled "triple" because of 6HiO forming the third 
 part of the formula. Result of decomposition of urea 
 into ammonium carbonate and union of latter with 
 magnesium phosphate. 
 
 Color and appearance: — Phosphatio sediments are 
 whitish or dirty-white. If triple phosphate crystals 
 are present in large numbers, they sparkle like minute 
 diamonds when the sediment is held up to a strong 
 light. The urine containing it is turbid when freshly 
 voided. 
 
 Crystalline form: — Triangular prism. 
 
 Chemical tests: — 
 
 1. Readily soluble in acids even in 20 per cent 
 acetic acid. 
 
 2. Insoluble in solutions of the caustic alkalies, as 
 liquor potassae. 
 
 3. Eed-litmus paper turned blue by ammoniacal 
 urine reddens again when dry, allowing us to infer 
 that the phosphatic sediment contains triple phosphate. 
 
 4. Urine has an odor of ammonia. 
 
 35 
 
274 URINARY ANALYSI.-i. 
 
 6. A rod moistened with hydrochloric acid held 
 near the urine shows fumes of ammonium chloride. 
 
 6. Urine effervesces vigorously when acids are added 
 to it. (Carbonate of ammonium decomposed by acid, 
 and carbonic acid gas given off.) The foam may rise 
 so fast as to bubble over from the test-tube before the 
 inexperienced urine tester knows what is happening. 
 
 Microscopical appearances: — 
 
 Triple phosphate (Fig. 58) occurs in the form of 
 
 Fig. 58. Ammonio-magnesium phosphate. (Daiber). 
 
 triangular prisms, complete and incomplete. The 
 colorless crystals are easily seen with a low power 
 (150 diameters) and with a high power are very large. 
 The incomplete forms are seen alone in slightly alka- 
 line urine, or in urine which having been acid is verg- 
 ing on alkalinity. The complete forms appear in 
 profusion in strongly alkaline ammoniacal urine. The 
 ends of the prisms are beveled. The term "coffln-lid" 
 is used in describing them. Seen in edge view they 
 appear as squares. Formed artificially they appear as 
 star-shaped, feathery crystals (Fig. 32). Both forms 
 may be artificially prepared by adding a small lump 
 of ammonium carbonate to two or three ounces of 
 urine and setting aside. The crystals are beautiful 
 objects when seen by polarized light. 
 
 Physiology: — Normal urine which has become stale and am- 
 moniacal deposits triple phosphate. If occurring in freshly 
 voided urine, the sediment is pathological. 
 ■ Pathology:— 
 
 1. Sediment due to ammoniacal decomposition of the urine 
 within the body; urea is converted into ammonium carbonate, 
 which in turn gives up its ammonium to magnesium phosphate 
 which is present. 
 
 2. Sediment found in obstructive diseases of the lower urinary 
 tract: retention of urine in bladder or pelvis of the Jiidney. Hence 
 
SEDIMENTS IN URINE. 275 
 
 in diseases of the spinal cord, paralysis of the bladder, enlarged 
 prostate, etc. 
 
 3. Sediment sometimes occurs in vegetarians who are under 
 mental strain; in time phosphatic stone may form in such cases, 
 as well as in others. 
 
 Clinical notes: — 
 
 1. Triple phosphate crystals in freshly voided urine 
 are common in conditions preceding "surgical kidney" 
 viz., septic inflammations of the urinary tract. 
 
 2. The first introduction of the catheter, especially 
 in cases of elderly men, is dangerous when triple phos- 
 phate crystals are found in freshly voided purulent 
 urine. 
 
 3. An immense number of triple phosphate crystals 
 in urine should always suggest presence of calculus, 
 especially in cases where other causes for the patient's 
 condition are not evident. In several cases, operations, 
 or renal colic and passage of stone, have verified diag- 
 noses of calculus made by the writer. 
 
 4:. The fact that the patient is voiding phosphatic 
 urine does not necessarily mean presence of phosphatic 
 calculus. The stone may be of any variety and set up 
 inflammation with decomposition of urine and forma- 
 tion of triple phosphate. 
 
 6. In one of the writer's cases in which immense 
 numbers of triple phosphate crystals were deposited, 
 without pus, in the urine of a man under great mental 
 strain for years, renal colic finally took place and the 
 patient voided a phosphatic calculus weighing 0.4 
 gramme (about six grains). The patient was after 
 this free from the phosphatic sediment except occa- 
 sionally when greatly fatigued or under nervous strain. 
 He has gained 50 pounds in weight and in 8 years 
 there has thus far been no recurrence of renal colic. 
 
 7. In the case in which Dr. Ohas. Adams removed 
 a renal calculus weighing nearly half a pound (Fig. 59), 
 the writer found immense numbers of triple phosphate 
 crystals, together with pus, in the fresh urine. 
 
270 
 
 VmXAIiY ANALYSIS. 
 
 Fig. 59. Eenal calculiis(actual size; reiiio\-e'l Uy Dr. Chas. Adams. 
 
SEDIMENTS IN VSINE. 277 
 
 •IMPLE PHOSPHATES (eAETHT PHOSPHATES). 
 
 Chemical constitution: — Basic phosphates of cal- 
 cium and magnesium. Cas(P04)2 and Mg8(P04)a. 
 Neutral calcium phosphate, CaHP04. 
 
 Occurrence: — In alkaline urine. Neutral calcium 
 phosphate in feebly acid, neutral, or alkaline urine. 
 
 Color and appearance: — The phosphatic sediment 
 is light colored, usually dirty white ; may occur as a 
 flocculent turbidity in freshly voided urine, which set- 
 tles rather slowly and is easily disturbed by shaking. 
 Occasionally the sediment is so abundant as to have a 
 creamy white color and may be mistaken by the 
 patient for seminal fluid. 
 
 Chemical tests: — 
 
 1. Urine more or less cloudy when freshly voided, 
 but the sediment is not dissolved by heat. (Differen- 
 tiated from urates). 
 
 2. Readily dissolved by acids, even by 20. per cent 
 acetic acid. 
 
 8. Eed litmus paper colored blue ; does not become 
 red again when dried, if triple phosphate is not present 
 in large quantity. (Urine alkaline from fixed alkali). 
 
 4. The urine does not smell ammoniacal, if triple 
 phosphate is not present in great quantity. 
 
 5. A rod moistened with hydrochloric acid does 
 not fume (if triple phosphate is not abundantly present). 
 
 Note: — Both simple phosphates and triple phosphate may occur 
 in the same sediment, hence tests 3, 4 and 5 are of value only 
 when triple phosphate is absent or present in relatively small 
 amount, ammoniacal decomposition not having as yet taken 
 place. 
 
 6. Urine effervesces on addition of acids but not so 
 vigorously as when triple phosphate has been deposited 
 by ammoniacal decomposition. 
 
 7. Urine when heated becomes turbid from further 
 deposit of phosphates, but the turbidity disappears 
 with effervescence when an acid is added. (Differen- 
 tiated from albumin). 
 
 Microscopical appearances: — The simple phos- 
 phates are either amorphous in form or, less com- 
 monly, crystalline. If amorphous, (Fig. 60, A), the 
 
278 
 
 URINARY ANALYSIS. 
 
 sediment appears in the form of minute pale granules 
 arranged in irregular patches and sometimes mistaken 
 for granular masses of organic matter. A drop of 20 
 per cent acetic acid quickly dissolves this sediment on 
 the slide. 
 
 "When crystalline the sediment usually consists of 
 neutral calcium phosphate, stellar or stellate phosphate, 
 (Fig. 61) a rarer sediment than any other phosphatic 
 deposit, save crystalline magnesium phosphate. 
 
 
 Fig. 60, Simple Phosphates and Carbonate of Lime. 
 
 A. Amorphous simple phosphates. S. Star-shaped simple phos- 
 phates (crystalline calcium phosphate). C. Amorphous carbonate 
 of lime. M. Combination of carbonate of lime with magnesium 
 salts. Magnified 800 diameters. (After Heitzmann). 
 
 Physiology:— 
 
 1. A slight sediment of amorphous simple phosphates recurring 
 after a full meal, when the urine is naturally less acid than at 
 other times can hardly be regarded as abnormal. 
 
 3. It is said that deposits of crystalline calcium phosphate may 
 take place in tlie urme of healthy people during the summer. 
 
 Pathology: — Circumstances favoring increase of alkalescence 
 of the Hood. The sediment of earthy phosphates is in the main 
 due to alkalinity of the urine and not merely to excess of phos- 
 phates in the urine. The latter occurrence is rare at least in 
 Chicago and vicinity and not necessarily accompanied by any 
 sediment at all unless the urine at the same time happens to be 
 neutral or alkaline. Urine alkaline from fixed alkali deposits 
 
SEDIMENTS IN URINE. 879 
 
 earthy phosphates with usually a few crystals of triple phosphate, 
 since ammonlacal decomposition usually quickly takes place in 
 such urines. 
 
 The sediment is found in cases of accumulation of carbonic 
 acid in the system, as: 
 
 1. Debility with feeble respiration, convalescences from acute 
 diseases. 
 
 3. Flatulent dyspepsia; fatty acids, formed by fermentative 
 changes, being oxidized in the blood into carbonic acid, and 
 carbonates formed which increase alkalescence of the blood and 
 diminish acidity of the urine. 
 
 Diagnosis: — 
 
 1. The persistent sediment of earthy phosphates 
 most frequently means flatulence of the small intestine. 
 The urine when heated becomes turbid; but when 
 acetic or nitric acid is added there is effervescence and 
 the urine clears up. 
 
 2. Phosphatio sediments are thought to be a sign 
 of "nerve waste" but the writer has shown that they 
 are not often, in fact very rarely, accompanied by any 
 increase in the total phosphorus in urine, estimated as 
 phosphoric acid. 
 
 8. Ealfe speaks of cases in which there is, in addi- 
 tion to the phosphatio sediment, a real increase in the 
 total phosphorus in the urine ; such cases are more 
 serious, may be attended by emaciation, and associated 
 with phthisis, may result in diabetes insipidus, or 
 alternate with diabetes mellitus. 
 
 4. Crystalline calcium phosphate may occasionally 
 be found in the urine of persons during the summer. 
 Roberts regards it as often an accompaniment of 
 serious disorder as cancer of pylorus, phthisis, and 
 exhaustion from obstinate chronic rheumatism. It 
 is also said to be found in diseases of the brain. 
 
 Clinical notes: — 
 
 1 . The term phosphaturia is used to designate the 
 conditions in which phosphatio sediments occur in the 
 urine. 
 
 2. The patient with phosphatio sediment of simple 
 phosphates is usually low-spirited, thinks he is losing 
 seminal fluid, has to urinate often, is sallow, consti- 
 pated or of irregular bowels, and perhaps loses flesh. 
 These symptoms are quite regularly associated with 
 
880 URINARY ANALYSIS. 
 
 flatulent dyspepsia in debilitated persons and do not 
 result from the condition of the urine. 
 
 3. Phosphaturia has been noticed to follow gonor- 
 rhoea and it then has a particularly depressing efifeet 
 on the patient. It is also common during the period 
 of sexual activity in men. 
 
 4. It is true that spermatozoa are quite frequeiitly 
 found in urine depositing a phosphatic sediment ; 
 but this is not invariable nor is spermatorrhoea a neces- 
 sary concomitant of phosphaturia. 
 
 5. The phosphatic sediment in urine may be easily 
 cleared up by administration of acids as benzoic, bor- 
 acic, or phosphoric in sufficient doses to make the 
 urine acid. This often has a beneficial effect on the 
 patient's spirits. But radical treatment is that of 
 flatulent dyspepsia in most oases. 
 
 CRYSTALLINE CALCIUM PHOSPHATE. 
 
 Chemical constitution:— Hydrogen calcium orthophosphate, 
 CaHPOi, SHaO; (neutral calcium phosphate. neutral phosphate of 
 lime), a combination of phosphoric acid with calcium in which 
 one atom of the hydrogen of the acid still remains; in urinary 
 sediments called stellate or stellar phosphate. 
 
 Synonyms: — German, neutrales phonphorsaures Calcium phos- 
 phat. Fkench, phosphate de chaux neutre. 
 
 Occurrence: — In pale, abundant, feebly-acid, neutral, or alka- 
 line urine. When found, is usually in feebly-acid urine yerging 
 on alkalinity. 
 
 Color and appearance: — Occurs either in the whitish sediment 
 of amorphous phosphates, or together with oxalate of lime in a 
 light colored, flocculent sediment of small bulk. 
 Solubility: — 
 
 1. Not dissolved when the sediment is heated. 
 
 2. Soluble in acids, even in twenty per cent acetic acid, espe- 
 cially when shaken with it. 
 
 3. Decomposed by ammonia. 
 
 Chemical recognition: — If necessary the sediment may be sep- 
 arated by filtration, washed, dissolved in acetic acid, tested for 
 phosphoric acid with uranium nitrate, and for calcium with am- 
 monium oxalate. 
 
 Microscopical appearances:— Stellar phosphate occurs essen- 
 tially as crvstalline rods, usually grouped in stellar or rosette 
 form, or in form of lances or wedges, but sometimes lying entirely 
 unarranged. The crystals are colorless, but under the microscope 
 look dark towards the centre of the clusters. (Fig. 61). They can 
 be easily seen with a low power, 150 diameters, but are best 
 studied with higher. From triple phosphate they are distinguished 
 by their form. 
 
PHOSPHATIO SEDIMENTS IN UBINE. 
 
 2ai 
 
 Fia. 61. Stellar phosphate. (Beale), 
 
 Micro-chemical tests: — 
 
 1. Easily distinguished from uric acid by solubility without 
 effervescence, when a drop of twenty per cent acetic acid is 
 placed on the margin of the cover glass. 
 
 3. Not dissolved when the sediment is warmed on the slide. 
 (Differentiation from crystalline urates). 
 
 Physiology:— The appearance of crystalline calcium phosphate 
 depends on an excess of calcium phosphate in a feebly-acid urine. 
 According to Bence Jones this sediment may be produced at 
 pleasure by taking lime-water. 
 
 It is said that this sediment may occur in the urine of healthy 
 persons during the summer. 
 
 Pathology: — Any condition in which an excess of calcium 
 phosphate is found in feebly acid urine. 
 
 Clinical notes:— 
 
 i. According to some writers the sediment of stellar phosphate 
 is found in cases of serious disorder of the brain. 
 
 2. Roberts takes a gloomy view of the sediment; he regards it 
 as an accompaniment of some grave disorder, as cancer of the 
 pryloruB, phthisis, and exhaustion from obstinate chronic rheuma- 
 tism. The crystals are then plenty. 
 
 3. My own experience is as follows: Out of 640 urinary sedi- 
 ments recently examined, stellar phosphate occurred 9 times, or 1 
 
283 UBINABY ANALYSIS. 
 
 in 70. The patients were 6 men and 3 women. The cases were 
 (1) chronic prostato-urethritis with impotence and profound men- 
 tal depression; (2) paresis of the bladder from injury; (3) hyper- 
 semiaof the liver; (4) urine following recovery from uraemia; 
 (5) nervous prostration from over-w ork; (6) renal calculus, removed 
 by Dr. Chas. Adams; (7) debility; no other diagnosis; (8) pregnancy; 
 (9) post-gonorrhoea 1 cystitis. 
 
 But two of these were examined during the summer. The 
 crystals were plenty in all cases. 
 
 CALCIUM CAEBONATB. 
 
 Chemical composition:— Normal or basic calcium carbonate, 
 CaCOa, carbonate of lime, a combination of carbonic acid with 
 calcium, in which the hydrogen of the acid is completely replaced 
 by calcium. 
 
 Synonyms:— German, kohlensaurer Kalk. French, carbonate 
 de ohaiix. 
 
 Occurrence: — A rare sediment found in alkaline urine. 
 
 Color and appearance: — Whitish sediment like that of phos- 
 phates. 
 
 Form: — Amorphous and crystalline. 
 Solubility: — 
 
 1. Soluble in acids, even 20 per cent acetic acid, with Serves- 
 oenee (evolution of carbonic acid gas). 
 
 Microscopical appearances:— Should be studied with a high 
 power, 300 to 500 diameters, when it appears as dumb-bell shaped 
 masses, and coarsely granular concretions. According to some 
 observers it appears also as minute spherules like the spherules of 
 calcium oxalate. Heitzmann's slide of carbonate of lime shows 
 them somewhat prismatic in form. Fig. — gives the different 
 appearances. See also Fig. 60. 
 
 9© 
 
 
 fl^ DooOotl 
 
 a 
 
 Fig. 62. Calcium carbonate, 
 (a) Daiber. (b) A few crystals from one of Heitzmann's slides. 
 
 Micro-chemical tests:— Readily distinguished from uric acid 
 and calcium oxalate by solubility with evolution of bubbles, when 
 a drop of 20 per cent acetic acid is placed on the margin of the 
 cover glass (calcium phosphate dissolves, but without bubbles). 
 
 Patholog'y: — According to Heitzmann the sediment occurs in 
 cases of bone caries and tuberculosis; also in rickets. 
 
PHOSPHATIO SEDIMENTS IN URINE. 283 
 
 CRYSTALLINE MAGNESIUM PHOSPHATE. 
 
 Chemical constitution:— Tribasio, or normal magnesium phos- 
 phate, Mg,(P04)a.22H20, phosphate of magnesia, a combination 
 of phosphoric acid with maguesium, in which the hydrogen of 
 the acid is completely replaced by magnesium. 
 
 Synonyms:— German, Magnesium phosphat; phosphorsaure 
 Magnesia. French, phosphate de mugnisie. 
 
 Occcurrence: — A very rare sediment, which occurs in concen- 
 trated urine of feebly acid, neutral, or alkaline reaction. 
 
 Color and appearance:- Whitish sediment. 
 
 Form:— Crystalline. 
 Solubility:— 
 
 1. Readily soluble in acetic acid and re-preoipitated on addition 
 of sodium carbonate solution. 
 
 3. In a solution of one part by weight ammonium carbonate in 
 five of water it is in time partly dissolved. (See Micro-chemical 
 Tests). 
 
 Microscopical appearances: — Crystallizes in large, highly re- 
 fracting, rather long rhombic tablets or plates. (Fig. 63). They 
 
 a b 
 
 Fig. 63. Crystalline magnesium phosphate. 
 a (Daiher), b {Jaksch). 
 
 can be seen with a low power, 150 diameters; best studied with 
 500 diameters. 
 
 Micro-chemical tests:— 
 
 1. DifftTentiate from calcium oxalate by ready solubility in 
 acetify acid. 
 
 2. From triple phosphate by the action of ammonium carbonate 
 solution which makes them faint and after some minutes eats 
 away the edges. (Triple phosphate not changed by ammonium 
 carbonate). 
 
 SOAPS OP lime and magnesia. 
 
 Chemical constitution: — Calcium and magnesium salts of the 
 higher fatty acids. 
 
 Occurrence:— In feebly acid urine. 
 
 Microscopical appearances:— Crystals (Fig. 64) closely resemb- 
 ling tyrosin, but not yielding the characteristic reactions of that 
 body. 
 
 Patljology:- Seen once by Jaksch in the case of a woman with 
 severe puerperal septicaemia. 
 
384 
 
 URINARY ANALYSIS. 
 
 FlQ. 64. Soaps of lime and magnesia. (Jakseh). 
 
 INDIGO IN THE SEDIMENT. 
 
 Chemical constitution: — Derived from the decomposition of 
 indoxyl sulphate (indican), the indoxyl being oxidized into indigo 
 blue, thus: 3 (CsHeNOH) + Oa = C„H,„NjOa + 2H,0. 
 (Indoxyl.) (Indigo-blue.) 
 
 Occurrence: — Not rare in decomposing (alkaline) urine which 
 sometimes shows a bluish-red pellicle of microscopic crystals of 
 indigo-blue owing to the decomposition of the indican. Found 
 also at the bottom of the glass. 
 
 Microscopical appearances:— Blue rhombic crystals and fine 
 blue needles (Fig, 65), mostly cohering in clusters; also amorphous 
 in flakes. 
 
 / 
 
 C3 »'", 
 
 Pig. 65. Indigo. (.Daib&r). 
 
 Cliemlcal test: — The substance when heated sublimes in violet 
 vapors. 
 
 Patliology:— Jakseh has found it in remarkable abundance in 
 the ammoniacal fermentation of the urine of jaundice, and also 
 in the acid urine of a case of abscess of the liver. 
 
RARER SEDIMENTS IN URINE. 
 
 285 
 
 CHAPTEE XLIY. 
 
 SEDIMENTS OF INFREQUENT OCCURRENCE. 
 
 Certain sediments of infrequent occurrence not con- 
 fined to urine of any particular reaction are the 
 following : 
 
 Fat, Oholesterin, Hsematoidin, Melanin. 
 
 SEDIMENTS OP FAT. (LIPURIA). 
 
 Synonyms:— German, Fett. French, Oraisse. 
 
 Occurrence:— In urine of any reaction. 
 
 Appearance:— If abundant the urine becomes milky, but the 
 milkiness is cleared by addition of ether. 
 
 Chemical tests: — Soluble in ether; also in hot alcohol, carbon 
 disulphide, and chloroform. Less soluble in benzol, insoluble in 
 water. 
 
 Microscopical appearances: — Fat appears in the sediment 
 under the microscope as bright, highly refracting granules, usu- 
 ally requiring a high power, 300 to 500 diameters for recognition, 
 except when very abundant or 
 of extraneous origin, from lubri- 
 cants, etc. The margins of the 
 granules are dark and somewhat 
 irregular. Micro-chemically tlie 
 granules may be seen to be dis- 
 solved by ether, by placing a 
 drop of the latter on the margin 
 of the cover-glass. 
 
 It may occur in the form of 
 needles (Fig. 66), or be grouped 
 about margario acid needles. 
 See also Fig. 67. 
 
 Physiology: — Fat occurs in 
 the urine physiologically in or 
 during: 
 
 1. Pregnancy. 
 
 3. Administration of fatty 
 substances, as olive oil, cod-liver 
 oU, etc. 
 
 3. After inunctions of 
 substances. 
 
 Pathology:— Fat is found in the urine pathologically in or dur- 
 ing the following conditions: 
 
 1. Chyluria. 
 
 3. Fatty degeneration at some point in the urinary apparatus as 
 in fatty degeneration of the kidneys, and chronic parenchymal 
 
 Fig. 66. Margaric acid needles 
 with fat granules grouped about 
 fatty them. (Daiber). 
 
286 URINARY ANALYSIS. 
 
 tous nephritis; also where pus from an old abscess finds its way 
 into the urinary passages; in pyonephrosis. 
 
 3. Constitutional affections associated with marked cachexia or 
 dependent on systemic Intoxication, as phthisis, long-continued 
 suppuration, pyaemia, yellow fever, poisoning by phosphorus or 
 carbonic oxide, poisoning from external use of carbolic acid, 
 chronic poisoning by turpentine, severe injuries to the bones, 
 diabetes. 
 
 Diagnostic Hints:— 
 
 1. If large fat granules are abundantly seen in the sediment 
 with the microscope, use of the catheter may be inferred. 
 
 2. When small fat granules are found, not due to extraneous 
 matters, fatty degeneration of the kidneys is the condition, more 
 certainly if fatty casts are also found. 
 
 3. Connective tissue studded with fat granules is probably de- 
 rived from the kidneys. 
 
 4. In the urine of women, fat granules of sebaceous origin 
 (smegma) may be seen with the microscope in vaginal epithelia, 
 and in epidermal scales from the nymph se. These are particu- 
 larly noticeable in cases of vaginitis and vulvitis, as from mastur- 
 bation in female children, but are not significant of the latter 
 unless connective tissue be also found. (Heitzmann). 
 Clinical Notes:— 
 
 1. Recovery from parenchymatous nephritis is possible, at least 
 in children, even when the sediment for months is a mass of fatty 
 casts and free fat granules. In one such case, which I saw, the 
 patient, a boy of eight, had for six months such a sediment in his 
 urine together with a very large percentage of albumin — con- 
 stantly above all figures on the Esbach tube. 
 
 2. Purdy speaks of seeing a large amount of fat in the urine 
 occurring intermittently and alternat- 
 ing with sugar. 
 
 3. Cushing, of Boston, saw a case 
 in which a large amount of fat in the 
 urine indicated not only an abscess 
 opening into the urinary tract, but 
 also suflScient sloughing going on to 
 set free the oil of the fatty tissue. 
 
 4. Ebstein speaks of fat in a case of 
 hydronephrosis; Henderson in heart- 
 disease; various authors in diseases of 
 the pancreas; in acute yellow atrophy 
 of the liver. 
 
 5. Jaksch says it may occur in the 
 form of needles (Fig. 67), especially in Yia. 67. Fat in crystalline 
 connection with chronic nephritis and form. (Jaksch), 
 septicaemia. 
 
 CHOLESTERIN IN THE SEDIMENT. 
 
 Chemical constitution: — C!nH440.HiiO, a fatty substance of 
 alcoholoid constitution. 
 
 Synonyms:— German, Cholesterin; Gallenfett. French, Chol- 
 esierine. 
 
 Occurrence: — A very rare sediment. 
 
 Form:— Crystalline. 
 
RARER SEDIMENTS IN URINE. 
 
 287 
 
 Microscopical appearances:— Large, very thin, rhombic plates 
 overlapping (Fig. 68) each other. Occasionally found in urine 
 voided late at night, when patient is exhausted. 
 
 Fia. 68. Cholesterin and fat granules. (Long), 
 
 BILIRUBIN AND H-ffiiMATOIDIN IN THE SEDIMENT. 
 
 • 
 
 Bilirubin, CisHisNsOi, is an extremely rare occurrence in the 
 sediment of urine. It may appear as 
 amorphous 2/eHow granules, red-broiow 
 rhombic tablets, or needle-form bodies 
 (Fig. 69) imbedded in other substances 
 (mucus, or connective tissue), as in 
 nephritis or in cancer of the liver. 
 
 Hsematoidin occurs in forms similar 
 to bilirubin. Chemically it is said to 
 A differ, being insoluble in potassium 
 ^ hydroxide solutions, as liquor po- 
 ^ tassEe, and colored transient blue by 
 nitric acid. (Bilirubin soluble in 
 „ _„ „ .,. caustic potash, colored green by 
 
 Fig. 69. Hsematoidin. nitric acid). 
 {Daiber). 
 
 melanin in the sediment. 
 
 Constitution: — A black pigment of organic composition con- 
 taining sulphur and iron, in addition to carbon, hydrogen, and 
 nitrogen. 
 
 Synonyms:— Geeman, Melanin. French, Melanine. 
 
 Occnrrence: — Usually in solution in the urine, rarely as a 
 sediment. 
 Solubility:— 
 
 1. Soluble in boiling strong mineral acids, and in boiling acetic 
 and lactic acids. 
 
 3. Soluble in strong solutions of the caustic alkalies and 
 ammonia. 
 
 3. Insoluble in cold alcohol and ether. 
 
 4. Insoluble in acetic acid and in dilute mineral acids. 
 Beco^nition; — Occurs in the sediment in form of small, lumpy 
 
 granules much resembling carbon particles. 
 
288 URINARY ANALyniS. 
 
 Testg:— Best applied to the urine itself. (See Melanuria). 
 Pathology:— See Melanuria. 
 
 HICROSCOPICAL EXERCISE III. 
 
 i. Examine crystals of uric acid, noting color, and 
 observe whether the crystals are sharp-pointed or not. 
 Observe action of solution of sodium or potassium hy- 
 droxide on the crystals, and of acetic acid (20 per 
 cent). 
 
 2. Examine crystals of triple phosphate, noting size 
 and shape; also appearance of fragments. Observe 
 action of acetic acid (20 per cent) on the crystals, and 
 of sodium hydroxide. 
 
 3. Examine crystals of calcium phosphate as above. 
 
 4. Examine crystals of calcium oxalate, noting 
 small size, different forms, and action of reagents as 
 above, also of nitric acid. 
 
SEDIMENTS IN URINE. 289 
 
 CHAPTER XLY. 
 
 ANATOMICAL SEDIMENTS IN THE URINE. 
 
 If the objects seen with the microscope are not 
 affected by the chemical or micro-chemical tests already 
 described, they are probably anatomical in character 
 and will, as a rule, appear pale in color, and not 
 refract light sharply, though they may be regular or 
 irregular in form. We distinguish corpuscles, epi- 
 thelia and scales, tube-casts and similar formations, 
 fungi and micro-organisms, spermatozoa, and shreds 
 of connective tissue. 
 
 Among corpuscles we find blood corpuscles, pus 
 corpuscles, and mucous corpuscles. Corpuscles of all 
 kinds are small, roundish bodies, visible, but not 
 clearly distinguishable, with a power of 150 diameters, 
 and requiring 400-500 for identification. They are 
 nearer in size to small octahedra of calcium oxalate 
 than to any of the other common crystals. 
 
 Blood corpuscles: — Blood corpuscles in the urine 
 present different appearances. They may be (a) nor- 
 mal, like those freshly obtained, as from the finger by 
 puncture with a needle ; (5) crenated ; (c) spherical or 
 shrunken, with irregular outline ; (d) in form of faint 
 transparent rings, devoid of coloring-matter (haemo- 
 globin) from long stay in the urine. These last are 
 known as blood-shadows, or ghosts, and are smaller 
 than normal. 
 
 Figure 70 shows the different ways in which blood 
 corpuscles may appear in the urine, a being normal 
 with biconcave appearance; i, blood shadows or 
 "ghosts"; G, crenated as in acid urine; d, spherical 
 and swollen from imbibition of water. 
 37 
 
390 URINARY ANALYSIS. 
 
 Fig. 70. Different appearances of blood corpuscles in the urine. 
 
 a. Normal blood corpuscles, c. Crenated, as in acid urine. 
 
 b. Blood shadows. d. Swollen from imbibition of water. 
 
 EECOGNITIOlf OF BLOOD COEPUSOLES. 
 
 1. "When blood corpuscles are abundant, urine de- 
 posits a sediment varying in color from bright red to 
 dark-brown or almost black. If pus is also present, 
 the blood settles on top of the pus. 
 
 2. When blood corpuscles are abundant, albumin 
 is always found in the urine. 
 
 3. The corpuscles must be examined with a high 
 power, 400-500 diameters. 
 
 4. If at all abundant in the urine, the microscopical 
 field is seen to contain an immense number of small 
 roundish objects, whose mass exhibits a rusty color, 
 sometimes with tinge of green-yellow. 
 
 5. The individual corpuscles show no nuclei and 
 are not granular, owing to absence of cell contents. 
 
 SIGNIFICANCE OP BLOOD COBPUSOLES. 
 
 Presence of blood corpuscles in abundance constitutes the con- 
 dition known as hoematuria. Blood in the urine occurs under the 
 following conditions : 
 
SEDIMENTS IN VBINE. 291 
 
 Renal hsematnria: — In nephritis, acute or chronic; also in renal 
 hyperaemias, in lardaoeous disease, in renal abscess, in cystic dis- 
 eases of the kidney, in hydatids, in stone, in rare instances in 
 aneurism and embolism of the renal artery and thrombosis of the 
 renal vein, in cancer of the kidney, in tuberculosis of the kidney, 
 in malignant forms of acute infectious diseases as small-pox, yel- 
 low fever, malaria, etc.; and in leukaemia, purpura, scurvy, 
 haemophilia, and filariasis; also in poisoning by turpentine, creo- 
 sote, carbolic acid, cantharides, and the new synthetic com- 
 pounds; in cases of uterine and crural phlebitis; as a consequence 
 of injuries, blows or wounds, or indirectly from concussion. 
 
 Lastly, it is possible to find renal hsematuria in healthy kidneys, 
 from paralysis of the vaso-constrictor nerves of the blood-vessels 
 and consequent escape of the red blood corpuscles. 
 
 DIFFERENTIAL DIAGNOSIS IN RENAL H.a!M0RRHAGE3. 
 
 In renal hoBmorrhages the urine is usually acid in reaction 
 tsometimes alkaline in pyelitis), of homogeneous reddish-brown 
 color, of lowered specific gravity, containing blood-casts and 
 renal epithelium. (See Casts and Epithelium). The sediment is 
 usually more or less brown or coffee-colored in hue. The blood 
 in most cases is intimately mixed with the urine (except in angio- 
 neurotic cases, where the kidneys are healthy) and blood shadows 
 ■■■r "ghosts" are numerous. Clots are usually absent, except those 
 long, slender, pencil-shaped molds, due to passage through the 
 ureter. (The writer has, however, seen one case of haemorrhage 
 from the membranous and prostatic urethra in which such pencil- ^ 
 shaped clots were to be found). 
 Differential diagnosis in renal hsematnrias: — 
 
 1. Nephritis: — Presence of albumin, out of proportion to 
 amount of blood, together with tube-oasts, decrease in ratio of 
 day urine to night; deficiency of urea or of phosphoric acid or 
 increase in urea-phosphoric acid ratio (above 18 to 1). Symptoms 
 and history of nephritis. 
 
 Note: — If the proteid deposit in the Esbach tube rises above 
 the figure 4 the albumin is in all probability in excess of what the 
 blood would account for except possibly in excessive, persistent, 
 and prostrating haemorrhages. Doubtful cases are those where, 
 without casts, the proteid deposit in the Esbach tube is between 
 1 and 3. The writer has seen cases where blood alone in the 
 urine, without casts or evidences of nephritis, gave rise to albu- 
 min in quantity such that the proteid deposit in the Esbach tube 
 was between the figures 3 and 4. Albumin in such cases leaves 
 the urine, when the blood disappears. 
 
 3. Renal hyperaemia-.—^ot much blood, not much albumin, few 
 casts, scanty urine, urates or uric acid in sediment. 
 
 3. Renal carcinoma: — Troublesome, profuse, and repeated at- 
 tacks of bleeding. Persistent, burning pain in the back, partially 
 relieved by rubbing and by change of position. Renal tumor and 
 cachexia. Pus not abundantly present in the urine. Albumin 
 not in excess of blood. Bleeding much more profuse at times 
 than at others, with weeks or months interval. 
 
 4. Renal tubernilosis: — Urine contains, besides blood, more or 
 less pus, broken-down debris settling with difficulty; intermittent 
 hasmaturia, Ubually no pain, but tumor may be present. Emacia- 
 
292 URINARY ANALY/Slii. 
 
 tion, elevation of temperature; detec.ion and propagation of 
 bctoillus tuberculosis. 
 
 5. Renal stone: — ^Blood usually diminishes, when the patient is 
 at rest. Albumin small in tiuantity, pus corpuscles always found, 
 crystals usually. Fixed pain in region of the kidney, wincing on 
 part of patient on deep pressure over kidney at a certain point, 
 pain down course of ureter, sometimes with retraction of testicle, 
 and often extending down the thigh. 
 
 6. Malarial hcematuria: — Absence of nephritis and other signs 
 with history of malaria and presence of Plasmodium malarioe in 
 blood. 
 
 7. Bleeding from healthy kidneys, often symptomless:— Due to 
 over-exercise, hsemophilia, or angio-neurosis. In the latter cases 
 there may be renal tenderness on deep pressure. In one purely 
 angio-neurotic case (diagnosis verified by operation), which the 
 author saw, the blood on some occasions separated completely 
 from the urine, leaving clear normal urine above the sediment. 
 In such cases settle the blood in the centrifuge at low speed, pour 
 off supernatant urine, and settle this at high. The urine settled 
 at high speed shows nothing but blood-corpuscles, as does that at 
 low. [In cases of symptomless hsematuria put the patient on 
 milk-diet, give baths, and keep quiet for several weeks, using also 
 suggestive treatment. (The writer has found 30-drop doses of 
 tincture of Thlaspi Bursa Pastoris useful in the purely angio- 
 neurotic cases, but ait was of no value in a case of hsemophilia in 
 which it was tried). If the hsemorrhage is overcome by the above 
 treatment, it is probably angio-neurotic. The writer thinks these 
 cases not so rare as might be imagined]. 
 
 Hsematuria from bladder:— The urine is usually alkaline, often 
 ammoniacal and thick from muco-pus, clots are commonly found, 
 blood is brighter red and not intimately mixed with urine. Blood 
 clots of irregular form and large size are from bladder; epithelia 
 from middle layers of the bladder are quite commonly found. 
 The ratio of day urine to night is not usually permanently or seri- 
 ously changed in purely vesical haemorrhages. 
 
 DIFFERENTIAL BIAGNOSIS IN VESICAL H^MOERHAGES. 
 
 1. Blood in the urine in small quantities, together with pus, in 
 the case of old men, is quite common, as in the cystitis from en- 
 larged prostate. 
 
 2. Blood in cases of stone in the bladder is almost normal in 
 appearance, and is passed mostly at the end of micturition. 
 
 3. In inflammations of the neck of the bladder, blood, in small 
 quantity, may be passed at the end of micturition. History of 
 recent gonorrhoea, and presence of considerable albumin (^ to li 
 in the Esbach tube) will serve to distinguish from stone. 
 
 4. Profuse vesical haemorrhages occur in connection with 
 growths in the bladder. Dilute the urine abundantly with water; 
 the blood-corpuscles are dissolved, and flesh-colored fibers or 
 shreds easily found. (See Connective Tissue for figure). Epi- 
 thelia from middle layers of the bladder are usually abundantly 
 present in such cases. 
 
 Hsematuria from urethra:— Recognized by flow of blood be- 
 tween micturitions or when l^ood can be squeezed out of the 
 meatus by pressure. Usually due to gonorrhoea (acute stage), 
 chancre, growths, injuries, or surgical operations. 
 
SEDIMENTS IN URINE. 293 
 
 MISCELLANEOUS CLINICAL NOTES. 
 
 1. An alternation of clear and bloody urine in the same day is 
 never seen in hsematuria due to bladder tumors. 
 
 3. The urine voided three hours after eating is sometimes more 
 than ordinarily bloody in cases of calculous, pyelitis, or in cancer 
 of the kidney. 
 
 3. Blopd from the seminal vesicles will be clotted and mixed 
 with yellow bodies and spermatozoa. If the spermatic fluid is 
 bloody, the blood probably comes from the prostatic sinus. 
 
 4. Symptoms of malarial hsematuria sometimes resemble those 
 of stone in the bladder, namely, frequent painful micturition, 
 vesical tenesmus, sacral pain, and sleeples^ess; but in addition 
 there are in malarial hsematuria, rigors, usually daily, fever, and 
 sweat for several hours, and beginning usually at the same hour. 
 
 5. Laceration of the kidney may occur from accident without 
 external appearance of injury; the syrciptoms are hsematuria, pain 
 in the loins, possibly pus in the urine, typhoid condition, and 
 death in a few weeks. 
 
 6. Keyes reports that much albumin and tube-casts may be 
 found in some cases of hsematuria from enlarged prostate. 
 
 7. Vicarious menstruation by the kidneys is possible and spon- 
 taneous, and even regular monthly hsematuria has been noticed in 
 males. 
 
 8. Renal hsematuria may follow the high temperature of typhoid 
 fever, disappearing on the fall of the fever. 
 
 9. Renal hsematurias may be due to over-doses of turpentine, 
 and also to certain well-known and much-puflfed synthetic com- 
 pounds now on the market. Vesical hsemorrhages may be due to 
 overdoses of cantharides. 
 
 10. Hsemorrhage from the bladder is sometimes due to rupture 
 of varicose veins, especially in elderly patients. 
 
2t)4 
 
 URINARY ANALYSIS. 
 
 CHAPTEE XLYL 
 
 PUS CORPUSCLES IN THE UEINB. 
 MUCOUS CORPUSCLES. 
 
 Eecognition of'^pus by chemical means has already 
 been described. Microscopically we find pus corpus- 
 cles; these are about one- third larger than blood cor- 
 puscles, granular, and sometimes showing nuclei. The 
 latter may be brought out by addition of acetio aoid. 
 
 Figure 71 shows pus corpuscles. 
 
 Fig. 71. a. The usual globular pus corpuscles of acid urine, 
 5. Irregular pus corpuscles of acid urine, provided with pro- 
 cesses. 0. Swollen pus corpuscles of a strongly dilute or alka- 
 line urine, with visible nuclei. (JJltzmann). 
 
 EECOGNITION OF PUS COEPTJSOLES. 
 
 1. Urine containing abundance of pus corpuscles 
 deposits a dense white or greenish- white sediment. 
 In less abundance the deposit is flocculent. 
 
 2. At least a trace of albumin is to be found in the 
 urine, but seldom a large quantity. The precipitated 
 
FUS CORPUSCLES IN URINE. 395 
 
 proteids in the Esbaoh tube will settle below the 
 figure 1. 
 
 3. The corpuscles must be examined with a high 
 power, 400-500 diameters. 
 
 4. If at all abundant, the field is seen to contain an 
 immense number of small, colorless, roundish objects, 
 granular and sometimes exhibiting nuclei. 
 
 5. In ammoniacal urine it is hard to see the indi- 
 vidual corpuscles, which have broken up and coalesced 
 to form a granular mass. 
 
 6. In strongly dilute or alkaline urine they are 
 much swollen, and have visible nuclei in the central 
 portion, while the peripheral portions show only a 
 small number of granules. 
 
 7. In acid urine they are small and either globular, 
 or else irregular, sending out processes. The latter 
 occur in the more obstinate cases of pyuria. 
 
 8. Solution of iodine in potassium iodide colors pus 
 corpuscles a fine yellow, while the nuclei appear 
 darker and of a brown-yellow color. 
 
 SIGNEFICANCE 01" PUS CORPUSCLES. 
 
 In the urine of women pus corpuscles may merely indicate leu- 
 corrhcea. Whenever found, the urine should he examined after 
 a cleansing vaginal injection or use of vaginal tampon. Pus in 
 the urine is found in a large number of pathological conditions. 
 It may be due to chronic diffuse nephritis, renal abscess, tubercu- 
 losis, cancer, or calculus; and is found in pyelitis, pyelo-nephritis, 
 pyonephrosis, cystitis due to various causes, urethritis, prostatitis, 
 etc., etc. 
 
 DIFFERENTIAL DIAGNOSIS IN PYURIA 
 
 1. Pus from the kidneys is usually found in acid urine together 
 with casts and renal epithelium. It settles quickly on standing, 
 and is flocculent. The patient is usually sensitive to pressure over 
 one kidney or the other, and may show presence of a tumor. 
 When pus is retained in the calices, chills are often present. If 
 the pus is only in the pelvis of the kidney, casts will be absent or 
 scanty, and albumin not large in amount, below 1 on the Bsbach 
 tube. Frequent urging to urinate will not be a persistent symp- 
 tom, thougli it may be complained of for a time. 
 
 2. When pus is from the bladder, the deposit is glairy and 
 sticky, if the urine is ammoniacal, and there are found triple 
 phosphate crystals with large, flat, and often round epithelia. 
 Frequent and painful micturition is the rule in such cases. 
 
 In acute inflammation of the neck of the bladder the urine is 
 acid, and it may appear that the pus is from the kidney, but 
 albumin will be fairly abundant, perhaps settling to 1, or higher. 
 
896 URINARY ANALYSIS. 
 
 in the Esbach tube with frequency, straining after urination, and 
 doubtless a history of recent gonorrhoea. 
 
 Pus from the prostate may show itself in the form of "threads" 
 in the urine. The microscopic appearance of these threads is 
 shown in Fig. 72. 
 
 Fia. 73. A so-called gonorrhoeal thread, consisting of pus cor- 
 puscles and urethral epithelium. (Ultzmann). 
 
 3. Pus from the urethra may be squeezed out between the acts 
 of micturition, and the bulk of the pus is in the first glass, if the 
 urine be voided into two glasses. 
 
 CLINICAL NOTES ON PTUEIA. 
 
 1. Pigmented pus corpuscles justify a diagnosis of 
 chronic catarrhal cystitis. (Heitzmann). 
 
 2. Pus corpuscles with delicate red-brown haema- 
 toidin crystals in them signify previous hemorrhage, 
 as in the tubules or pelvis of the kidneys. (Heitz- 
 mann). 
 
 3. In chronic abscess of the kidney large quantities 
 of hsematoidin may be mixed with the pus. (Heitz- 
 mann). 
 
 4. In diseases affecting the renal parenchyma the 
 amount of pus, as a rule, is small, except when a large 
 abscess, located in the kidney structure proper, has 
 suddenly burst into the renal pelvis. 
 
 5. Pus corpuscles are more abundant in the urine of 
 acute nephritis than in that of chronic. 
 
 6. In the course of well- recognized chronic nephritis 
 
PUS COBPUSOLES IN URINE. 
 
 297 
 
 an increase in the number of pus corpuscles indicates 
 either an acute intercurrent nephritis or a complicat- 
 ing pyelitis, ureteritis, or cystitis. 
 
 7. In cases of simple renal hyperaemia pus corpuscles 
 are never abundant. 
 
 8. As a rule the sudden appearance of a large 
 
 Jn ^ 
 
 Fia. 73. Diagram of pus corpuscles of persons of different 
 
 constitutions, 
 
 E. Pus corpuscle of an excellent constitution; the bioplasm nearly 
 compact, containing a few small vacuoles, alive in a, alive 
 and contracted in b, dead and contracted in c. G, Pus cor- 
 puscle of a good constitution, the bioplasm coarsely granular, 
 alive in a, alive and contracted in b, dead and contracied in 
 c. M, Pus corpuscle of a middling good constitution; the 
 bioplasm less coarse, with a compact nucleus, alive in a, 
 amoeboid in b, dead in c. P, Pus corpuscle of a poor consti- 
 tution; the bioplasm comparatively scarce, finely granular, 
 vesicular nuclei very distinct; alive in a, amoeboid in b, dead 
 and burst in c. 
 
 Series P, indicates a broken-down constitution and rapidly ap- 
 proaching death. 
 
 Note: — Jagged forms of pus corpuscles found on drying, op 
 evaporation of the highly ammoniacal urine of chronic cyatitia, 
 should not be mistaken for a result of amceboid motion. 
 
 38 
 
298 URINARY ANALYSIS. 
 
 quantity of pus in urine, previously normal or nearly, 
 may most always be referred to the rupture of a neigh- 
 boring abscess into the urinary passages. 
 
 9. Heitzmann holds that the constitution of an indi- 
 vidual may be told by study of the pus corpuscles in 
 his urine. Fig. 73 illustrates his idea. 
 
 10. When pus is from the kidneys, free oil may 
 sometimes be found, v^rhen casts are absent. In a 
 recent case, confirmed by operation on the kidney, the 
 writer found abundance of free oil by sedimenting the 
 pus in the centrifuge, at a speed of 1,000 revolutions, 
 decanting the supernatant urine, and sedimenting this 
 at a speed of 1,700 revolutions. 
 
 11. Catheterization of the ureters is a most useful 
 process for determining the locality whence pus is 
 derived. 
 
 12. In posterior urethritis if the urine is voided into 
 two glasses the urine in the first glass will always be 
 cloudy, but that in the second will sometimes be clear, 
 sometimes cloudy, while the urine is acid in reaction. 
 
 MUCOUS COEPUSOLES. 
 
 These resemble pus corpuscles but are irregular in 
 size and in shape, have no nucleus but are granular; 
 they are less compact than the pus, and are more like 
 collections of fine granules. 
 
 MICROSCOPICAL EXERCISE IV. 
 
 1. Examine blood corpuscles {a) in acid urine, (5) in 
 urine which has stood for some time, and (c) in urine 
 diluted with water. 
 
 2. Examine pus corpuscles (a) in acid urine, (5) in 
 alkaline urine or urine diluted with water, (c) in 
 strongly ammoniacal stale urine. 
 
 3. To a field of pus corpuscles of the usual globular 
 form add a drop of acetic acid, and note effect on nuclei. 
 
 4. Obtain, if possible, pus from an old case of pyel- 
 itis and note microscopical appearance of corpuscles. 
 
 5. Sediment pus in centrifuge at 1,000 revolutions 
 for 5 minutes; decant, sediment decanted portion at 
 1,700, and look for oil. 
 
EPITHELIUM IN URINE. 
 
 CHAPTEE XLYII. 
 
 EPITHELIUM IN URINE. 
 
 Epithelium, the normal product of mucous surfaces, 
 in greater or less amount occurs in nearly all urine, 
 and is exceedingly abundant in the urine "of women, 
 when it forms a whitish flocculent sediment. 
 
 Whether diagnosis can be made with certainty by 
 identification of epithelium is a disputed point. The 
 late Charles Heitzmann, one of the ablest pathologists 
 in this country, was emphatic in his opinion as to the 
 possibility of recognition of the locality whence epi- 
 thelium was derived. He proved his own ability to 
 do so in several instances, when urine was referred to 
 him by the writer, from cases the symptoms and his- 
 tory of which were known to me but unknown to 
 him. There is not a shadow of doubt in my* own 
 mind about Heitzmann's ability to make diagnoses 
 from observation of what other writers are loth to 
 recognize as significant. 
 
 The epithelia found in urine are shown in the fol- 
 lowing, Figure 74, taken from Heitzmann : 
 
 SiaNIFICANCB OP EPITHELIA. 
 
 In urine of males: — 
 
 1. The lai-fresi. columnar epithelia from the urethra occur in 
 deeply seated blenDrrhcBic inflummation, and in ulcerations 
 which often lead to fdrination of a stricture. 
 
 2. Cuboidal epithelia, somewhat smaller than the average cu- 
 boidal epithelia of the bladder, come from the prostate in catar- 
 rhal i:nwtatitis (.oung men), and hypertrophy of the prostate 
 (men (n>r 40). 
 
 3. Ciliuted columnar epithelia, distinctly surpassing in size 
 those from the mucosa of the uterus, indicate slight catarrhal 
 inflammation of the ejaculatory ducts. They are rarely seen cili- 
 ated, as the cilia break off very easily; delicate parallel rods in 
 the interior indicate original ciliation. 
 
 In urine of females: — 
 
 1. Large, flat, vaginal epithelia indicate catarrhal vaginitis. 
 The largest cuboidal and columnar epithelia are observed in cases 
 of intense, deeply-seated, or ulcerative vaginitis. 
 
UBINABY ANALYSIS. 
 
 Fig. 74. Epithelia found In urine. 
 
 B, Bladder epithelia from upper layers; BM, bladder epithelia 
 from middle layers; BD, bladder epithelia from the deepest 
 layer; P, prostatic epithelia; E, epithelia from the ejaculatory 
 ducts; V, vaginal epithelia from upper layers; VM, vaginal 
 epithelia from middle layers; VD, vaginal epithelia from the 
 deepest layer; C, epithelia of the cervix uteri; U, epithelia nf 
 the mucosa of the uterus; PK, epithelia from pelvis of the 
 kidney; KC, kidney epithelia from the convoluted tubules; 
 KS, kidney epithelia froni the straight collecting tubules. 
 Magnified 500 diameters. {Heitzmann), Bartholiuian epi- 
 thelium corresponds to prostatic. 
 
EPITHELIUM IN URINE. 301 
 
 2. Flat cuboidal epithelia (smaller in size than vaginal and as a 
 rule finely granular, often with offshoots) are found, together with 
 pus and blood corpuscles and shreds of connective tissue, in ulcer- 
 ation of the cervix uteri. 
 
 Notel— Cnboidaleoithelia are originally angular, polyhedral formations, but, 
 by sneLiing in the nrioe, they asenme a more or less regular or even perfectly 
 Bpherical form, 
 
 3. Delicate, columnar, ciliated epithelia from the mucosa of the 
 uterus, accompanied by ciliated pus corpuscles, indicate catarrhal 
 endometritis. 
 
 In urine of hofh sexes: — 
 
 1. Flat epithelia of the bladder, in small numbers and without 
 pus corpuscles, are normal. 
 
 2. Flat epithelia in larger amount (with pus corpuscles and epi- 
 thelia from middle layers of the bladder, exhibiting endogenous 
 new formation of pus corpuscles) indicate acute catarrhal cystitis. 
 
 3. If the cuboidal epithelia largely outnumber the flat, or are 
 scanty in comparison with the large amount of pus corpuscles, 
 and especially if some pus corpuscles contain dark-brown pigment 
 granules, the case is one of chronic cystitis. 
 
 4. Clusters of uric acid crystals in freshly voided urine, together 
 with caudate epithelia somewhat smaller than those of the mid- 
 dle layers of the bladder. Indicate deposit of uric acid in the pelvis 
 of the kidney. 
 
 5. Pelvic epithelia, together with epithelia from the uriniferous 
 tubules, indicate pyelo-nephritis. 
 
 6. Pelvic epithelia with red blood corpuscles, and shreds of con- 
 nective tissue, indicate hemorrhage and ulceration in the kidney 
 pelvis. 
 
 7. Renal epithelia, together with pus corpuscles, signify catar- 
 rhal (interstitial) nephritis. 
 
 8. Renal epithelia, together with pus corpuscles and tube-casts, 
 signify croupous (parenchymatous nephritis). 
 
 9. The same with large quantities of pus corpuscles signify sup- 
 purative nephritis. 
 
 , EPIDERMAL SCALES. 
 
 These are irregular in size and in shape and some- 
 what resemble epithelia, but are without nucleus. 
 They are of no significance. 
 
 MICROSCOPICAL EXERCISE V. 
 
 1. Obtain the urine of a woman who has borne 
 children, and study the white sediment of vaginal 
 epithelia. Note epithelia from upper and middle 
 layers in cases where leucorrhoea exists. Note also 
 pus corpuscles. (Fig. 76). 
 
302 
 
 UHJXAL'Y ANAL YSLS. 
 
 Fig. 75. Sediment common in urine of women; vaginal epithelia 
 and debris. (Photo-micrograph). 
 
 2. Obtain urine from the same woman voided after 
 a cleansing vaginal injection, or drawn off by the 
 catheter, and note smaller quantity of epithelia and 
 absence of ])us corpuscles. 
 
 3. Let the urine, obtained as in 1, stand in a cold 
 place until urates have deposited, and notice how they 
 hide the epithelia. 
 
 4. (.)l:itain the urine from a case of cystitis and 
 demonstrate pus corpuscles and epithelia from the 
 middle layers of the bhulder. Demonstrate prostatic 
 epithelia in the urme of old men with enlarged pros- 
 tate. 
 
 5. If possible, obtain urine from a case of suppura- 
 tive nephritis and pyelitis, and demonstrate renal and 
 pelvic epithelia. 
 
 6. Obtain urine from a man who has the so-called 
 "clap-threads" in the urine and study their appear- 
 ance. Of what ai'e they composed? 
 
TUBE-CASTS IN URINE. 808 
 
 CHAPTEE XLYIII. 
 
 TUBE-CASTS IN THE UKINE. 
 
 Oasts are in all probability composed of the coagu- 
 lable elements of the blood which, after gaining access 
 to the renal tubules, entangle in them any free or 
 partly-detached products of the tubules, and form 
 molds of the latter. The substance of which they are 
 composed is a proteid not identical with any that we 
 recognize. 
 
 Tube-casts proper consist of a uniform, transparent, 
 gelatinous matrix to which other elements (epithelia, 
 corpuscles, and even various salts, both crystalline and 
 amorphous) may be accidentally attached. 
 
 They must be distinguished from (a) cast-UJce forma- 
 tions, i. e., groupings of salts, corpuscles, etc., which 
 lack uniform matrix, and (i) the band-like formations 
 known as cylindroids and mucous cylinders. 
 
 IDENTIFIOATION OF OASTS. 
 
 Study Figures 76, 77 and 78. 
 
 1. Casts should be sought for with a low power and 
 without cover-glass. The urine should be acid. 
 Alkaline urine rapidly dissolves casts. 
 
 2. They may be recognized by use of a power of 
 150 diameters, when they will look small, yet much 
 larger than corpuscles, spermatozoa bacteria, or small 
 crystals, as oxalate. 
 
 3. They are of uniform Ireadth, and usually longer 
 than they are broad. 
 
 4. They have usually at least one well-rounded 
 extremity, and well-defined borders. 
 
 5. They are not longitudinally striated, not jagged, 
 nor provided with processes, not jointed, segmented, 
 nor serrated. They may possibly be spirally twisted 
 at one or both ends. 
 
804 URINARY ANALYSIS. 
 
 6. They are distinguished from large epithelia by 
 absence of the nucleus, and by the well-rounded ex- 
 tremity. They refract, also, differently. 
 
 7. They are distinguished from bacteria, corpuscles, 
 spermatozoa, and oxalate crystals by their larger size, 
 uniform breadth, greater length than breadth, and 
 rounded extremity. 
 
 8. They are distinguished from large crystals by 
 absence of geometrical form and less refraction. 
 
 9. In some cases one end of the cast tapers off con- 
 siderably, and presents a spirally twisted appearance, 
 which may go on to such an extent that the entire 
 cast becomes transversely striated. Broad hyaline 
 casts may sometimes be branched dlchotomously at 
 one end. 
 
 10. Their kind must be determined by use of a high 
 power, 500 diameters. 
 
 11. To find hyaline casts tilt the mirror of the 
 microscope, so as to darken the field gradually, when 
 the outlines or shadows of delicate hyaline casts may 
 be seen, which otherwise might escape detection. 
 
 KINDS OF CASTS, 
 
 Hyaline casts: — These are colorless, usually very pale, trans- 
 fact which must be 
 sediment in order 
 
 parent, and readily soluble in acetic acid, a fa( 
 borne in mind, when this reagent is added to a 
 
 ^j> 
 
 A. 
 
 c: ci^ 
 
 1) 
 
 Fig. 76. Hyaline casts. (Simon). 
 
TUBE-CASTS IN URINE. 
 
 805 
 
 to dissolve phosphates. Small granules may almost always be 
 seen imbedded in or adhering to their matrix. In breadth these 
 casts are usually between 0.01 and 0.05 m.m.; in length they vary 
 greatly, in some cases being not much longer than they are wide, 
 but in others extending across the entire microscopic field. 
 
 It has often been said that it is impossible to reproduce hyaline 
 casts in cuts so that they appear at all natural. The writer 
 thinks, however, that figure 76, taken from C. E. Simon, is an 
 excellent representation of them', barring the borders, which in- 
 stead of being dotted should be continuous, as in Figure 77. 
 
 Fig. 
 
 77. Hyaline, epithelial, and blood casts, seen with a high 
 power. 
 The series a shows casts from convoluted tubules of the second 
 order; the series b, casts from the narrow portion of the loop- 
 tubules; the series c, casts from the straight collecting tubes. 
 H, hyaline casts; E, epithelial casts; B, blood casts. Magni- 
 fied 500 diameters. (After Heitzmann), 
 39 
 
306 
 
 UBINABY ANALYSIS. 
 
 Epithelial casts:— These have the hyaline matrix more or lees 
 concealed by epithelia. Close observation will usually show a fine 
 boundary line at some portion of the structure, even when epi- 
 thelia are very numerous, and a drop of acetic acid serves to dis- 
 solve the matrix and set the epithelia free. 
 
 Blood casts and pus casts:— These consist of the hyaline matrix 
 with blood corpuscles or pus corpuscles imbedded in or adhering 
 to the matrix. Pus casts are exceedingly rare and no cuts of 
 them appear in the majority of our text-books. In a recent case 
 observed by the author, in which operation disclosed pus in one 
 kidney, several pus casts were found in the urine. 
 
 mm 
 
 Fia. 78. Granular, fatty, and waxy tube-casts, seen with a high 
 
 power. 
 
 The series a shows casts from convoluted tubules of the second 
 order; the series b, casts from the narrow portion of the loop- 
 tubules; the series c, casts from the straight collecting tubules. 
 O, granular casts; F, fatty casts; W, waxy casts. Magnified 
 500 diameters. (After Heitzmann), 
 
TUBE-CASTS IN URINE. 307 
 
 Granular casts: — These have the hyaline matrix, and well- 
 defined boundary with granular matter imbedded in or adhering 
 to the matrix. Granular casts are of several kinds, as finely 
 granular, or coarsely granular. The latter are usually of more 
 serious significance. Coarsely granular casts may at times be 
 very long, large, and dark in color, especially in rapidly fatal 
 cases. 
 
 Fatty oasts: — These have the hyaline matrix dotted with fat 
 granules. Free fat is usually also discoverable in the field. 
 
 Waxy casts: — These are strongly refractive of light, have a 
 yellow or yellow-gray color, and are but slowly attacked by acetic 
 acid, if at all. As a rule only small fragments of them occur, but 
 these are broad and stout. They may be coated with urates, or 
 may contain crystals of calcium oxalate, etc., but do not com- 
 monly present these features. Some of these waxy casts give the 
 amyloid reaction, that is, assume a mahogany color when treated 
 with a dilute solution of iodo-potassic iodide, turning to dirty 
 violet on addition of dUute sulphuric acid, but this is not patho- 
 gnomic, as formerly supposed, of amyloid kidney, but due prob- 
 ably to degeneration, due to long stay in the uriniferous tubules. 
 
 OAST-LIEE FORMATIONS. 
 
 These are composed of various elements having the cast form, 
 but lacking the matrix soluble in acetic acid. 
 
 Amorphous urates may occur simulating granu- 
 lar casts in form (Fig. 79). 
 
 Bacteria may be grouped in a cast-like manner, 
 but close inspection shows irregular outline, and 
 abundance of groupings not in cast form. 
 
 Scematoidin and granular detritus may alao 
 assume the cast form. 
 
 Epithelia may be found in cast form. Such 
 formations are hollow, being thrown off en masse ^^ 
 
 from the uriniferous tubules. Seen only in par- '^.?^P''^^ 
 enchymatous nephritis. ■p a 7Q 
 
 Blood corpuscles enmeshed in fibrin are common ^ "*• '."• 
 in renal haemorrhages, and may assume the cast . t^ast-iiKe 
 f„ formations of 
 
 , The differential diagnosis between a true cast amorphous 
 ' and a cast-like formation can be made by addition urates, 
 of a drop of acetic acid, which dissolves the hyaline matrix of a 
 true oast, but has no effect on a cast-like formation. 
 
 CTLINDROIDS AND MUCOUS CYLINDERS. 
 
 Cylindroids have the appearance of hyaline tube-casts, but are 
 very large and band-like. They have uniform breadth and often 
 contain crystals, epithelia, and corpuscles. They are soluble in 
 acetic acid. They are of renal origin. True casts are sometimes 
 seen, which terminate at one or both ends in cylindroids. 
 
 Mucous cylinders are never of uniform breadth, seldom or never 
 contain morphologic or mineral constituents, and are insoluble in 
 acetic acid. They are found in any urine containing abundance 
 of mucus, and are of no other significance. 
 
URINARY ANALYSIS. 
 
 Fig. 80. a and b, cylindroids. (Jakseh), 
 
 EXTEANEOtrS OBJECTS SOMEWHAT EESEMBLnTG OASTS. 
 
 These are very numerous and may be divided into 
 fibers, wool, feathers, and fungi, as mycelium, lepto- 
 thrix, and bacteria. Figure 81, from Heitzmann, 
 shows the most common ones found in urine. 
 
 Cotton fibers axe wavy and twisted with edges more compact 
 than the centre is. 
 
 Linen fibers are straight, composed of smaller fibrilla, with 
 breaks and breaches from hackeling. 
 
TUBE-CASTS IN URINE. 
 
 809 
 
 Sheep's wool has fine serrations along the edges; cuticle on sur- 
 face is imbricated. 
 
 The mj^ceZmm, especially of penicillium glaucum, is very com- 
 mon in urine; with a high power it appears segmented as in the 
 figure — . 
 
 Leptofhrix is small and very slender. 
 
 Bacteria are very small, and cannot be easily recognized with 
 150 diameters. 
 
 Pig. 81. Accidental occurrences in the sediment of urine. 
 
 S, Silk fibers; C, cotton fibers; L, linen fibers; W, sheep's wool; 
 F, feather; St, starch-granules of rice; Cr, cork particles; O, 
 oidium, the seed of mildew; M, mycelium of mildew; Mo, 
 micrococci; B, bacteria; Lt, leptothrix. Magnified 500 diam- 
 eters. (After Heitzmann). 
 
310 URINARY ANALYSIS. 
 
 Zooglcea masses of bacteria, exceedingly common in the urine 
 of women, are often mistaken for granular casts by beginners. 
 They have no matrix, are irregular in outline, and occur in great 
 abundance without definite shape. 
 
 SIGNIFIOAKOE OF OASTS, 
 
 1. The writer finds that with the centrifugal ma- 
 chine a few casts may be found in 1 out of every 3 
 specimens of the 24 hours' urine examined. Such 
 casts are usually 2 or 3 small hyaline, or 1 or 2 small 
 granular, per sediment of 15 c.o. urine. 
 
 2. In cases in which stimuli, as severe exercise, 
 cold baths, etc., occasion albuminuria, casts may also 
 be found. 
 
 3. When casts and albuminuria occur together, it 
 may be assumed that the albuminuria is renal. 
 
 4. Albuminuria and a few hyaline casts, especially 
 if latter are only temporarily present, signify a mild 
 circulatory disturbance of the kidneys. 
 
 5. Continuous presence of hyaline casts in abund- 
 ance, together with albuminuria, especially if marked, 
 indicates the existence of a nephritis. 
 
 6. Numerous hyaline, epithelial, and blood casts 
 signify acute croupous (parenchymatous) nephritis. 
 {Seitzmcmn). 
 
 7. JSTumerous granular, fatty, and waxy casts sig- 
 nify chronic croupous (parenchymatous) nephritis. 
 {Heitzmann). 
 
 8. Casts of both acute and chronic forms indicate a 
 subacute form, chronic inflammation with acute recur- 
 rences. {HeitzTnomri). 
 
 9. The greater the number of casts, the more seri- 
 ous the nephritis. {Heitzmann). 
 
 10. A large number of blood casts in the urine of 
 adults indicates a fatal termination in a short period of 
 time. [Heitzmann). 
 
 11. The size of the casts is of great prognostic value 
 (Fig. Y7). Narrow casts together with a small number 
 of casts of medium width, signify a mild degree of 
 nephritis. Casts of medium width denote inflammft- 
 tion of the cortical substance. Casts of all three sizes 
 
TUBE-CASTS IN URINE. 311 
 
 the largest arising from the straight collecting tubules, 
 signify inflammation in the whole organ, in which case 
 there is a very unfavorable prognosis. {Heitsmann). 
 
 12. Hyaline casts studded with fine granules may 
 be called "verging on granular," and indicate aa 
 incipient chronic nephritis as in third or fourth week 
 of scarlet fever. "When casts have distinct outlines 
 they are ' 'verging on waxy, ' ' as granular-waxy, fatty- 
 waxy. Epithelial casts may be ' 'verging on fatty and 
 waxy," either or both. Hyaline, epithelial, fatty, 
 and granular casts have indistinct outlines, but when 
 verging on waxy the outlines are distinct. Fatty 
 casts may be told from casts of cocci by their glossy, 
 distinct granules ; cocci are smaller, sharply defined, 
 as in zooglcea, and darker. Fat granules are larger, 
 less sharply defined,, and not so dark. {Heitzmann). 
 
 13. Fatty casts are most commonly associated with 
 subacute or chronic inflammations of the kidney of 
 protracted course, with tendency to fatty degeneration 
 of the renal tissues. {Jaksoh). 
 
 14. Epithelia found in tube-casts, if shrunken and 
 atrophic, indicate an inflammatory renal process com- 
 plicated with degenerative changes. Epithelial casts 
 without presence of distinct changes affecting the 
 renal parenchyma are probably never seen. 
 
 16. Pus corpuscles in small numbers on hyaline 
 casts are common in various nephrites, especially in 
 acute cases. 
 
 16. Pus-casts indicate suppurative inflammation of 
 the kidneys. 
 
 17. Cylindroids accompany hyaline casts, and are of 
 the same significance. 
 
813 URINARY ANALYSIS. 
 
 THE WEITKR'S OBSERVATIONS ON MOKTALITT IN ALBUHINITSIA WITH 
 AND WITHOUT CYLINDRUEIA. 
 
 In an article in the New York Medical Times, July, 1895, the 
 writer gave the statistics of mortality in 500 cases of albuminuria 
 as follows: 
 
 SUMMARY NO. 1. 1888-1896. 
 
 I. Non-albuminuric cases whose present condition is known 
 
 with certainty 253 
 
 Deaths.. 28 
 
 Percentage of mortality thus far 11 
 
 11. Albuminurics without casts 255 
 
 Deaths 37 
 
 Mortality per cent thus far 14 
 
 III. Albuminurics with casts 804 
 
 Deaths 89 
 
 Percentage of mortality thus far, about 80 
 
 SUMMARY NO. 8. 
 
 I. Albuminurics with casts . 304 
 
 Without granular, fatty, or waxy casts 177 
 
 Deaths 36 
 
 Percentage of mortality thus far 20 
 
 II. With granular, fatty, or waxy casts . 127 
 
 Deaths 58 
 
 Percentage of mortality thus far 41 
 
 III. Mortality in those of II, according to sex: 
 
 (a) Total number of men 93 
 
 Deaths 37 
 
 Percentage of mortality thus far ..: .. 40 
 
 (6) Total number of women . 34 
 
 Deaths 16 
 
 Percentage of mortality thus far .. 47 
 
 Prom these figures it will be seen (1) that the death-rate was 
 greater among those who had albuminuria without casts than 
 among those who had no albuminuria at all, and (2) that the 
 death-rate among those who had albuminuria with casts was 
 greater than in those without casts, while (3) the death-rate of 
 those albuminurics with granular, fatty, or waxy casts was double 
 that of those with only hyaline, epithelial, or blood casts. 
 
TUBE-CASTS IX URINE. 
 MICROSCOPICAL EXERCISE VI. 
 
 313 
 
 _ 1. Obtain the urine of a patient with post-scarla- 
 tinal nephritis and study the different kinds of tube- 
 casts. Notice in a severe case the large number of 
 objects in the field and the variety of them, not less 
 than four different constituents being present in 
 abundance. (Fig. 82). 
 
 Fia. 82. The field in nephritis. (Photo-micrograph). Note tube- 
 casts, corpuscles, epitlielia, etc. 
 
 2. Obtain the urine from a case of chronic nephritis, 
 preferably with dropsy and high-colored, scanty, albu- 
 minous urine, and study the casts. AVhat are the pre- 
 vailing ones? 
 
 3. Obtain the urine of a man over 40 with chronic 
 interstitial nephritis and look for casts? Are they 
 numerous? What kind? 
 
 4. Add dust from the dustpan to a sample of nor- 
 mal urine and study the sediment for extraneous 
 
 objects. 
 
 <10 
 
314 V BINARY ANALYSIS. 
 
 CHAPTER XLIX. 
 
 SPERMATOZOA, CONNECTIVE TISSUE, MICRO-ORaAN- 
 ISMS, PARASITES, 
 
 Spermatozoa: — (Fig. 83), 
 are found in the urine of 
 healthy adults after pollu- 
 tions or coitus and are then 
 of no significance. 
 
 Constant presence of sper- 
 matozoa in the urine is noted 
 in spermatorrhoea due to 
 sexual excesses or masturba- 
 tion. 
 
 In cases in which semen 
 is passed during defecation Fi»- 83- Spermatozoa.^ ^ 
 or from irritation of ammoniacal urine, as in cystitis, 
 no deleterious effects seem to appear. 
 
 Spermatozoa are found in the urine after epileptic 
 seizures and sometimes after hystero-epileptio attacks ; 
 also in certain spinal diseases, and in severe illness as 
 typhoid. 
 
 In the urine spermatozoa are almost always quies- 
 cent; they are in form thread-like bodies provided 
 with a head and a long, tapering, tail-like extremity. 
 The entire length is about 1-600 of an inch and they 
 must be searched for with a high power. 
 
 Connective tissue: — Little is to be found in medical literature 
 regarding this substance in the urine, except what has been writ- 
 ten by Heitzmann. The appearance of connective tissue fibers in 
 the urine is a frequent phenomenon. They are, as a rule, small 
 and are distinguished from mucous threads by their greater 
 refraction, their almost invariable occurrence in bundles of vary- 
 ing size, their fibrillary or finely granular appearance, and of the 
 presence in them at times of formations similar to nuclei. Linen 
 fibers possess strong refraction but split in a way essentially dif- 
 ferent from connective tissue. 
 
CONNECTIVE TISSUE IN VBINE. 315 
 
 Shreds of connective tissue are found in the urine in: 
 
 1. Ulcerations. 
 
 S. Abscesses. 
 
 3. Tumors. 
 
 4. Hannorrhages. 
 
 5. Trauma. 
 
 6. Cirrhosis and atrophy of the kidneys. 
 
 7. Hypertropliy of tlie prostate. 
 
 Connective tissue studded with fat is probably from the kidnevs 
 
 Figure 84, a photo-micr.jgraph, by Dr. Charles Gordon Fuller 
 
 of Chicago, from one of the writer's slides obtained from Dr! 
 
 Fig. 84. Shred of connective tissue in urine of a case of tumor of 
 the bladder. Photo-micrograph by Dr. Charles Gordon Fuller, 
 of Chicago. 
 
 Heitzmann, shows a shred of connective tissue found in the case 
 of a tumor of the bladder. 
 
 When tumors are present in the urinary tract, connective ti.ssue 
 is most abundant. If papilloma of the mucous membrane of the 
 bladder exist, there will be found, especially on diluting the urine 
 with water and sedimenting with the centrifuge, much elongated 
 shreds of connective tissue, which, under the microscope, appear 
 spread out like branches, knotted or convoluted, shriveled, and 
 containing blood vessels in which are but few inflammatory cor- 
 puscles and no epithelium-nests. 
 
 Micro-organisms: — Healthy urine is an aseptic fluid which, on 
 standing exposed to the air, soon contains great numbers of micro- 
 
316 URINARY ANALYSIS. 
 
 organisms. Abnormal urine nearly always contains micro-organ- 
 isms: These are fungi, pathogenic and non-pathogenic. Non- 
 pathogenic fungi are molds, yeasts, and flssion-fungi. Molds are 
 found on the surface of old saccharine urine which has undergone 
 alcoholic fermentation, or less frequently on the surface of putrid 
 urines containing no sugar. (See Fig. — ). 
 
 The yeast plants (saccharomyces urinae) are found in acid urine 
 and abundantly in saccharine urine. The sporules occur as small 
 roundish bodies (Fig. — ), suggesting blood corpuscles in size and 
 shape, but are irregular, sometimes of large size with nuclei, and 
 are more elongated or oval. They are often arranged in bead-like 
 forms, some of which may have several small bud-like bodies 
 attached to them. In great numbers they are indicative of pres- 
 ence of sugar. 
 
 Fission fungi are found as the urine begins to putrefy; it is then 
 cloudy, not easily filtered clear, never sharply acid, and usually 
 neutral or feebly alkaline. Such urine is common in the case of 
 delicate women and in men with stricture or who use catheters 
 or bougies. The fungi in these conditions are the micrococcus 
 ureae (Fig. 85), and various rod-like bacteria; occasionally long 
 spiral bacilli with large spores and cocci occur. Nearly all these 
 microbes possess the power to transform! urea into ammonium 
 carbonate. 
 
 
 V .^ 
 
 Fig. 85. Micrococcus ure89. 
 
 The micrococcus urese accurs in almost pure culture on the sur- 
 face of fermenting urine in the form mostly of characteristic 
 chains as in the figure. The individual coccus is large anri is 
 sometimes mistaken for a blood-shadow or "ghost." The diag- 
 nosis of ammoniacal fermentation within should not be made 
 unless the presence of ammonia can be demonstrated in freshly 
 voided urine, as some urines undergo fermentation, particularly 
 in warm weather, shortly after being voided, and especiallv if the 
 vessel employed is not absolutely clean. 
 
 SarcinsB (Fig. 86) occur in urine and are ^ 
 
 smaller than those found in the stomach, m 
 being in point of size comparable to those ^ g 
 of the lung. The writer has noticed them 
 particularly abundant in a case of chronic 
 cystitis occurring in a patient with paraly- 
 sis agitaus. sas ' o 
 
 Pathogenic fungi are numerous and be- * ^ o 
 
 long to two orders, micrococci and bacilli. ^ 
 In suppurative diseases we find the char- 
 acteristic micrococci as the staphylococcus @ 
 
 pyogenes albus, aureus, oitreus, and the ^ • 
 streptococcus pyogenes. The bacilli found ^ o 
 
 include the bacillus coli communis the uro- 
 bacillus liquefaciens septicus, the bacillus „ .*"*•. ^°' . 
 tuberculosis, and many others. As a gen- oarcinfe \n urine, 
 eral rule the organisms causing the morbid processes are elimi- 
 
BACTERIA IN URINE. 317 
 
 nated. Pathogenic organisms have been found in the urine in 
 erysipleas, measles, scarlatina, relapsing fever, sepsis, typhoid 
 fever, tuberculosis, etc., but unfortunately it is only exceptionally 
 that the diagnosis of specified fevers can be made by bacteriologio 
 examination of the urine. 
 
 Even the search for the tubercle bacillus in the urine is fre- 
 quently fruitless. By use of Dr. Purdy's small tubes, designed for 
 sedimentation of bacteria, and a high speed, 5000 or more revolu- 
 tions per minute, of the centrifuge one is more likely to find the 
 tubercle bacillus, which should always thus be sought for in the 
 case of pyuria accompanied by ansemia, wasting, and evening 
 temperature. The urine must be obtained with the catheter to 
 avoid admixture with the urine of smegma bacilli which can be 
 with difficulty distinguished from the tubercle bacilli. Injection 
 of a few drops of the sediment of such urine into the anterior 
 chamber of the eye of a rabbit; the urine being obtained under 
 bacteriologic precautions, is advisable, the development of miliary 
 tubercles of the iris being watched for. The search for the bacil- 
 lus is made as in sputum and should only be undertaken by an 
 expert. Those not familiar with bacteriology do not realize the 
 care and experience necessary in this operation. 
 
 The relation of micro-organisms to nephritis is now occupying 
 the minds of a number of observers and some interesting studies 
 have been made, as for example, of the role of the bacillus ooli 
 communis. In general, however, nephritis is referable to ptomain 
 intoxication rather than to the action of bacteria, although their 
 presence in the kidneys may be regarded as indicating the exist- 
 ence of some definite alteration of the renal parenchyma. 
 
 Non-pathogenic bacteriuria has occasionally been noticed but 
 the occurrence is very rare and possibly not associated with any 
 pathologic condition, although the bacillus coli communis has 
 been obtained in pure culture from cases of pyelitis. 
 
 Oonocoeci may be found in the cellular elements in urinary sedi- 
 ments, but in making the examination for them a drop of the 
 discharge should be taken from the meatus on a cover-glass, 
 spread out in as thin a layer as possible, allowed to dry, 
 passed three or four times through the flame of a Bunsen, and 
 stained with a drop of carbol fuchsin without application of heat. 
 Excess of coloring matter is removed by rinsing in water, the 
 specimen is dried between layers of filter-paper mounted in a drop 
 of water and examined, preferably with an oil immersion lens. 
 The gonococci consist of minute roll-shaped cocci, chiefly met 
 with as diplococci, the individual cocci being seemingly divided 
 by a bright, transverse band often presenting the so-called roll 
 form; also called the kidney or bean shape. The cocci usually 
 appear in pairs lying close together, their flattened surfaces usu- 
 ally presented to each other. Presence of gonococci within the 
 cellular elements is deemed characteristic. The reader is referred 
 to works on Bacteriology for flgures. 
 
 Animal parasites: — The ova of distoma haematobium and the 
 filaria sanguinis hominis occur in the urine. The parasites cause 
 various serious urinary diseases, as hydronephrosis, pyonephrosis, 
 pyelitis, and pyelonephritis, and the ova serve as nuclei for stone. 
 Echinococcus, ascarides, starongylus gigas, and infusoria are also 
 found. Filaria are found in our Southern States, and cause chy- 
 luria. The eggs of distoma are oval, flask-shaped bodies. 
 
bia URINARY ANALYSIS. 
 
 CHAPTER L. 
 
 THE URINE AND CHARACTERISTIC SYMPTOMS OF DIS- 
 EASES OF THE KIDNEYS. 
 
 The following pages show the clinical features of 
 the most common urinary diseases : 
 
 Acute renal hypereemia {active congestion): — 
 
 Frequency, urgency, possibly vesical tenesmus. Urine contains 
 less than 10 per cent bulk of albumin, a few hyaline casts, and 
 perhaps a little blood. Suppression possible. 
 Chronic renal hypersemia (passive congestion): — 
 
 Cardiac symptoms, dropsy, dyspnoea, cyanosis (not in milder 
 cases); weak, thready pulse; hacking cough. Urine decreased in 
 quantity, specific gravity increased, albumin small, casts few, 
 hyaline; urates and mucus. 
 Acute diffuse nephritis (including post-scarlatinal nephritis):— 
 
 Dropsy, pallor, high pulse and temperature, nausea, vomiting, 
 headache, stupor, coma, convulsions. Blood the urinary feature. 
 Albumin abundant, numerous hyaline, epithelial, and blood casts; 
 later, granular and perhaps fatty casts. 
 
 Chronic diffuse nephritis (including parenchymatous or croup- 
 ous, formerly so-called): — 
 
 Obstinate dropsy, anaemia, pallor and puflSness of face, debility 
 and loss of flesh. Night urine exceeds day. Albumin abundant. 
 Dark granular, fatty, and waxy casts. Later, urine more abund- 
 ant, lighter in color, less albumin. 
 
 Chronic interstitial nephritis {contracting kidney, terminating 
 in cirrhosis): — 
 
 Rising at night to urinate; full, hard 
 pulse; displacement of apex beat of 
 heart, accentuation of second sound (at 
 second right intercostal space, one-half 
 inch from the sternum), retinitis, post- 
 cervical neuralgia, dizziness, drowsiness, 
 coma, convulsions. Slow course, sudden 
 death. Polyuria. Deficiency of phos- 
 phoric acid marked. Trace of albumin, 
 increased at times. Casts, few hyaline. 
 Night urine equals or exceeds day. 
 
 Note: — The kidneys finally become 
 contracted, small, and hard. The actual 
 size possible is shown in figure 87. 
 Lardaceous disease (am^Zoid disease):— Fig. 87. Cirrhotic 
 
 Gastro-intestinal symptoms the fea- tidney, actual size, 
 ture; diarrhoea. Sallow complexion. (McNutt). 
 
 History of syphilis or suppurations. Tuberculous family history. 
 Dropsy. Enlarged spleen and liver. Albumin abundant; casts 
 not abundant, large hyaline or waxy. 
 
CHARACTERISTIC SYMPTOMS. 319 
 
 Cystic disease of kidneys:— 
 
 Cardiac symptoms of chronic interstitial nephritis. Soft, non- 
 fluctuant, kidney-shaped, bilateral renal tumor of slow growth. 
 Urine of chronic interstitial nephritis, plus blood; more albumin 
 and large granular casts. Cystitis may complicate, with pyuria. 
 
 Puerperal nephritis: — 
 
 Headache, visual troubles, dizziness, nausea, vomiting, convul- 
 sions. Urine suddenly becomes scanty, urea suddenly increases 
 in grains per ounce (13 to 14), albumin jumps from a trace to a 
 large quantity, in twenty-four hours or less; casts present, not 
 always abundant unless patient previously have chronic nephritis. 
 
 DIAGNOSTIC DIFFERENTIATION. 
 
 Chronic renal hypersemia is to be differentiated from chronic 
 interstitial nephritis as follows: — 
 
 THE UEINE IN 
 CHRONIC EENAL HYPEREMIA, CHRONIC INTERSTITIAL NEPHRITIS, 
 
 Oliguria; Polyuria; 
 
 Solids increased in grains Solids decreased in grains 
 
 per ounce; per ounce; 
 
 Color increased; Color decreased; 
 
 Albumin small; Albumin small; 
 
 Casts few, hyaline; Casts few, hyaline; 
 Urates and uric acid in sediment; No crystalline sediment; 
 
 Usually blood corpuscles in Usually no blood unless cystic 
 
 sediment. disease. 
 
 THE SYMPTOMS OF 
 CHRONIC RENAL HTPERiEMIA, CHRONIC INTERSTITIAL NEPHRITIS, 
 
 Valvular diseases; No valvular diseases; 
 
 No hypertrophy of heart; Hypertrophy of heart; 
 
 Weak thready pulse; Full hard pulse; 
 
 Dropsy, chiefly of lower No dropsy till late; 
 
 extremities; 
 
 No uraemia; Chronic uraemia; 
 No rising at night to urinate; Nocturnal micturition common; 
 
 No visual disorders. Visual disorders. 
 
 Chronic diffuse nephritis must be differentiated from lardaceous 
 (amyloid) disease. 
 
 THE URINE OF 
 CHRONIC DIFFUSE NEPHRITIS, LARDACEOUS DISEASE, 
 
 Urinary sediment abundant; Urinary sediment scanty; 
 
 Albumin large; Albumin large; 
 
 Casts abundant, including dark Casts few but large size, broad 
 granular and fatty; hyaline and waxy. 
 
 Pus corpuscles, epithelia, gran- Few cellular elements, 
 ular debris abundant in sedi- 
 ment. 
 
330 
 
 URINARY ANALYSIS. 
 
 THE SYMPTOMS OF 
 
 CHKONIC DIFFUSE NEPHRITIS, 
 
 Dropsy; 
 
 ADaemia striking, pallid puffy 
 
 face; 
 Ureemia not till late; 
 Dyspepsia and diarrhoea not 
 
 permanent; 
 Liver and spleen not enlarged. 
 
 LARDACEOUS DISEASE, 
 
 Dropsy; 
 
 Cachexia: — face sallow or 
 
 bronzed; 
 Uraemia rare; 
 Dyspepsia and diarrhoea are 
 
 notable features; 
 Liver and spleen enlarged. 
 
 Cystic disease of the kidneys must be differentiated from 
 chronic interstitial nephritis and from renal cancer: — 
 
 CYSTIC DISEASE. 
 
 Non-fluctuant swell- 
 ing in the sides; 
 
 Recurrent severe 
 haematuria; 
 
 Slow growth of 
 tumor; 
 
 No pain; 
 
 Sallow, cachectic ap- 
 pearance; 
 
 Age, 40 to 55. 
 
 CHRONIC INTERSTITIAI. 
 NEPHRITIS. 
 
 No swelling; 
 No haematuria; 
 No growth; 
 
 CANCER. 
 
 Patient well-pre- 
 served; 
 Age over 40. 
 
 Nodular growth of 
 unequal resistance; 
 
 Irregular intermit- 
 tent haematuria; 
 
 Bapid growth: 
 
 Pain; 
 Emaciation and 
 
 cachexia; 
 Age under 5 or 
 
 over 60. 
 
 Fig. 86. Stone in the kidney. 
 
CHARACTERISTIC SYMPTOMS. 
 
 321 
 
 Renal embolism: — 
 
 History of endocarditis; sudden renal pain, perhaps with 
 repeated chills and cardiac symptoms; if renal pain severe, vom- 
 iting and collapse. Sudden albuminuria gradually diminishing in 
 two to four weeks; hyaline, epithelial, and leucocyte casta for a 
 few days, then disappearing. 
 
 Benal calculus: — 
 
 Dull ache deep in loin; patient flinches on deep pressure with 
 thumb over one kidney; renal colic, violent unilateral pain down 
 the course of the ureter to the testicle; gastric disturbances; gen- 
 eral nutrition good. Urine contains blood which is increased by 
 exercise; crystals, especially sharp-pointed uric acid, and oxalate 
 concretions. Figures 88 and 89 show stone in kidney. 
 
 Benal cancer: — 
 
 Symptoms are increasing tumor between the costal arch and 
 the crest of the ilium; lobulated; nearly always fixed; pain early, 
 usually persistent, sometimes intermittent; dull ache in begin- 
 niiig, later lancinating not affected by movements. Emaciation; 
 anaemia; cachexia (brownness or sallowness of the skin); debility. 
 
 Urine contains blood, appearing and disappearing at intervals 
 without cause. Pus very small in amount, albumin corresponds 
 *o blood. Acetone present. Urination frequent. 
 
 8(0, 
 
 '"a /a 
 
 eorti, 
 
 » 
 
 ooi 
 
 ,^V»^ 
 
 sW® 
 
 stone lu pelvis. 
 
 Fig. 
 
 — Stone in ureter. 
 
 Nephro-lithiasis. 
 Stone in the kidney. {MoNutt), 
 
 41 
 
322 URINARY ANALYSIS. 
 
 Sarcoma of kidney: — 
 
 Microscopic al diMiiuosis of small round-cell sarcoma: The urine 
 contains: i. Pus ccupusoles; 3, red blood corpuscles; 3, shreds of 
 connective lishue; 4, sarcoma corpuscles, in size midway between 
 red blood corpuscles and pus corpuscles, either coarsely granular 
 Of homogeneous, i. e., composed of compact living matter, non- 
 nucleated They are larger than red blood corpuscles, and more 
 granular; differ from pus in lirninj; no nucleus. The diagnosis of 
 sarcoma is not possibltj unless ulceration of the tumor is present, 
 which involves the presence both of red blood corpuscles and 
 shreds of connective tissue. 
 
 Renal tuberculosis:— 
 
 Polyuria; dysuna prominent and increasing progressively until 
 the bladder is comfortable only when empty, usually no pain at 
 end of urination. More or less pain in renal region, with tender- 
 ness on deep pressure. Rise of 3 to 4 degrees in the temperature 
 at night; or periods of fever for several days, with periods of 
 remission. Profuse night-sweats, loss of appetite, debility, loss 
 of flesh, cough, and diarrhoea. 
 
 Urine increased, traces of albumin, a few blood corpuscles, and 
 pale cloudy urine, acid and of low specific gravity ; followed, 
 when ulceration sets in, by alkaline milky urine containing pus, 
 the latter remaining in suspension even on long standing. Blood 
 in 1 case out of 4, may be small, but sometimes is abundant. 
 Finally, offensive ammoniacal urine, with ropy muco-pus, triple 
 phosphate, cheesy masses, and with more albumin than pus and 
 blood accounts for. The bacillus tuberculosis, if present, is best 
 recognized by cultures in gelatin and inoculation of animals. 
 
 Hydronephrosis: — 
 
 Tumor m loin, sudden diminution of which corresponds with 
 sudden increase in non-purulent urine which sometimes contains 
 blood or blood-clots causing renal colic. 
 
 Pyonephrosis:— 
 
 Tumor in loin with scanty purulent urine, chills, evening tem- 
 perature, debility: all symptoms relieved by copious flow of uiine 
 containing blood and pus. 
 Acute pyelitis: — 
 
 Accoiijpaj.ies pyonephrosis and suppurative nephritis. 
 Chronic pyelitis:— 
 
 ching and diagging lumbar pain, worse on pressure and 
 ■exercise. Polyuria; greenish urine; odor slightly of rotten eggs; 
 pus not sticky, if the urine is acid; albumin more or less abund- 
 ant; pus corpuscles, with tooth-like projections; triple phosphate 
 crystals in acid urine. Frequent painless micturition. 
 Acute pyelo-nephritis (Suppurative nephritis; surgical kidney): — 
 
 Copious pyuria witli constitutional symptoms: chills, high tem- 
 perature, brown tongue, etc. Sediment of uiiue contains pus, 
 blood, casts, bacteria, bacteria casts. Albumin abundant. 
 Disease rapidly fatal, if both kidneys affected. 
 Movable Kidney:— ' 
 
 Patient commonly a thin woman who has rapidly borne chil- 
 dren. Dull, aching, dragging pain in the side with severe par- 
 oxysms. Gastro-intestinal symptoms, more or less mobile tumor 
 manipulation of which causes peculiar, sinking, or fainting sensa- 
 tions, or nausea. Scanty high-colored urine or short suppression 
 
CHARACTERISTIC SYMPTOMS. 323 
 
 followed by short polyuria. Hsematuria not infrequent. Slight 
 albuminuria. Differentiation from tumors, etc. difScult. 
 Cystitis (Inflammation of the Bladders- 
 Causes: — Local bladder infection by bacterial germs: hence 
 many causes, as gonorrhoea, stricture, enlarged prostate, stone, 
 sexual excess, etc. 
 
 Symptoms:— Pns in the urine, frequent urination and pain 
 especially after urinating. No persistent constitutional symptoms. 
 The Urine: — In -'acid cystitis" or more recent disease of the 
 bladder, the urine is acid when voided. More turbid in the first 
 glass than in the second, plainly albuminous, with floccultmt pus; 
 microscopically, large round epithelia from middle layers of the 
 bladder, pus corpuscles, blood corpuscles, and possibly bacteria, 
 with a few imperfect crystals of triple phosphate. In "alkaline 
 cystitis" or older cases the color of the urine is lighter, reaction 
 alkaline, odor ammoniacal or pungent or both; albumin in traces 
 only, sticky pus; microscope always shows bacteria, chiefly the 
 pathogenic, as bacillus coli oommMrns and staphylococcus pyogenes 
 aureus, pus corpuscles, blood corpuscles, bladder epithelia, and 
 plenty of triple phosphate. 
 Stone in the Bladder:— 
 
 Symptom,s:—T\\e features are pain and interruption of mictur- 
 ition. The pain may be felt along urethra, at end of penis, in 
 testicles, or down the thighs, is severe with spasm at close of 
 micturition, worse on motion, frequency of urination is present, 
 worse on motion. 
 
 Urine: — At first urine normal in appearance with deposit of 
 crystals. Later the urine of cystitis plus crystals, and blood at 
 the close of micturition aggravated by motion. 
 
 Tuberculosis of the Bladder:— 
 
 Symptoms: — Patient 15 to 30 years old of tuberculous family; 
 increased frequency of urination during the day, followed by 
 hematuria and rising at night; severe tenesmus at close of mic- 
 turition with constitutional symptoms of tuberculosis; evening 
 temperature, night-sweats, etc. Features are relief from pain 
 when bladder is empty, persistent perineal pain, pain in the mid- 
 dle of the penis, hsematuria without cause and not dependent on 
 exercise. 
 
 The Urine:— FjTJiia; hsematuria, sometimes slight, sometimes 
 pronounced; finally urine of cystitis. 
 
 Cancer of the Bbiuder: — 
 
 Symptoms: — E'eatures are pain just before the beginning of 
 urination with frequency of micturition. In some cases sharp 
 pain radiating to the thighs above symphysis or in perineal region. 
 Hsematuiia. 
 
 The Urine: — Irregular and very large shreds of connective tis- 
 sue. Epithelia with very large prominent nuclei; blood; features 
 of cystitis. Epithelial nests in granular connective tissue are 
 suspicious and very irregular shreds with nests characteristic. 
 
 Benign Growths of the Bladder:— 
 
 Typical shreds, in the urine, of connective tissue of yellow 
 brown color like yellow casts. Great size is characteristic, and 
 more regular forni than in cancer. 
 
324 URINARY ANALYSIS. 
 
 MISCELLANEOUS. 
 
 Diabetes Mellitus: — 
 
 Polyuria; glycosuria, diaceturia; lipuria; lipaclduria, with 
 emaciation, thirst, hunger, debility, nervous disorders, and sub- 
 normal temperature. Pale urine of high specific gravity. 
 
 Diabetic Coma: — 
 
 Gastric pain, dyspnoea, and drowsiness in course of diabetes 
 mellitus. 
 
 Diabetes Insipidus:— 
 
 Great polyuria; thirst; emaciation and debility; sub-normal tem- 
 perature; pale urine of low specific gravity. 
 
 Chyliiria:— 
 
 Milky urine, which does not settle, with a pink tinge of blood, 
 tending to coagulate spontaneously. Urine contains fat, fibrin 
 and albumin. 
 
 THE DIAGNOSIS OF PEEaNANOT. 
 
 Dr. Wm. B. Gray, of Richmond,. Virginia, places li inch of 
 urine in a small-sized test-tube, adds one-third its volume of mag- 
 nesian fluid and lets precipitate settle 15 to 30 minutes. In preg- 
 nancy the triple phosphate crystals formed by the above procedure 
 differ in appearance from the normal. The normal triple phos- 
 phate formed by precipitation is stellate and markedly feathery. 
 Soon after conception (30 days) the crystals lose their feathery ap- 
 pearance, the change beginning at the top and progressing toward 
 the base. One side only may be affected, or both, leaving only 
 the shaft and perhaps a few fragments, the shaft assuming a 
 beaded or jointed appearance. These changes are most marked 
 in the early months and occur in a very large percentage of preg- 
 nant women. Examine freshly voided urine. 
 
 Note: — For pathology and treatment of these disorders see the 
 author's new book, "The Clinical Features and Treatment of 
 Urinary Diseases." 
 
 Special: — The Appendix of this book on Urinary Analysis is 
 published separately and contains a complete course in the quan- 
 titative analysis of research work, including the Kjeldahl process 
 for nitrogen, the Liebig-Pfliiger process for urea, the Ludwig-Sal- 
 kowski process for uric acid, the Salkowski-Volhard process for 
 chlorides, determination of the urotoxic coefficient, etc., etc. 
 Also a complete method for the analysis of urinary calculi, and 
 Charles Heitzmann's method of preserving and mounting urinary 
 sediments. 
 
APPENDIX. 
 
 This Appendix contains standard methods for quantitative deter- 
 minations of the acidity of urine, urea, total nitrogen, uric acid, 
 kreatinin, xanthin, paraxanthin, chlorine, sulphuric acid (pre- 
 formed and conjugate sulphates), phosphoric acid, glycero-phos- 
 phoric acid, oxalic acid, albumin, sugar, and the urotoxic co- 
 efficient. Those engaged in research work will appreciate the 
 convenience of an arirangement by which the quantitative deter- 
 minations are consecutively described, instead of being scattered 
 throughout the whole of the preceding pages. In addition I have 
 included Mceschel's resumd of drugs which interfere with sugar 
 and albumin tests. Long's methods of analysis of calculi, and 
 Heitzmann's method of preserving and mounting urinary sedi- 
 ments. 
 
 At the end of the Appendix are certain tables which the author 
 finds convenient for reference, and to which frequent allusion has 
 been made in the clinical part of the book. 
 
 DETERMINATION OF THE ACIDITY OF URINE. 
 
 Solutions required are (a) phenolphthalein, i gm. in a mixture 
 of 200 c.c. water and 300 c.c. alcohol, best prepared fresh for each 
 determination, and (5) decinormal potassium hydroxide solution 
 made by diluting 100 c.c. of normal potassium hydroxide solution 
 to I, coo c.c. with pure water. 
 
 Normal potassium hydroxide solution is made as follows: Dis- 
 solve 75 gm. of potassium hydroxide in 1050 c.c. of water at 15° C. 
 (60° F. ), and fill a burette with this solution. Dissolve 0.63 gm. 
 of pure,oxalic acid in crystals in about 10 c.c. of water and add to 
 it a few drops of phenolphthalein. Now add the potassium hy- 
 droxide solution from the burette, until the oxalic acid is just 
 neutralized, a faint pink tint being seen in the solution. Note the 
 number of c.c. of potassium hydroxide used, and dilute the re- 
 mainder so that 10 c.c. of it will exactly neutralize 0.63 gm. of 
 oxalic acid. The method of determining the total acidity of the 
 urine is as follows: To 50 c.c. of urine add several drops of phe- 
 nolphthalein and add decinormal potassium hydroxide solution 
 until the pink color appears. Each c.c. of the potassium hy- 
 droxide solution used is equivalent to 0.006285 gm. of oxalic acid. 
 The total acidity of the 24 hours' normal urine averages an equiva- 
 lent of 2 gm. of oxalic acid. 
 
 Highly colored urine should first be shaken with animal char- 
 coal and filtered. 
 
 The acidity of urine at different times of the day can be deter- 
 mined by this method. Since recognition of the true end reaction 
 is impossible, owing to the action of the alkali employed on the 
 acid sodium phosphate, a mixture of neutral and. acid sodium 
 phosphates resulting at first which produces an amphoteric reac- 
 
326 APPENDIX: Urea. 
 
 tion, it is necessary to add slight excess of the hydroxide and the 
 reading taken when the reaction has become faintly alkaline, the 
 degree of acidity found being a trifle too high. 
 
 DETERMINATION OF UREA (UEBIG-PFLUEGER 
 METHOD). 
 
 (a). Mercuric Nitrate Solution. — Weigh out a quantity of 
 pure mercury and heat in a porcelain dish with two or three 
 times its weight of strong nitric acid, sp. gr. 1.42. Evaporate the 
 dissolved mercury to the consistence of a thick syrup, adding 
 from time to time a few drops of nitric acid to complete oxida- 
 tion which is shown by cessation of red fumes. Pour the syrupy 
 residue into ten times'its volume of water with constant stirring. 
 Let settle, pour oflF supernatant liquor, dissolve sediment in a few 
 drops of nitric acid and add to the liquid poured off. Dilute with 
 distilled water so that 71.5 gm. of mercury is contained in one 
 liter of solution. 
 
 [b). Baryta Solution. — To one volume of a cold saturated 
 solution of barium nitrate add two volumes of a cold saturated 
 solution of barium hydroxide. Keep in a well-stoppered bottle. 
 The solution is used to precipitate phosphates and sulphates which 
 interfere with the mercuric nitrate reaction. 
 
 Xc). Sodium Carbonate Solution. — Heat pure sodium carbon- 
 ate in a platinum dish to low redness, weigh out 53 gm. of the 
 salt thus dried, dissolve in distilled water, and dilute to one liter. 
 
 (rf). Standard Urea Solution. — Dissolve 2 gm. of pure urea 
 in distilled water and dilute to make 100 c.c. 
 
 PRELIMINARY TEST. 
 
 1. To exactly 10 c.c. of the urea solution add 19 c.c. of mercuric 
 nitrate solution. Shake, let stand a minute, filter. Wash precipi- 
 tate with a little distilled water, and to the mixed filtrate and 
 washings add enough of a weak solution of methyl orange to give 
 a pink color. N^xt from a burette run in enough sodium carbon- 
 ate with constant shaking until the pink changes to yellow; not 
 over 1 1.5 c.c. of the alkaline solution should be required. From 
 this calculate the amount needed for each c.c. of mercuric nitrate. 
 
 2. To exaH:tly 10 c.c. of the urea solution now add 19.5 c.c. of 
 mercuric nitrate solution. Also add the correct number of c.c. of 
 soda solution required to neutralize the acid of the nitrate. 
 
 3. Make a pasty mass of chloride — free sodium bicarbonate in 
 water, washing off excess of the bicarbonate, if necessary, with a 
 little cold water in a beaker and pouring off the water. 
 
 4. By means of a stirring rod transfer a drop of the liquid ob- 
 tained in 2 10 a dark glass plate and there mix it with a drop of 
 the semi-fluid obtained in 3. The color should be white. 
 
 5. Continue adding the mercury solution to the urea-carbon- 
 ate solution as in 2, drop by drop, and stirring well, and after 
 addition of each drop of mercury solution, test as in four. A 
 slight yellow color on the plate will finally be obtained, and if the 
 mercurv solution is correct just 20 c.c. should be necessary for 
 this. 
 
APPENDIX. 327 
 
 TEST OF THE URINE. 
 
 1. To 50 c.c. of urine add 25 c.c. baryta solution. Shake thor- 
 oughly, filter through dry filter into a flask. Filtrate should be 
 (a) alkaline, if not (iJ) precipitate over again with equal parts 
 urine and baryta solution. 
 
 2. Take 15 c.c. of the alkaline filtrate obtained in i (a) or 20 
 c.c. if of (6), and neutralize by adding carefully one drop at a time 
 dilute nitric acid. Test with litmus after each drop. ' 
 
 3. The filtrate thus prepared is titrated with the mercury solu- 
 tion. Begin by adding a c.c. at a time, and after each addition 
 bring a drop of the mixture in contact with a drop of the semi- 
 fluid sodium bicarbonate ou a plate of dark glass. The drops 
 should be placed side by side and mixed at the edges. At first 
 the mixture remains white, even after stirring, but as the addition 
 of mercury is continued a point is reached where the drop from 
 the beaker brought in contact with the moist bicarbonate gives a 
 light yellow shade. On stirring the drops together this yellow 
 should disappear, but this shows that the end of the reaction is 
 nearly reached. Add now the mercury solution in drops and test 
 after each addition. When the point is reached where a faint 
 yellow. shade persists after stirring together the drop from the 
 beaker and the sodium bicarbonate, it is time to neutralize with 
 the normal sodium carbonate solution. Run in the right number 
 of cubic centimeters corresponding to the mercury used and now 
 make the test for the final reaction again and continue until the 
 yellow color appears. 
 
 Regard this test as preliminary and make a new one with 15 c.c. 
 of the filtrate neutralized as before. Run in directly within i c.c. 
 of the amount of mercury required, as shown by the first test, 
 neutralize and complete as before. For each cubic centimeter 
 used, after deducting for chlorides, calculate 10 mg. of urea. 
 
 4. Deduct for chlorides by determination of the chlorides pres- 
 ent in 10 c.c. of urine (see Chlorides), calculate to sodium chloride, 
 and for each milligram of it found deduct .0238 c.c. from the vol- 
 ume of the mercuric nitrate, or approximatefji deduct 2 c.c. from 
 the volume of the mercury solution. 
 
 5. If more than two per cent of urea is present more than 20 
 c.c. of mercuric solution will be needed in the titration. If the 
 volume of the latter solution is greater than the sum of the 
 volumes of the prepared urine and soda solution used in neu- 
 tralization, this sum must be subtracted from the volume of the 
 mercury solution and the result multiplied by 0.08. The product 
 is added to the number of cubic centimeters of mercuric nitrate 
 used, to give the corrected result. If, on the other hand, the 
 volume of mercuric nitrate used in titration is less than the sum 
 of the volumes of prepared urine and soda solution, the difference 
 is multiplied by 0.08 and the product taken from the number of 
 c.c. of mercuric solution used, to give the corrected result. In 
 these calculations the volume of mercuric nitrate taken up by 
 the chlorides must be considered as part of the diluting liquid. 
 The same must be remembered in adding sodium carbonate for 
 neutralization. 
 
 The correction may be expressed in this formula, according to 
 Pflueger: 
 
328 APPENDIX: Total Nitrogen. 
 
 C=-(Vi-V2)Xo.o8, 
 in which 
 C = the correction to be added or subtracted. 
 Vj = the sum of the volumes of the urine, soda solution and 
 
 mercuric nitrate combined with the chlorides. 
 Vj = the volume of mercuric nitrate taken by urea. 
 In illustration we may take an actual case: 
 
 15.0 c.c. = the prepared urine (neutralized). 
 15.8 c.c. ^= the sodium carbonate used. 
 1.8 c.c. = the mercuric solution used by chlorides. 
 
 Vi = 32.6 c.c. 
 V, = 26.0 c.c. 
 
 6.6 
 
 —(Vi—V2)Xo.o8=— 0.528=0. 
 Therefore, 26 — 0.5 = 25.5 is the corrected volume of mercuric 
 nitrate, indicating, with the latter solution of standard strength, 
 25.5 gm. of urea in a liter.* 
 
 KJELDAHIv PROCESS FOR TOTAL NITROGEN. 
 
 Solutions required: (a). Normal sulphuric acid made by 
 mixing 30 c.c. of pure concentrated acid, specific gravity 1.835, 
 with enough water to make 1050 c.c. The mixture is cooled and 
 its strength determined with normal potassiiim hydroxide (see 
 Acidity). It is then diluted with water until 10 c.c. will exHCtly 
 neutralize lo c.c. of the normal potassium hydroxide solution. 
 
 (5). Fuming sulphuric acid. 
 
 (c). One-fifth normal potassium hydroxide solution. 
 
 \d). Solution of sodium hydroxide, specific gravity 1.3. 
 
 (^). Solution of litmus. 
 
 The one-fifth normal potassium hydrate is prepared by intro- 
 ducing 100 c.c. of normal potassium hydrate solution into a 500 
 c.c. graduated flask and filling with distilled water to the mark. 
 
 The sodium hydrate solution is made by dissolving 320 grams of 
 the pure sticks in ai)out 500 c.c. of distilled water, allowing to cool, 
 and when cold, in&oducing into a 1,000 c.c flask and filling with 
 water to the mark. 
 
 The litmus solution is made by pulverizing 50 grams of litmus, 
 introducing the powder into a flask containing 300 c.c. of distilled 
 water, warming an hour or two in a water bath with frequent 
 shaking, and decanting through a. filter. Divide the filtrate into 
 two equal volumes and redden one by introduction of small quan- 
 tities of dilute nitric acid, using a glass rod. Then mix the two 
 volumes, add 50 c.c. of strong alcohol, and keep in a dark, cool 
 place in small bottles filled to the neck, each closed with a cork, 
 having a groove cut in one side to allow access of air. 
 
 APPARATUS REQUIRED. 
 
 A 200 c.c. round-bottom Bohemian flask. 
 
 A 750 c.c. Erlenmeyer flask. 
 
 A condenser. 
 
 A 400 c.c. flask as a receiver. 
 
 A safety tube, 50 c.c. burette, etc. 
 
 * I/ong's Chemical Physiology. 
 
APPENDIX. 329 
 
 PROCESS OF DETERMINATION. 
 
 Introduce 5 c.c. urine frotu a burette into a 200 c.c. round-bottom 
 flask, 'and add 10 c.c. fuming sulphuric acid. To prevent loss 
 while the fluid is heated, introduce (according to Arnold) into the 
 mouth of the flask a test tube which fits loosely into its neck, hav- 
 ing been enlarged in its upper third by heating in the flame of a 
 blast lamp and blowing out. If the enlargement of the test tube 
 is near or in the middle third, remove the upper part of the tube 
 with a file. Place the flask on wire gauze secured at an angle of 
 45°, and heat the fluid with a gas or spirit lamp. Continue the 
 applicatiou of heat until the fluid becomes light yellow in color. 
 This usually takes place in one to one and one-half hours. The 
 fluid should be kept in constant ebullition. After cooling, place 
 the flask in cold water, as heat is generated by diluting, and add 
 water in small quantities, mixing well by shaking gently after 
 each addition, and when the dilution has reached about 100 c.c. 
 the fluid is introduced into the 750 c.c. Erlenmeyer flask. Rinse 
 several times with water, and add the rinsings to the fluid. The 
 quantity of fluid in the Erlenmeyer flask should not exceed 200 
 c.c. Into the 400 c.c. flask to receive the distillate, introduce 10 
 c.c. normal sulphuric acid from a burette. The condensing tube 
 of the cooler should be somewhat long, and the end to enter the 
 receiver bent, that its orifice may be brought as near the acid as 
 possible without coming in contact. As the fluid is dense when 
 the solution of sodium hydrate is introduced, it is liable to bump 
 during the distillation, to prevent which small fragments of zinc 
 are introduced into the flask. By the action of NaOH on zinc, 
 hydrogen is evolved, which prevents the bumping; but it was 
 found (Pfeiffer and Lehmann) that the hydrogen and aqueous 
 vapor a small quantity of sodium hydrate is carried over, hence a 
 safety tube is introduced between the Erlenmeyer flask and con- 
 denser. This is made by drawing out the end of a combustion 
 tube. 20 cm. long and 18 m.m. internal diameter, in the flame of 
 a blast lamp to 8 or 10 m.m. which passes through a hole in the 
 cork of the Erlenmeyer flask.* The upper end of the tube is con- 
 nected with the cooler by means of a cork, through which passes a 
 bent glass tube. To the fluid to be distilled add 60 c.c. of the solu- 
 tion of sodium hydrate (sp. gr. 1.30) and three fragments of zinc 
 as nearly spherical as possible, the weight of which not to exceed 
 0.5 grm. The sodium hydrate and zinc having been introduced, 
 connection with the condenser is made at once to prevent loss of 
 ammonia Distill slowly until the ammonia separates from the 
 fluid and is carried into the receiver and absorbed by the sulphuric 
 acid. This is usually accomplished by distilling thirty minutes. 
 To determine with greater accuracy if all the ammonia is distilled, 
 place a small piece of red litmus paper at the oriflce of the con- 
 densing tube, and if ammonia is still passing over, the red litmus 
 paper turns blue. 
 
 The quantity of ammonia absorbed by the 10 c.c. normal sul- 
 phuric acid is determined by titrating with the one-fifth normal 
 
 *Itwas found by Dr. Van Nueys that by a safety tube of the dimensions 
 here given, the purpose is accomplished as well as with others more complex 
 in construction which have been recommended. 
 
330 APPENDIX: Uric Add. 
 
 potassium hydrate. For this purpose, the solution of litmus is 
 added to the fluid in quantity sufficient to impart a distinct red 
 color, when the solution is titrated with the one-fifth normal potas- 
 sium hydrate from a 50 c.c. burette, until by the addition of o.r 
 c c, after shaking, the solution turns purple or blue. 
 
 CAI.CULATION OF RESULTS. 
 
 In I c.c. normal ammonia there is 0.017 gram NH, or 0.014 
 gram nitrogen, i c.c. normal acid will neutralize 1 c.c. normal 
 ammonia; therefore, by multiplying the number of c.c. normal 
 acid neutralized by 0.017, the product is the quantity of NHj in 
 grammes, or by multiplying by 0.014, t^ie number of grams nitro- 
 gen is determined. 
 
 Example: 31 c.c. of one-fifth normal potassium hydrate was 
 required to neutralize the acid instead of 50 c.c, as would be the 
 case in the absence of ammonia 31 c.c. one-fifth normal solu- 
 tion is equal to 6.2 c.c. of the normal (^jL^S.a), and as loc.c. of the 
 normal sulphuric acid was employed, 3.8 c.c. was neutralized by 
 the ammonia formed from 5 c.c. urine (10 — ^6.2=3.8), and as 3.8 
 c.c. normal ammonia would neutralize 3.8 c.c. normal sulphuric 
 acid, there is in 3.8 c.c. normal ammonia the quantity of nitrogen 
 found in 5 c.c. urine, which is 0.0532 gm. (3.8X0.014=0.0532), and 
 in 100 c.c. urine there is 1.064 g™- nitrogen (0.0532X20=1.064). 
 
 THE GUNNING METHOD. 
 
 In this method neither potassium permanganate nor sulphide 
 is used, but 10 gm. of powdered potassium sulphate and ordinarily 
 20 c.c. of concentrated sulphuric acid. Digestion as in the 
 Kjeldahl process, as also dilution, neutralization and distillation. 
 In neutralizing it is convenient to add a few drops of phenol- 
 phthaleiu by which one can tell when the acid is completely 
 neutralized, remembering that the pink color which indicates 
 an alkaline reaction is destroyed by considerable excess of strong 
 fixed alkali. Titration as in Kjeldahl method. 
 
 A very satisfactory apparatus is now used by the Connecticut 
 Agricultural Experiment Station, which is described in full in 
 their annual report for 1889. For use in determining nitrogen in 
 the urine the flasks may be made smaller. 
 
 Dr. Long advises use as standard acid one-tenth normal sul- 
 phuric acid, which is colored with a single drop of methyl orange; 
 the standard acid must still show a pink color after the distillation 
 process. 
 
 DETERMINATION OF URIC ACID. 
 
 The principal methods now in vogue are the Salkowski-Ludwig 
 and the Haycraft. 
 
 Thb salkowski-i,udwig. 
 
 Solutions required : 
 
 (a). Aminoniacal silver nitrate solution made by dissolving 25 
 gm. of silver nitrate in 100 c.c. of water, adding ammonia water 
 until the precipitate first appearing is completely dissolved, mak- 
 ing up to 1,000 c.c. with water and keeping in a dark bottle away 
 from the light. 
 
 (b). Magnesia mixture made as follows: Dissolve 100 gm. of 
 magnesium sulphate and 100 gm. of ammonium chloride in 800 c.c. 
 
APPENDIX. 331 
 
 of water, add ic» c.c. of strong ammonia water, allow mixture to 
 stand 24 hours and filter. It must be strongly alkaline and al- 
 most or quite clear. 
 
 (£■). Solution of sodium sulphide made by dissolving 25 to 30 
 gm. of pure crystals (NajS, gHjO) in 1,000 c.c. of distilled wa- 
 ter. To make the test measure out 200 c.c. of the urine of 24 
 hours and put it in a beaker. Add 20 c.c. of the silver solution to 
 an equal volume of the magnesia mixture and then ammonia 
 enough to clear up any precipitate which forms. Pour the clear 
 mixture into the urine in the beaker and stir well. A precipitate 
 of silver urate and phosphates (silver and earthy) forms. 
 
 The beaker is allowed to stand at rest about an hour, after 
 which the contents are filtered and the precipitate washed with 
 weak ammonia on the filter. To do this the ammonia is sprayed 
 into the beaker from a wash bottle and rinsed around thoroughly. 
 This is done several times, the liquid being poured on the filter. 
 Where available a Gooch crucible serves well for the collection 
 of the precipitate, as the filtration is slow on paper without aspir- 
 ation. It is not necessary to remove any of the precipitate which 
 clings to the beaker, as will be seen. When the washing is com- 
 plete transfer the precipitate and filter paper, or asbestos it the 
 Gooch crucible is used, back to the beaker and pour over it a 
 boiling mixture of 20 c.c. of the sulphide solution (c), and 20 c.c. 
 of distilled water. Stir up thoroughly, allow to stand some time 
 and then add 50 c.c. of boiling water. Place the beaker on a. 
 sand bath or gauze and bring the contents to boiling, stirring con- 
 tinually. Keep hot some minutes and then allow to stand until 
 cold, the precipitate being stirred meanwhile occasionally. 
 
 The treatment with the sulphide solution decomposes the silver 
 urate with precipitation of black insoluble silver sulphide, the 
 uric acid remaining in solution as soluble urate. The cooled 
 liquid is filtered into a porcelain dish, and the precipitate washed 
 with warm water, the washings going also into the dish. Enough 
 hydrochloric acid is now added to combine with all the bases 
 present and liberate the uric acid, which is the case when the 
 liquid becomes acid in reaction. It is now slowly evaporated to a 
 volume of about 10 c.c, best on a water bath, and then allowed to 
 stand an hour for the complete separation of the uric acid. This 
 is then collected on a weighed Gooch crucible, the crystals beiug 
 transferred gradually by aid of the filtered liquid. When the 
 crystals are on the asbestos they are washed with a little acidu- 
 lated water several times. The crucible is dried at 100° C. 
 (212° F.), put back in the funnel and treated with a small amount 
 of pure carbon disulphide to remove traces of sulphur. Finally 
 wash with ether, dry at ico° C, and weigh with a chemical bal- 
 ance. 
 
 Results obtained show the amount of uric acid in grams in 
 200 c.c. of urine; multiply by 5 to find grams per liter and by 
 the number of liters of urine in 24 hours (1,000 c.c. = i liter) to 
 find total quantity of uric acid in 24 hours. Reduce this to grams 
 by multiplying by 15.43. 
 
 THE HAYCRAFT METHOD FOR URIC ACID. 
 
 Solutions required : 
 
 (a). Ammoniacal solution of silver nitrate: Dissolve 5 gm. 
 
332 APPENDIX: Uric Acid. 
 
 of silver nitrate crystals in lOO c.c. of water and then enough 
 ammonia water to give solution strong alkaline reaction. Make 
 up to 200 c.c. with the ammonia. 
 
 (b). Ammonium sulphocyanate solution: A fiftieth normal 
 solution of ammonium sulphocyanate is used which is made by 
 diluting 100 c.c. of decinormal ammonium sulphocyanate to 500 
 c.c. in a measuring flask. 
 
 [Decinormal ammonium sulphocyanate is made as follows: 
 Dissolve about 7.7 gm. of the pure crystals of ammonium sulpho- 
 cyanate in water and make up to a liter. Determine its strength 
 by titration with decinormal silver nitrate solution made as fol- 
 lows: Weigh out accurately 10.766 gm. of pure silver and dis- 
 solve in a flask with pure nitric acid. Remove excess of nitric 
 acid by evaporation and blow air through to drive out nitrous 
 fumes. Cool and dilute to one liter. This solution may also be 
 made by dissolving 16.954 gm. of the crystals of silver nitrate 
 (fused at low temperature before weighing) in water to make a 
 liter, but its strength must be tested, as described under chlo- 
 rides. 
 
 Determination of the strength of the decinormal ammonium 
 sulphocyanate solution is made as follows: Measure into a flask 
 or beaker 25 c.c. of the decinormal silver solution, and add to it 
 2 or 3 c.c. of a nearly saturated solution of ferric alum free from 
 chlorine. This gives some color and a slight opalescence. Now 
 add about 2 c.c. of pure, strong nitric acid which decolorizes and 
 clears the mixture. Into the mixture now let the sulphocyanate 
 flow a little at a time, shaking after each addition. When the 
 red color disappears more slowly on shaking, then add the sul- 
 phocyanate drop by drop till at last a single drop is enough to 
 give a permanent reddish tinge. Less than 25 c.c. will do this. 
 Repeat the test and if the same result is found dilute the sulpho- 
 cyanate so that 25 c.c. will exactly do the work. That is, if 24.2 c.c. 
 were required, then if you have goo c.c. of sulphocyanate solution, 
 24.2 : 25 = 90o:x, or x := 929.75. That is, add 29.8 c.c. of water 
 to the 900 c c. of sulphocyanate.] 
 
 (c). Am,monium, ferric sulphate (ferric alum), saturated solu- 
 tion, as indicator. 
 
 One cubic centimeter of a fiftieth normal (30) solution of the 
 sulphocyanate liberates and indicates .00336 gm. of uric acid. 
 
 If a solution of a sulphocyanate is added to a solution of a sil- 
 ver salt containing nitric acid and ferric sulphate, a complete 
 reaction takes place between the sulphocyanate and silver before 
 the characteristic reaction between the former salt and the ferric 
 compound appears. In other words, the sulphocyanate and the 
 silver combine first, and then any further amount of sulphocyan- 
 ate added unites with the iron, producing a red color (of ferric 
 sulphocyanate), indicating the completion of the first reaction. 
 
 The process for determining uric acid in the urine is as follows: 
 Measure out 50 c.c. of the urine and warm it gently if it contains 
 a sediment of urates. Add 3 to 4 gm. of pure sodium bicarbonate 
 and then ammonia enough to give a strong alkaline reaction. 
 This may give a precipitate of phosphates which need not be 
 heeded. Next add 5 c.c. of the silver solution (a), and mix thor- 
 oughly. This produces a precipitate of silver urate along with 
 the bulky phosphates thrown down by the ammonia. Allow to 
 stand half an hour and then filter. A paper filter and funnel may 
 
APPENDIX. 333 
 
 be used iu the usual manner, but much better results are obtained 
 by the use of the Gooch crucible and asbestos with the aid of an 
 aspirator. Rinse the sides of the beaker thoroughly with weak 
 ammonia and pour this on the precipitate in the funnel or cruci- 
 ble. Continue the washing of the precipitate with weak ammonia 
 water until all traces of silver are washed out, as may be shown 
 by allowing a few drops of the filtering washings to fall into some 
 dilute hydrochloric acid in a test tube. The washing is complete 
 when a cloudiness is no longer obtained in this test. 
 
 Now pour some pure dilute nitric acid into the beaker in which 
 the precipitation was made, and which was washed free from silver 
 by the ammonia, and shake it around until any traces of the silver 
 urate precipitate are dissolved. Put the funnel or Gooch crucible 
 over a clean receptacle and pour this acid liquid on the precipitate. 
 Silver urate dissolves completely in dilute nitric acid, and enough 
 of this is added, a little at a time, to bring about complete solu- 
 tion. It now remains to titrate the silver in the solution. To this 
 end add 5 c.c. of the ferric alum solution, and if the mixture is 
 not clear and colorless, about 2 c.c. of pure strong nitric acid. 
 Then from a burette run in the sulphocyanate (6), a little at a time, 
 shaking after each addition until a faint red shade of ferric sulpho- 
 cyanate becomes permanent. Toward the end of the titration a 
 red appears as each drop of liquid from the burette falls into the 
 silver'solution below, but this color fades out on shaking and does 
 not persist until the last particle of silver has been taken up by the 
 sulphocyanate. Supposing now that 15 c.c. of the latter solution 
 are required to reach this point we have 15X00336^.0504 gm. as 
 the amount of uric acid in the 50 c.c. of urine taken. A volume as 
 large as this would seldom be required, 5 to 10 c.c. corresponding 
 to 16.8 to 33.6 mg., is usually sufl5cient. 
 
 The Hopkins method is one in which, after removal of phos- 
 phates, titration by potassium permanganate is used. While easier 
 in some respects than the two previous methods, there are certain 
 difficulties in it which make it not so preferable to the two methods 
 just described as to warrant description in full. 
 
 QUANTITATIVE DETERMINATION OF KREATININ IN 
 THE URINE. 
 
 In 240 c. c. of urine the phosphates are first removed by ren- 
 dering the urine alkaline with milk of lime and then adding cal- 
 cium chloride as long as a precipitate forms. If the volume now 
 be less than 300 c. c, water is added to that amount. The mixture 
 is filtered after having been allowed to stand for one-quarter to 
 one-half hour, and washed with a little water; 250 c. c. of the mix- 
 ture are then measured oil, slightly acidified with dilute hydro- 
 chloric acid so as to prevent any transformation of kreatinin into 
 kreatin during the long process of evaporation. This amount is 
 evaporated on a water-bath to a, syrupy consistence, and then 
 thoroughly mixed with 20 to 30 c. c. of absolute alcohol. The 
 mixture is poured into a stoppered flask provided with a 100 c. c. 
 mark, and after thoroughly rinsing out the evaporating dish with 
 absolute alcohol, the washings are also placed in the bottle and 
 absolute alcohol added to the 100 c. c. mark. The bottle is thor- 
 
334 APPENDIX: Kreaiinin. 
 
 oughly shaken and set aside in a cool place for twenty-four hours, 
 the mixture being agitated from time to time. It is now filtered 
 and rendered slightly alkaline with a drop or two of sodium 
 carbonate solution, as kreatinin hydrochloride is not precipi- 
 tated by chloride of zinc. The reaction, however, should be only 
 faintly alkaline, as otherwise zinc oxide will be precipitated. 
 The mixture is now slightly acidified with acetic acid. Eighty 
 c. c, corresponding to i6o c. c. of urine, are treated with lo to 15 
 drops of an alcoholic solution of zinc chloride, prepared by dissolv- 
 ing the salt in 80 per cent, alcohol and diluting with 95 per cent, 
 alcohol to a specific gravity of 1.2. The mixture is then well 
 stirred and set aside in a cool place for two or three days. The 
 crystals, which are usually deposited upon the sides of the vessel 
 in the form of wart-like masses, are then collected upon a dried 
 and weighed filter, always using portions of the filtrate to bring 
 the crystals completely upon the filter. These are washed with a 
 small amount of go per cent, alcohol until the washings are with- 
 out color and give only a slight opalescence when treated with a 
 drop of nitrate of silver solution. The crystals are finally dried at 
 a temperature of 100° C. (2I2°F.), and weighed. By multiplying 
 the weight thus found by 0.6243 the amount of kreatinin is ob- 
 tained. > 
 
 Precautions: i. Albumin and sugar, if present, must first be 
 removed. In diabetic urines it is best, after having removed the 
 sugar by fermentation, to take one-fifth of the total quantity elim- 
 inated in 24 hours, and to evaporate this to about 300 c.c. before 
 removing the phosphates. 2. The weighed material should be 
 examined microscopically to see whether notable quantities of 
 sodium chloride be present. Should such be the case it is neces- 
 sary to determine the amount of zinc present and to estimate the 
 kreatinin from this. To this end the alcoholic solution containing 
 the kreatinin-zinc chloride is evaporated to dryness after the 
 addition of a little nitric acid. The residue is incinerated, ex- 
 tracted with water, washed, dried, fused and finally weighed. 
 
 As 100 parts of kreatinin-zinc chloride correspond to 22.4 parts 
 by weight of zinc oxide, the corresponding amount of the com- 
 pound is found according to the following equation: 22.4 . 100^ 
 y : X and ^^=4.4642, in which y represents the amount of zinc 
 oxide found, and x the corresponding amount of kreatinin-zinc 
 chloride. By multiplying the number thus ascertained by 0.6243 
 the corresponding amount of kreatinin is found. 
 
 3. Instead of doing this the precipitate in the alcoholic solution 
 may be examined microscopically before filtering, and if sodium 
 chloride crystals be found, providing that the kreatinin-zinc 
 chloride crystals adhere to the sides of the vessel, the sodium 
 chloride may be dissolved in a little water and poured off. 
 
 4. If the crystals of kreatinin-zinc chloride adhere very firmly 
 to the sides of the vessel, so that their removal would be incom- 
 plete, it is perhaps best to dissolve them in a little hot water, to 
 evaporate to dryness, and to weigh the kreatinin compound 
 directly. 
 
 5. If the urine shows an alkaline reaction it is best to acidify 
 with sulphuric acid and to boil for half an hour, before removing 
 the phosphates, so as to transform any kreatiu that may be pres- 
 ent into kreatinin, when the examination should be continued as 
 described. (Simon.) 
 
APPENDIX. 335 
 
 DETECTION OF PARAXANTHIN AND XANTHIN. 
 
 In the examination of the urine Rachford assumes, for reasons 
 given in his paper, the following propositions: i. Four liters of 
 normal urine is too small a quantity to determine the presence of 
 paraxanthin. 2. Three liters of pathological urine are quite 
 enough to determine whether paraxanthin occurs in sufficient ex- 
 cess in this urine to make it a probable factor in disease. 
 
 In every case at least two specimens of urine should be exam- 
 ined. One of three liters of urine passed during and just after 
 the attack, supposed to be due to leucomain poisoning; and the 
 other of four liters of urine passed, in an interval between the at- 
 tacks, when the patient is at his best. 
 
 Method (from E. Salkowski and Salomon). — The phosphates are 
 precipitated with ammonium hydrate; after tweuty-four hours the 
 urine is filtered or decanted from the precipitate, and a three per 
 cent, solution of nitrate of silver is added to it; the silver solution 
 should be added as long as precipitation occurs. The urine is 
 removed from the precipitate of silver compounds, and this pre- 
 cipitate' is washed iive or six times with distilled water, the water 
 being removed each time from the precipitate by decantation. 
 This process may require a week. The silver compounds sus- 
 pended in water are now decomposed with hydrogen sulphide, 
 the current of HjS is made to pass through the water, in which 
 the silver compounds are suspended, for hours; the liquid is now 
 filtered, to separate it from the precipitate, and evaporated down 
 to about 50 c.c. if 2,000 c.c. of urine have been used, the remaining 
 uric acid is thereby separated; this liquid being filtered, ammonia 
 is again added; after twenty-four hours it is again filtered and 
 precipitated with silver nitrate, the silver being added as long as 
 precipitation occurs; the silver compounds are again separated 
 from the liquid by filtration; they are allowed to remain on the 
 filter paper and kept in a dark place for twenty-four or thirty-six 
 hours; the filter paper holding the dry precipitate of silver com- 
 pound is put in hot nitric acid of i.i specific gravity; the acid 
 dissolves the nitrates of xanthin and paraxanthin in the precipi- 
 tate, and thus separates them from the nitrate of hypoxanthin, 
 which is insoluble in nitric acid; if working with three liters of 
 urine, from 6 to 7 c.c. of acid should be sufficient to dissolve the 
 xanthin and paraxanthin. After two hours the nitric acid is 
 again heated and filtered while hot, so as to insure the solution of 
 the xanthin and paraxanthin; the nitric acid solution is now care- 
 fully neutralized with ammonium hydrate, and for the third time 
 xanthin and paraxanthin are precipitated; the precipitate is 
 washed, suspended in water, and again decomposed with hydrogen 
 sulphide; this fluid is filtered while hot, and the nitrate is evapo- 
 rated to 10 c.c; a little ammonium hydrate is now added, and 
 after twenty-four hours the last traces of phosphates and oxalate 
 will be precipitated; the liquid is again evaporated on a sand-bath, 
 and when the liquid begins to get turbid evaporation is suspended, 
 and as the liquid cools the xanthin, if present, will separate out; 
 filter and again evaporate to 2 c.c. Again the liquid is allowed 
 to cool, so that the xanthin may crystallize out, and the 2 c.c of 
 "final fluid" is added to 3 or 4 c.c. of distilled water, and this 
 dilute "final fluid" is tested for paraxanthin. If this fluid 
 contain paraxanthin — a, the needle-shaped crystals can be 
 
336 APPENDIX: Chlorides. 
 
 obtained by evaporating a drop on a glass slide; b, tbe character- 
 istic white precipitate should result when a drop of this fluid is 
 added to a solution of potassium hydrate; c, a few drops of this 
 fluid when injected hypodermically into a mouse or rat should 
 produce the symptoms of paraxanthin poisoning. 
 
 That the crystalline mass that separated out in the final evap- 
 orations was xanthin may be proven as follows: Dissolve the 
 supposed xanthin crystals and add picric acid, and if xanthin be 
 present a precipitate of long white glistening crystals of picrate 
 of xanthin will form; or a better test is to mix two or three drops 
 of suspected xanthin solution with two or three drops of nitric 
 acid, chemically pure, in a porcelain dish, and evaporate over 
 flame to dryness, and a yellow precipitate results; to this yellow 
 precipitate add ammonium hydrate and heat; if the precipitate 
 takes on a purple color xanthin is present. 
 
 The quantity of xanthin present can be determined by carefully 
 weighing the crystals that separate out in evaporating down to 
 the "final fluid." But for clinical purposes this is scarcely neces- 
 sary, as one can judge by the mass of crystals formed whether 
 there be a great excess of xanthin or not If there only be a thin 
 layer of xanthin crystals at bottom of the final fluid, then the xan- 
 thin is not very greatly increased, but if the xanthin crystals sep- 
 arate out in much larger quantities, adhering to the sides of the 
 glass vesfsel and forming a mass that cannot be redissolved in 6 
 or 8 c.c. of distilled water at room temperature, then it may be 
 safely asserted that the xanthin is very greatly increased in quan- 
 tity. 
 
 The stomach contents should be diluted with distilled water and 
 boiled, and then filtered through filter paper with the aid of a 
 vacuum filter; the mass remaining on the filter should be again 
 mixed with distilled water, boiled, and again filtered; this fluid is 
 then treated in the same way as the urine. 
 
 DETERMINATION OF CHLORIDES. 
 
 The method of Salkowsky-Volhard is as follows: 
 Reagents necessary : 
 
 1. A solution of silver nitrate of such strength that every c.c. 
 corresponds to o.oi gram of sodium chloride. 
 
 2. A solution of potassium sulphocyanide of such strength that 
 25 c.c. correspond to 10 c.c. of the silver nitrate solution. 
 
 3. A solution of a ferric salt saturated at an ordinary tempera- 
 ture, such as ammonio-ferric alum. 
 
 4. Nitric acid (specific gravity 1.2). 
 Preparations of these solutions; 
 
 i; The silver nitrate to be used for this purpose must be pure, 
 the crystallized salt being used. In order to test the purity of the 
 salt, about i gram is dissolved in distilled water, heated to the 
 boiling point, the silver precipitated by dilute muriatic acid and 
 filtered oif. The filtrate when evaporated in a platinum crucible 
 should leave either no residue at all or only a very faint one; 
 otherwise it is necessary to recrj'stallize the salt and test again, 
 until the desired degree of purity is obtained. 
 
 To bring the solution to its proper strength 0.15 gm. of sodium 
 chloride which has been previously dried carefully by heating in a 
 platinum crucible is accurately weighed oS", dissolved in a little 
 
APPENDIX. 337 
 
 distilled water and further diluted to loo c.c. To this solution a 
 few drops of a solution of chrpmate of potassium are added and 
 the mixture titrated with that of silver nitrate containing 29.059 
 gm. in 100 c.c. of water. The nitrate of silver will first precipitate 
 every trace of sodium chloride present and then combine with the 
 potassium chromate forming red silver chromate. The slightest 
 orange tinge remaining after stirring indicates the end of the re- 
 action. Were the solution of silver nitrate of the proper strength 
 exactly, 15 c.c. should have been used, as every c.c. is to represent 
 0.01 gtp. of sodium chloride As a matter of fact, less will in all 
 probability be needed, the solution having been purposely made 
 too strong. Its correction then becomes a simple matter, it 
 merely being necessary to determine the degree of dilution re- 
 quired. Supposing that 29.059 gms. of silver nitrate to have been 
 dissolved in goo c.c. of water, and that 14.5 c.c. instead of 15 c.c. 
 had been required to precipitate the 0.15 gm. of sodium chloride, 
 it is evident that every 14.5 c.c. of the remaining solution must be. 
 diluted with 0.5 c.c. of water. It is hence only neccessary to 
 divide the number of c.c. of the silver nitrate solution remaining 
 by 14.5; the result multiplied by 0.5 represents the amount of 
 water which must be added in order to bring the solution to the 
 required strength. 
 
 Hence the rule for the correction of a solution which has been 
 found too strong: 
 
 N . d 
 
 C= , 
 
 n 
 in which C represents the number of c.c. which must be added to 
 the solution remaining; N the total number of c.c. remaining after 
 titration; and the number of c.c. consumed in one titration; and 
 the difference between the number of c.c. theoretically required and 
 that actually used in one titration. 
 
 In the example given the equation would then read: 
 
 936.5X0 5 
 
 C— =32.29 
 
 14-5 
 32.29 c.c. of distilled water are added to the remaining 936.5 c.c, 
 and the strength of the solution tested by a second titration. If 
 the solution be found too weak, it is best to make it too strong and 
 then to correct, as described. , 
 
 2. Preparation of the potassium sulphocyanide solution. 
 
 In order to bring this solution to its proper strength, 10 c.c. of 
 the silver nitrate solution are diluted to 100 c.c, 4 c.c. of nitric 
 acid (specific gravity 1.2) and 5 c.c. of the ammonia-ferric alum 
 solution added, and the mixture titrated with the KSCN solution; 
 the end reaction is recognized by the production of a slightly 
 reddish color, which persists on stirring. The KSCN solution 
 having been purposely made too strong, it will be found that 
 less than 25 c.c will be needed in order to precipitate all the silver 
 present. The quantity of water necessary for dilution is ascer- 
 tained as above according to the formula: 
 
 N . d 
 
 C= , 
 
 n 
 
 3. The solution of ammonia-ferric alum is a solution saturated 
 
 42 
 
338 APPENDIX: Chlorides. 
 
 at ordinary temperatures, care being taken to insure the absence 
 of chlorides in the salt, which may be effected, if necessary, by re- 
 crystallization. 
 
 Method applied to the urine: lo c.c. of urine are placed in a 
 small stoppered flask bearing a loo c.c. mark, diluted with 50 c.c. 
 of distilled water and acidified with 4 c.c. of niiric acid. From a 
 Mohr's burette 15 c.c. of a standard solution of silver nitrate are 
 added, the mixture is thoroughly agitated and diiuted with dis- 
 tilled water to the 100 c.c. mark, the silver chloride formed is fil- 
 tered off through a dry folded filter into a dry graduate, 80 c.c. of 
 the filtrate are placed in a beaker, and after the addition of 5 c.c. 
 of the ammonio-ferric alum solution, titrated with the potassium 
 sulphocyanide solution until the end reaction — i. e., a slightly red- 
 dish tinge — is seen. If necessary, two such titrations should be 
 made, the sulphocyanide sohition being added i c.c. at a time in 
 the first, while in the second the total number of c.c. needed to 
 bring about the end reaction, less one c.c, are added at once and 
 then one-tenth of a c.c. at a time. 
 
 The amount of chlorides present in the urine is calculated as fol- 
 lows: Example: — Total quantity of urine 600 c.c; 6.5 c.c. of 
 potassium sulphocyanide solution were required to bring about the 
 end reaction in 80 c.c. of the filtrate. This would correspond to 
 8.125 c.c. for the total 100 c.c. of filtrate representing 10 c.c. of 
 urine, as is seen from the equation. 
 
 N: 8o-=x: 100 
 80x^100 n 
 x=ioo n 5n 
 
 80 4 
 in which x represents the number of c.c corresponding to lOO c.c. 
 of the filtrate and N the number of c.c. actually used. 
 
 These 8.125 c.c. were used in precipitating the remaining c.c. of 
 the silver nitrate solution not decomposed by the chlorides. As 
 25 c.c. of the potassium sulphocyanide solution correspond to 10 
 c.c of the silver nitrate solution, the excess of silver solntion in 
 c.c. is found by the equation: 
 
 25 : io=N ■ X 
 then 25 x=ioN 
 
 x= loN 2N 
 
 25 5 
 in which x represents the excess of silver nitrate solution in c.c, 
 N that sulphocyanide solution as found in the equation above, x 
 in this case being 3.25 c.c. 
 
 The difference between the total amount of silver solution em- 
 ployed {i. e., 15 c.c.) and the excess (i. e., 3.25 c c.) indicates, of 
 course, the number of c.c. necessary for the precipitation of the 
 chlorides in 10 c.c. of urine. In the case under consideration 
 11.75 c.c. were employed. As i c.c of the silver solution repre- 
 sents o.oi gram of NaCl, there must have been present in the 10 
 c.c. of urine 0.1175 gram; in 100 c.c, hence, 1.175 grams, and in 
 the total amount — i. e., 600 c.c. of urine — 7.05 grams. 
 
 From these considerations the following short rule results: In- 
 stead of first multiplying the number of c.c. of the potassium 
 sulphocyanide solution corresponding to 80 c.c. of the filtrate by 
 
APPENDIX. 339 
 
 A, as seen from the equation above, and the result by — in or- 
 4 5 
 
 der to find the number of c.c. of the potassium sulphocyanide 
 solution representing the excess of silver nitrate in loo c.c. of the 
 filtrate and then deducting the result from 15, it is simpler to 
 multiply by yi. directly and deduct the result from 15, the number 
 of grams of sodium chloride contained in 1000 c.c. of urine being 
 thus found. This figure is then corrected for the total amount of 
 urine. 
 
 n 
 Hence the equations, I., x = 15 ; II., 1000 : x : : A : Ch, or 
 
 2 
 
 n 
 
 A(I5— ) 
 2 
 
 the combined formula Ch= , 
 
 1000 
 in which Ch represents the quantity of chlorides contained in the 
 total amount of urine, A the amount of urine actually passed, n 
 the number of c.c. of the potassium sulphocyanide solution used 
 in the precipitation of the excess of chlorides in 80 c.c. of the 
 filtrate. 
 
 6.5 
 (15- -) 
 2 
 
 So in the above case Ch=6oo =:7.o5. 
 
 1000 
 The method described may be employed in the presence of 
 albumin, albumoses, peptones and sugar; the urine, however, must 
 be fresh, so as to insure the absence of nitrous acid. (Simon.) 
 
 DETERMINATION OF THE SULPHATES. 
 
 (a) total sulphates: 100 c.c. of clear, filtered urine are treated 
 with 8 c.c. of hydrochloric acid 1 1.12), and heated to the boiling 
 point; when 20 c.c. of a saturated solution of barium chloride are 
 added. The mixture is kept in the water-bath until the barium 
 sulphate has thoroughly settled, which it will do in about half an 
 hour. Filter through a Gooch filter with a close-fitting plug of 
 asbestos, the whole having been previously dried and weighed. 
 Care should be taken never to allow the filter to become dry, and 
 small amounts of hot water must be added to the last c.c. remain- 
 ing, the final traces being placed upon the filter with the aid of a 
 rubber-tipped glass rod. The precipitate is washed with boiling 
 water until a specimen of the washings is no longer rendered 
 cloudy, even on standing for a few minutes, on the addition of a 
 drop of dilute sulphuric acid. Gum-like substances, as well as 
 pigments, are removed by washing with hot alcohol (70 per cent.), 
 and then filling the filter two or three times with ether. A suction 
 apparatus is necessary, and in the absence of a special pump a 
 simple glass tube bent upon itself may be employed. 
 
 If a paper filter has been used, it is placed in a weighed plati- 
 num or porcelain crucible and ignited. The ash is then heated, 
 at first moderately, and almost completely covered with the lid. 
 It is then heated, only half covered, from five to seven minutes, 
 until the contents of the crucible are white. The crucible when 
 
340 APPENDIX: Phosphoric Acid. 
 
 cooled is placed in a desiccator and weighed, the difiference be- 
 tween the first and the second weight giving the weight of the 
 barium sulphate obtained from lOO c.c. of urine. 
 
 A reduction of some of the barium sulphate usually takes place 
 during the process of combustion, owing to the presence of or- 
 ganic material, so that the weight of the barium sulphate ob- 
 tained is actually too low. This error may be corrected in the 
 following manner: The barium sulphate is washed into a stiiall 
 beaker with a small amount of water, colored red by a few drops 
 of an alcoholic solution of phenolphthalein, and titrated with a 
 one-tenth normal solution of sulphuric acid until the red color has 
 disappeared. Every c.c. of the one-tenth normal solution corre- 
 sponds to 0.004 grams of barium sulphate, so that the actual 
 amount of barium sulphate contained in 100 c.c of urine is ascer- 
 tained by adding the figure thus found to that obtained by weigh- 
 ing (see below). 
 
 Quantitative; Estimation of the Conjugate Sui^phates. 
 One hundred c.c. of clear, filtered urine are mixed with 100 c.c. 
 of an alkaline solution of barium chloride (see above), themixture 
 being thoroughly stirred. After a fewminutes this is filtered through 
 a dry filter into a dry graduate up to the 100 c.c. mark. This por- 
 tion, corresponding to 50 c.c. of urine, is now strongly acidified 
 with dilute hydrochloric acid and brought to the boiling point. It 
 is kept upon the boiling water-bath until the barium sulphate 
 formed has settled and the supernatant fluid is clear. The pre- 
 cipitate is filtered off, washed, dried and weighed, as described 
 above. The barium sulphate thus obtained multiplied by 2 and 
 deducted from the amount found according to the first method 
 indicates the amount referable to the performed sulphates. The 
 molecular weight of barium sulphate^ being 232.82, that of SO3 
 79.86, of H2SO4 97.82, and of S 32, the figure expressing the 
 amount of H^SO^, SO3, or S, corresponding to i gram of barium 
 sulphate, is found according to the following equations: 
 
 232.82:79.86: :i:x, and x=o.3430i. .•. i gram of barium sul- 
 phate=o.3430i gram of SO3. 
 
 232.82:97.82: :i:x, and x^o.4201,'5. .-. i gram of barium sul- 
 phate=o.42025 gram of H^SO^. 
 
 232.82:32. :i:x, and x=o.i3744. . . i gram of barium sulphalte 
 =0.13744 gram of S. 
 
 To calculate results it is only necessary to multiply the weight 
 of barium sulphate fouud by 0.34301, 0.42015, or 0.13744 in order 
 to ascertain the amount of sulphuric acid contained in 50 c.c. of 
 urine in terms of SO3, H^SO^, or S, respectively. 
 
 PREPARATION OF VOLUMETRIC SOI.UTIONS FOR 
 DETERMINATION OF PHOSPHORIC ACID. 
 
 (See page 147.) 
 
 1. Weigh out 44.78 gm. of uranium nitrate and dissolve in 
 about 900 c.c. of distilled water. 
 
 2. Dissolve 10.085 gm. of pure dry and non-deliquescent disodic 
 hydrophosphate to make 1000 c.c. of distilled water. 
 
 3. Dissolve 100 gm. of acetate of sodium in distilled water, add 
 100 c.c. of 30 per cent, acetic acid and dilute the whole to 1000 c.c. 
 
APPENDIX. 341 
 
 4. Make a solution of ferrocyanide of potassium 10 gm. to 100 
 c.c. of distilled water. Keep in a dark place. 
 
 Transfer 50 c.c. of the phosphate solution to a beaker, add 5 c.c. 
 of the acetate solution and heat on the water bath. 
 
 Fill a burette with the uranium solution and by means of a 
 glass rod place a number of drops of the ferrocyanide solution on 
 a white plate. Run in the uranium solution, stir well with a rod 
 and from time to time bring a drop of the liquid in the beaker in 
 contact with one of the drops on the plate. As soon as the red- 
 dish precipitate appears stop, read off number of c.c. of uranium 
 used, and repeat the operation several times until the exact num- 
 ber of c.c. necessary to cause the red color to appear be deter- 
 mined. Dilute the uranium solution according to the formula: 
 
 N d 
 
 n 
 in which C will represent the number of c.c. of water to be used 
 for dilution, N the total volume of uranium solution left after the 
 testing is over, n the number of c.c. of uranium solution necessary 
 to cause appearance of the red color on the plate, and d the differ- 
 ence between the n and 20 (the latter being the number of c.c. 
 theoretically required to precipitate 50 c.c. of the phosphate). 
 
 Suppose, for example, after the tests are over there are 750 c.Q. 
 of uranium left and that 18 c.c. were required to cause appearance 
 of red color on the plate, then 0=756X20—18-^18. That is 750X 
 2H-i8, or 83.33. Dilute the 750 c.c. of uranium solution witti 83.33 
 c.c. of distilled water. Test again and it will be found that 20 c.c. 
 of the diluted solution will exactly precipitate 50 c.c. of the phos- 
 phate solution, as shown by the red color on the plate. The pro- 
 cess with the urine has been described on page 147. 
 
 OXALIC ACID. 
 
 Neubauer's Method, modified by Fuerbringer. — ^The quantity 
 of urine passed in twenty-four hours is measured and treated with 
 a few c.c. of alcoholic solution of thymol to prevent bacterial 
 growth. Treat the urine with ammonium hydrate until, after stir- 
 ring, the odor of ammonia is perceptible. Add a solution of cal- 
 cium chloride until a precipitate ceases to form, and with acetic 
 acid render distinctly acid, avoiding a great excess. The phos- 
 phates of calcium and magnesium dissolve in acetic acid, while 
 calcium oxalate precipitates with more or less uric acid. Let stand 
 twenty-four hours, filter through a small filter paper, collect and 
 transfer the precipitate to the paper, with a glass rod provided 
 with a small piece of rubber tubing on one end. Wash with 
 water until the wash water is free of chlorides, known by testing 
 with a solution of silver nitrate and a few drops of nitric acid. 
 When washed, transfer the filter, with precipitate, to a small 
 beaker and treat with dilute hydrochloric acid and water, avoiding 
 a great excess of the former; warm on a water bath, and stir with 
 a glass rod so the acid will come in contact with every part of the 
 precipitate. The calcium oxalate will dissolve in the acid, while 
 any uric acid present will remain, undissolved. Filter, through a 
 small filter paper, into a beaker of 250 or 300 c.c. capacity, wash 
 with water and determine when washed, as before. Evaporate the 
 filtrate with wash water to about 200 c.c, transfer from the dish to 
 
342 APPENDIX: Albumin. 
 
 a beaker, rinse the dish with water and add rinsings to tlie fluid in 
 the beaker when the fluid is rendered alkaline with ammonium 
 hydrate, known by turning turmeric paper dark red after the fluid 
 is well mixed by stirring. Having stood well protected from dust 
 twenty-four hours, filter through a small filter paper free of ash, 
 wash with water until the wash water is free of chlorine, known 
 by producing no turbidity when tested with a solution of silver 
 nitrate with a few drops of nitric acid. Dry the filter, with precipi- 
 tate and ash in a platinum crucible, and by the heat of a blast 
 flame reduce the oxalate to oxide. Cool in a desiccator and weigh. 
 Repeat the process of heating and weighing until the weight be- 
 comes constant. Multiply the weight of the oxide by 1.6071 to 
 find the weight of oxalic acid. 
 
 QUANTITATIVE DETERMINATION OF ALBUMIN. 
 
 Scherer's Method. — Urine in which albumin is to be estimated, 
 if not clear, is filtered. Into a beaker of about 200 c.c. capacity, 
 100 c.c. urine is introduced. If the reaction of the urine is not 
 strongly acid, add acetic acid until the reaction is decidedly acid, 
 but avoid an excess of the acid. Suspend the beaker in a water 
 bath and keep thd water in the bath at the boiling temperature. 
 At the expiration of thirty minutes, if, by ti ansmitted light, the 
 urine is clear between the flakes of coagulated albumen, the pre- 
 cipitation is complete. If, however, the urine is cloudy, a small 
 quantity of acetic acid is added, the urine stirred, and the heat 
 continued, when the separation of albumin in flakes will take 
 place. Filter through a filter, having been dried at no° C. be- 
 tween watch glasses and cooled in a desiccator and weighed. The 
 albumen, having been transferred to the filter, is washed with water. 
 As the filtering and washings are likely to require several hours, a 
 filter pump or aspirator bottle may be employed with advantage, 
 the filter having the support of a platinum cone. The washing is 
 continued until no cloudiness is produced when tested with a solu- 
 tion of silver nitrate and some nitric acid. Having been washed 
 with water, wash with about 50 c.c. absolute alcohol, followed by 
 about the same quantity of ether. Any fat present is removed by 
 the alcohol and ether, and the water is so far removed as to facili- 
 tate the drying. The funnel is covered with paper or a glass plate 
 and placed upright in an air bath and heated gradually until the 
 paper and precipitate are somewhat dry, when the filter, with the 
 precipitate, is placed between the watch glasses employed before. 
 The heating in the air bath at 1 10° C. is continued until the weight 
 becomes constant, which is ascertained by heating two hours, cool- 
 ing in a desiccator and weighing, repeating the process until the 
 weight becomes constant. The difference in weight caused by the 
 precipitate is taken as the weight of albumin, except in case the 
 urine contains much albumin; when the filter paper and precipi- 
 tate are ashed and the ash weighed in a platinum crucible. By 
 subtracting the weight of the ash from that of the precipitate, the 
 remainder is the weight of albumin, or, instead of ashing, 50 c.c. 
 urine may be taken and 50 c.c. water added before acidifying and 
 heating. The albumin, when dry, should not exceed 0.3 gm. in 
 weight; if less, the quantity of inorganic matter present is very 
 small. 
 
APPENDIX. 343 
 
 QUANTITATIVE DETERMINATION OF SUGAR BY 
 FEHLING'S SOLUTION. 
 
 As a rule urines of specific gravity of 1030 should be diluted 
 five times, and if the density be still higher ten times. To be 
 certain that the proper degree of dilution has been reached, 5 c.c. 
 of Fehling's solution are treated with i c.c. of the diluted urine, a 
 little caustic soda and distilled water being added to make in all 
 about 25 c.c. This mixture is thoroughly boiled, and if the fluid 
 still remains blue another i c.c. of diluted urine added, and so on 
 until the last two tests differ by i c.c. of urine, the last c.c. added 
 causing a separation of cuprous oxide. In this manner the per- 
 centage of sugar may be approximately determined. Albumin, if 
 present, must first be removed by boiling. 
 
 Ten c.c. of Fehling's solution, diluted with 40 c.c. of water, are 
 placed in a porcelain dish and boiled. While boiling, the diluted 
 urine is added from a burette, %. c.c. at a time, when, as a rule, 
 the precipitated cuprous oxide will rapidly settle, so that gradu- 
 ally a white bottom may be seen through the blue fluid, the color 
 of which becomes less and less intense upon the further addition 
 of urine until, finally, the solution is almost colorless. When this 
 point is reached the urine is added only drop by drop, until the 
 decolorization is complete. The degree of dilution multiplied by 
 5 and the result divided by the number of c c. of diluted urine em- 
 ployed will then indicate the percentage amount of sugar. 
 
 Unfortunately, it is difficult as a general rule to determine ex- 
 actly the point when all the copper has been reduced, i. e., the 
 point at which the blue color has entirely disappeared. When it 
 is thought that this has been reached, about i c.c. should be filtered 
 through thick Swedish filter paper, and the filtrate, which must be 
 absolutely clear, acidified with acetic acid and treated with a drop 
 or two of a solution of potassium ferrocyanide. If unreduced 
 copper be still present in the solution, a brown color will result, 
 indicating that insufiicient urine has been added. But if, on the 
 other hand, no brown discoloration be noted, it is possible that the 
 desired point has already been passed, when the titration should 
 be repeated. At times the precipitate will not settle at all, and 
 even pass through the filter, so that it is almost impossible to 
 determine the end of the reaction. In such cases the following 
 procedure, suggested by Cause, will be found serviceable: 
 
 Ten c.c. of Fehling's solution are diluted with 20 c.c. of distilled 
 water and treated with 4 c.c. of 1-20 per cent^ solution of potas- 
 sium ferrocyanide. While boiling, the diluted urine is now added 
 drop by drop, until the blue color has entirely disappeared, a pre- 
 cipitate not appearing at all with this method. 
 
 In order to obtain reliable results, however, the Fehling's solu- 
 tion must be prepared with great care, and its strength deter- 
 mined. This may be done in the following manner: o 2375 gram 
 of crystallized cane sugar, pure and dried at 100° C, is dissolved 
 in 40 c.c. of distilled water, to which 22 drops of a i-io per cent, 
 solution of sulphuric acid have been added. This solution is kept 
 upon a boiling water-bath for an hour, when it is allowed to cool 
 and diluted to 100 c.c. with distilled water. Twenty c.c. of this 
 solution will then contain exactly 0.05 gram of glucose, corre- 
 sponding to 10 c.c. of Fehling's solution, if this be of the required 
 
344 APPENDIX: Glycero-Phosphoric Acid. ■ 
 
 strength. If too strong, so that 21 c.c, for example, of the sugar 
 solution are required to obtain a complete reduction of the copper, 
 the strength ot Fehling's solution may be determined according to 
 the equation: 20:0.05: :2i:x, and x=o.o525. If too weak, on the 
 other hand, so that 19 c.c , for example, are required, its strength 
 is similarly determined: 20:0.05: :i9:x, and x=o.o475. If necessary, 
 the solution may of course be brought to the exact strength in the 
 manner indicated elsewhere, by first making it too strong and then 
 ascertaining the required degree of dilution. (Simon.) 
 
 DETERMINATION OF GLYCERO-PHOSPHORIC ACID. 
 
 Sotnischewsky's process is to render the 24 hours' urine alka- 
 line with milk of lime and precipitate with calcium chloride. 
 Filter, evaporate filtrate, and extract residue with alcohol. The 
 residue not dissolved with alcohol is dissolved in water. To both 
 solutions add a solution of ammonia and magnesia and allow the 
 mixture to stand 24 hours in order to remove traces of the inor- 
 ganic phosphoric acid that may still be present. Filter, render 
 the filtrate strongly acid with sulphuric acid and boil for some 
 time in order to separate the glycero-phosphoric acid. After 
 cooling, solution of ammonia is to be added, when, on standing, 
 crystals of ammonium-magnesium phosphate are deposited. 
 These are to he collected and weighed, whence the amount of 
 phosphoric acid derived from the organic compounds can be 
 deduced. 
 
 Another method. — Acidify 250 c.c. of urine strongly with nitric 
 acid and boil 30 minutes. (The fumes given off have an over- 
 powering odor, so that the flask should be provided with a de- 
 livery tube dipping into water.) 
 
 When cold precipitate the phosphoric acid by rendering the 
 solution alkaline with ammonium hydrate, and treating with 50 
 c.c. of magnesia mixture and ammonium hydrate (50 to 100 c c.) . 
 Mix well and let stand 6 to 12 hours. Filter, and transfer the 
 precipitate to the filter by means of a stirring rod provided with a 
 small piece of rubber tubing placed on its end. Wash the pre- 
 cipitate with water containing one-third its volume of ammonium 
 hydrate. The washing is continued until some of the wash water, 
 having been boiled in a test tube to drive off excess of ammonia, 
 and rendered acid with nitric acid, ceases to yield a turbiditv with 
 a solution of silver nitrate. When the precipitate is washed it is 
 immediately transferred to a graduated 250 c.c. flask. This is 
 brought about by perforating the filter with a glass rod, and with 
 a fine stream of water from a wash bottle every trace of the pre- 
 cipitate i.s removed from the paper. Dissolve the precipitate with 
 acetic acid, and with water fill to the mark. (The writer finds 
 that it is not easy to dissolve all the precipitate with acetic acid as 
 directed; in which case dissolve in nitric acid and reprecipitate 
 with magnesia mixture and ammonia js above. ) 
 
 Mix well by shaking. With a pipette introduce 50 c.c. of the 
 solution into a 200 c.c. fla.sk, add 5 c.c. of the solution of sodium 
 acetate, heat to the boiling point (preferably on a sand-bath), and 
 from a burette containing the uranium solution titrate while hot 
 and determine as under phosphoric acid. 
 
 Multiply the number of c.c. of uranium solution used by 0005, 
 the product of which is the weight of P2O5 in 50 c.c. of the solu- 
 
APPENDIX. 345 
 
 tion. Multiply by 20 to get into grams per liter and by the num- 
 ber of litfers of urine in 24 hours to get grams per 24 hours. Sub- 
 tract from the total grams for 24 hours the result of a determina- 
 tion of the total phosphoric acid itself, exclusive of glycero-phos- 
 phoric acid, and the result is the quantity of glycero-phosphoric 
 acid. 
 
 DETERMINATION OF SUGAR BY THE POLARISCOPE. 
 
 Soleil-Ventzke's apparatus is constructed in such a manner that 
 if a solution of glucose be employed, the length of the tube being 
 10 cm., every entire line of division on the scale will indicate i 
 per cent, of sugar. 
 
 The tube of the saccharimeter should be carefully washed out 
 with distilled water, and at least once or twice with the filtered 
 urine, when it is placed on end upon a flat surface, and filled with 
 the urine to such a degree that this forms a convex cup at the end. 
 The little glass plate is now carefully adj|>sted, so as to guard 
 against the admission of bubbles of air. The metallic cap is then 
 placed in position, care being taken to avoid undue pressure. 
 The examinations are made in a dark room, an ordinary lamp be- 
 ing used, and several readings taken, until the differences do not 
 amount to more than one-tenth or two-tenths per cent. The tubes 
 should be thoroughly cleansed immediately after the experiment. 
 
 In every case the filtered urine should be free from albumin, 
 and, if markedly colored, previously treated with neutral acetate 
 of lead in substance and filtered. 
 
 If it be desired to demonstrate only the presence of sugar, the 
 compensators are first brought to the zero position. If now, upon 
 the interposition of the tube filled with urine, a difference in the 
 color of the two halves of the field of vision be noted, the presence 
 of an optically active substance in the urine may be assumed, 
 and if at the same time the deviation be to the right, the presence 
 of glucose is rendered highly probable, while a deviation to the 
 left will generally be referable to levulose or oxybutyric acid. 
 Indican, peptones, cholesterin, and certain alkaloids, it is true, 
 also turn the plane of polarization to the left, but as a rule these 
 substances need not be considered, cholesterin occurring but 
 rarely, while indican in diabetic urines is usually present in only 
 small amounts, and a concurrence of sugar and peptones has not 
 as yet been observed Lactose and maltose, which also turn the 
 plane of polarization to the right, may be distinguished from each 
 other and from glucose by the phenylhydrazin test. Levulose 
 turns the plane of polarization to the left. Oxybutyric acid is 
 practically always associated with the presence of glucose, and 
 may be recognized by allowing the urine to undergo fermentation, 
 when the filtered urine will .become distinctly gyro-rotatory. 
 (Simon.) 
 
 DRUGS WHICH INTERFERE WITH ALBUMIN AND 
 SUGAR TESTS. 
 
 A very suggestive resum^ is given by Moeschel as follows: 
 I. Albumin Tests are interfered with by: 
 
 Alkaloids. Benzoates. Oil of Santal. 
 
 Analgen. Benzoinum. Piperazine. 
 
346 APPENDIX: Albumin and Sugar Tests. 
 
 Antipyrine. Chloroform. Plums. 
 
 Balsam Peru. Copaiba. Styrax. 
 
 Balsam Tolu. Cranberries. 
 
 Benzo"sol. Hypnone. ■ • . 
 
 After the administration of acids, some tests for albumin in the 
 urine do not respond. Neutralize such urine with a few drops of 
 sodium hydrate and filter. Acidify slightly with acetic acid before 
 applying any test. Cloudy urines, also such containing a precipi- 
 tate (mucin, medicinal balsams and resins), should be faintly 
 acidulated with acetic acid and carefully filtered before applying 
 any tests. 
 
 II. Sugar Tests are interfered with by: 
 
 Acetanilide. Kalmia. Salicylates. 
 
 Antifebrin. Morphine. Salol. 
 
 Antipyrine. Mercurialis perennis. Senna. 
 
 Betol. Ol. gaultheriae. Sulphonal. 
 
 Chloral hydrate. Phenacetine. Uva ursi. 
 
 Chloroform. Rheum. Urethan. 
 
 Copaiba. Rumex. Vaccin. myrtillus. 
 
 Epigffia. 
 
 To which may be added: 
 Ammonium salts. See b below. Glycerin. 
 
 Benzoates. Glycosuric acid. See e. 
 
 Bromides. Iodides. 
 
 Camphor. Pyrocatechiu. 
 
 Carbohydrates. See c. Serum globulin. 
 
 Cubebs. Turpentine. 
 
 Creatinine. See d. Uric acid, urates. See 
 
 d and/. 
 
 a. Temporary glycosuria may be occasioned by poisoning with 
 alcohol, amyl nitrite, carbonic oxide, chloral, hydrocyanic acid, 
 morphine, sulphuric acid. 
 
 b. Ammonium salts should be removed before testing. Such 
 is accomplished by boiling with NaOH until no more ammonia is 
 given off. 
 
 c. Under certain conditions some carbohydrates (animal gum) 
 may be present in the normal urine, causing reduction. 
 
 d. Creatinine (also uric acid and urates) can be removed by 
 precipitating with mercuric chloride, which operation does not 
 affect any glucose pr.esent. 
 
 e. To remove glycosuric acid in urine of diabetics, acidify the 
 urine with H2SO4 and shake with ether, from which it may be 
 crystallized. 
 
 f. To test for glucose in urine in which salicylates are the dis- 
 turbing compounds, the following course may be adopted: Add 
 solution of lead subacetate to the- urine, which precipitates almost 
 all the salicylic acid, also the chlorides, phosphates and sulphates, 
 uric acid, urates, albumin, glycuronic acid, and coloring matter. 
 The lead remaining in solution is precipitated with dilute sulphu- 
 ric acid, and the excess of acid carefully neutralized with soda or 
 potash. Thus prepared, the urine may be tested for glucose with 
 the usual reagents. 
 
 g. Nylander's test is interfered with by the use of arsenic, 
 iodides, mercurials, large doses of quinine, salicylates, and 
 sulphur. 
 
APPENDIX. 347 
 
 III. Spectroscopic Influences are exerted by: 
 
 Acetanilide. Chloral hydrate. Salol. 
 
 Antifebrin. Copaiba. Santonin. 
 
 Antipyrine. Epigsea. Sulphonal. 
 
 Benzosol. Frangula. Uva ursi. 
 
 Betol. Kalmia. Vaccin myrt. 
 
 Cascara sagrada. Salicylates. 
 
 IV. Important Suggestions: 
 
 1. The reactions obtained should always be compared with the 
 perfectly clear, untested urine contained in the same sized test- 
 tube holding an amount of fluid equal to that tested. 
 
 2. Filtration is assisted by slightly acidulating with acetic 
 acid. Use a good filtering-paper, preferably doubled, and 
 moisten thoroughly with distilled water before using. The filter 
 fulfills its purpose only after all the cellulose fibers have swollen 
 by absorption. 
 
 3. Filtration through talcum, to remove mucin and bacteria, 
 also removes large quantities of albumin and glucose. 
 
 4. Animal charcoal is likewise objectionable. 
 
 DETERMINATION OF THE UROTOXIC COEFFICIENT. 
 
 Acid urine being carefully and exactly neutralized with sodium 
 bicarbonate and filtered is injected into the veins of a weighed 
 rabbit. The posterior marginal vein on the dorsal part of the 
 face is convenient for injection. The weight of the person void- 
 ing the urine is taken beforehand and the amount of urine voided 
 by him is measured. Day urine should be collected separately 
 from night and the toxicity determined separately. The urine is 
 injected in small quantities at a time, and the result of each injec- 
 tion studied. 
 
 The quantity of normal urine necessary to kill a rabbit varies 
 between 30 c.c. and 60 c.c. for each kilogram of weight of the 
 animal, or 45 c.c. per kilo on an average. 
 
 Pathological urines are some more poisonous, others less poison- 
 ous than normal. 
 
 The amount of cubic centimeters of urine necessary to kill one 
 kilogram of animal is found as follo,ws: Multiply the amount of 
 urine injected before the death of the animal by 1,000, and divide 
 product by weight of the animal in grains. 
 
 Thus, suppose 46 c.c. of urine required to kill a rabbit weighing 
 1,600 grams, then, 46 times 1,000 
 
 -=28.95 c.c. 
 
 1,600 
 of urine for each kilogram of animal. 
 
 To calculate the urotoxic coefficient of any man, divide the 
 quantity of his urine passed in a given period, day or night, or 
 better, each separately, by the number of c.c. of urine required to 
 kill each kilogram of animal. Thus, suppose a man void 700 c c. 
 of urine during the working hours, 46 c.c. of which are needed to 
 kill a rabbit weighing 1,720 grams. Then, 46 times 1,000 
 
 1,720 
 
348 APPENDIX: Analysis of Calculi. 
 
 or 26.74 equals the number of c.c. of urine necessary for each kilo- 
 gram of rabbit, and 700 
 
 =26.178 urotoxics. 
 
 26.74 
 so-called. If the period during ivhich the urine was collected was 
 16 hours, then 26.178 
 
 16 
 or 1. 6361, is the urotoxy or unit of toxicity per hour. If the man 
 weigh 81 kilograms, then 1.6361 
 
 or o. 2002 
 
 81 
 represents the urotoxic coeflScient per kilogram of the man's 
 weight in an hour. 
 
 In other words, this man voids for each kilogram of his weight 
 in one hour what would kill 20.02 grams of living material. 
 
 In determining the toxicity of the 24 hours' urine collect the 
 day and night separately, ascertain the toxicity of each in c.c. per 
 kilogram of animal, and add together, otherwise if the urines be 
 mixed before the toxicity is determined, there will be a loss of 
 about one-third A person eliminates during sleep something 
 which is partly antidotal to the day urine. 
 
 COMPLETE ANALYSIS OF CALCULI. 
 
 The writer prefers Dr. Long's methods, as follows: 
 
 I. Heat test: Reduce some of the calculus to a powder and 
 heat to bright redness on platinum foil. If the powder is com- 
 pletely consumed suspect uric acid, ammonium urate, cystin, 
 xanthin, organized matter; if the powder is either not consumed 
 at all, or only partly so, calcium oxalate, phosphates. 
 
 Uric Acid may be recognized by dissolving a little of the pow- 
 der in weak alkali, precipitating by hydrochloric acid, and exam- 
 ining the precipitate with the microscope. [The writer finds, 
 however, that in the West calculi of uric a,cid are frequently 
 coated with phosphates; hence after dissolving what is possible in 
 tlje alkali, filter and precipitate filtrate with hydrochloric acid, 
 letting stand some hours.] 
 
 Ammonium Urate acts as above like uric acid and is further 
 recognized by liberation of ammonia (odor) when heated with a 
 little pure sodium hydroxide solution. 
 
 Cystin : Dissolve powder in ammonia, filter and allow drops 
 of filtrate to evaporate spontaneously on slide. Identify by mi- 
 croscope. (See cut of Cystin in the book. ) 
 
 Organized flatter is recognized by odor of burnt feathers when 
 heated to redness. 
 
 Calcium Oxalate. — Stones of this substance are very hard and 
 break with a crystalline fracture. They are often called "mul- 
 berry calculi." When the powder is heated it decomposes, leav- 
 ing carbonate, which may be recognized by its efiervescence with 
 acids. 
 
 Calcium and Magnesium Phospliates. — These leave a residue 
 in which the metals and phosphoric acid may be detected by 
 simple tests of qualitative analysis. The ignited powder is sol- 
 uble in hydrochloric acid without effervescence. When ammonia 
 is added to this solution in quantity sufficient to give an alkaline 
 
APPENDIX. 
 
 349 
 
 reaction, a precipitate of triple phosphate or calcium phosphate 
 appears, which may be recognized by the microscope 
 
 The above tests are generally sufficient to tell all that is prac- 
 tically necessary about the calculus. If more detailed information 
 IS desired a systematic analysis may be made according to the usual 
 methods. 
 
 The writer greatly prefers, however, the following- i 
 Systematic Analysis.— i. Reduce the calculus to«fine pow- 
 der and pour over it some water and finally dilute hydrochloric 
 acid in a beaker. Warm gently half an hour, or longer, on the 
 water bath. Then allow to cool and filter. 
 
 2. Treatment of the residue. It seldom happens that the cal- 
 culus is completely soluble in the weak acid. A residue usually 
 remains vfhich may contain uric acid, xanthin, calcium sulphate, 
 and remains of organized matter. To prove the xanthin treat the 
 residue with warm dilute ammonia and filter. The filtrate con- 
 tains the xanthin if it is present. Acidify it with nitric acid and 
 add a small amount of silver nitrate solution. This produces a 
 flocculent precipitate which dissolves by warming, and crystallizes 
 on cooling in bunches of fine needles. 
 
 In the residue free from the xanthin look for calcium sulphate 
 by extracting with water and applying the usual tests. This solu- 
 tion may contain uric acid which is recognized by evaporation and 
 crystallization after adding a little hydrochloric acid. In the final 
 residue some uric acid may be also present. Dissolve in alkali, 
 reprecipitate with hydrochloric acid, and examine any crystals 
 which may form under the microscope. 
 
 3. Treatment of the hydrochloric acid solution. This may con- 
 tain calcium oxalate, cystin, the phosphates and possibly some 
 xanthin. Look for the last in a small portion of the solution. 
 Make this portion alkaline with ammonia, add a few drops of cal- 
 cium chloride solution, filter if a precipitate forms and treat the 
 filtrate with ammoniacal silver nitrate solution. In presence of 
 xanthin a flocculent precipitate forms. 
 
 Dilute the remaining and larger portion of the hydrochloric 
 acid solution with twice its volume of water, add enough ammonia 
 to give a strong alkaline reaction and then acetic acid to restore a 
 weak acid reaction. By this treatment phosphates are held in 
 solution, while calcium oxalate, if present, precipitates. Therefore 
 allow the mixture to stand half an hour and then filter off any pre- 
 cipitate which appears. This precipitate may contain cystin as 
 well as calcium oxalate. Cystin may be dissolved by pouring 
 ammonia on the filter, and on evaporating the ammoniacal solu- 
 tion is obtained in form suitable for microscopic examination. 
 
 The residue free from cystin is dried and heated to redness on 
 platinum foil. This treatment converts calcium oxalate into car- 
 bonate. Place the foil in a beaker and add some dilute acetic 
 acid; an effervescence shows the carbonate. To the clear solution 
 add next some ammonium oxalate which gives a white precipitate 
 of calcium oxalate, if the latter metal is present. 
 
 Next look for phosphates and bases in the acetic acid solution 
 obtained after filtering off cystin and calcium oxalate. More cal- 
 cium may be present, in excess of that combined as oxalate, which 
 may be recognized by adding a little solution of ammonium oxalate. 
 If a precipitate forms treat the whole of the liquid with ammonium 
 oxalate, after warming on the water bath, allow to stand an hour 
 
350 APPENDIX: Mounting Sediments. 
 
 and filter. Concentrate the filtrate to a small volume, transfer to 
 a large test-tube and add enough ammonia to produce an alkaline 
 reaction. If a precipitate now appear it must consist of magnesium 
 phosphate, showing both magnesium and phosphoric acid present 
 in the original. If no precipitate appear, magnesium is absent, -but 
 phosphoric acid may still be present. To find it divide the am- 
 moniacal liquid into two portions. To one add a few drops of 
 magnesia <tiixture (white precipitate), and to the other add nitric 
 acid in slight excess, and then a few drops of ammonium molyb- 
 date reagent (yellow precipitate). Both tests must be successful. 
 A-ynmonium salts are recognized by heating the original powdered 
 calculus with pure potassium hydroxide solution; odor of ammonia 
 and reaction on red litmus paper (turned blue) in the fumes. 
 
 Sodium and potassium are recognized by treating solution of the 
 powdered calculus in hydrochloric acid with pure ammonia and a 
 little ammonium carbonate in excess. Let precipitate settle and 
 filter. Evaporate to dryness in a platinum dish, and heat residue 
 strongly to drive off all ammonium salts. 
 
 PRESERVING AND MOUNTING URINARY SEDIMENTS. 
 
 The method of the late Dr. Charles Heitzmann was to add to the 
 thickest sediment (which now can be easily obtained by use of the 
 centrifuge) a few drops of a strong chromic acid solution. Let 
 stand a week, then gradually add a little chemically pure glycerine 
 day after day for three or four days. Let stand for a few days 
 more until all water has evaporated, then mount without any addi- 
 tion, clean, and surround with asphalt. The exact amounts of the 
 chromic acid and glycerine used must be learned by practice. 
 
 TABLES. 
 
 The following tables will save time in figuring. The table at 
 the top gives figures more in accordance with the writer's observa- 
 tions in each case. The table at the bottom, unless otherwise spe- 
 cified, is based on English standards which the writer finds are in 
 excess of American. In many cases a deduction of even 25 per 
 cent, from the upper table (per cent, of normal average) may be 
 made with closer approximation to American standards in health. 
 Example: Table i: — 1360 c.c. is given as average normal for an 
 American, but not infrequently we find 950 c.c. voided in 24 hours 
 by healthy males, so that care must be taken not to assume figures 
 above 75 per cent, in the upper tables as indicating necessarily 
 anything abnormal. Figures less than 50 per cent, of normal in 
 the upper tables are usually significant of disease if the condition 
 is permanent and the weight, diet and exercise are average. 
 
APPENDIX. 
 
 351 
 
 
 
 
 TABLE I 
 
 
 
 
 QUANTITY 
 
 OK URINE IN 24 HOURS. 
 
 
 
 MALBS. 
 
 % 
 
 
 FEMALES. 
 
 % 
 
 Fluid- 
 
 Cubic 
 
 normal 
 
 Fluid- 
 
 Cubic 
 
 normal 
 
 ounces. 
 
 centimeters 
 
 . av'ge. 
 
 ounces. 
 
 centimeters. 
 
 av'ge. 
 
 
 - 46. 
 
 1360 
 
 100 
 
 37- 
 
 IIOO 
 
 100 
 
 
 43- 
 
 1290 
 
 95 
 
 34-83 
 
 1045 
 
 95 
 
 A 
 
 40.83 
 
 1225 
 
 90 
 
 33- 
 
 990 
 
 90 
 
 A 
 
 38.5 
 
 1155 
 
 .85 
 
 31.16 
 
 935 
 
 85 
 
 
 36.33 
 
 1090 
 
 80 
 
 29-33 
 
 880 
 
 80 
 
 
 . 34- 
 
 1020 
 
 75 
 
 27-5 
 
 825 
 
 75 
 
 
 ' 31-66 
 
 950 
 
 70 
 
 25-66 
 
 770 
 
 70 
 
 
 29-5 
 
 885 
 
 65 
 
 23-83 
 
 715 
 
 65 
 
 B 
 
 27.16 
 
 815 
 
 60 
 
 22. 
 
 660 
 
 60 
 
 
 25- 
 
 750 
 
 55 
 
 20.16 
 
 605 
 
 55 
 
 
 , 22.66 
 
 680 
 
 50 
 
 18.33 
 
 550 
 
 50 
 
 
 20.33 
 
 610 
 
 45 
 
 16.5 
 
 495 
 
 45 
 
 
 i8.i6 
 
 545 
 
 40 
 
 14.66 
 
 440 
 
 40 
 
 C 
 
 1583 
 
 475 
 
 •35 
 
 12.S3 
 
 385 
 
 35 
 
 
 13.66 
 
 410 
 
 30 
 
 II. 
 
 330 
 
 30 
 
 
 . 11-33 
 
 340 
 
 25 
 
 9.16 
 
 275 
 
 25 
 
 
 9- 
 
 270 
 
 20 
 
 7-33 
 
 220 
 
 20 
 
 
 6.83 
 
 205 
 
 15 
 
 5-5 
 
 165 
 
 15 
 
 D 
 
 4.5 
 
 135 
 
 10 
 
 3.66 
 
 no 
 
 10 
 
 
 2.33 
 
 70 
 
 5 
 
 1-83 
 
 55 
 
 5 
 
 
 1. 16 
 
 35 
 
 2>^ 
 
 0.83 
 
 25 
 
 2>^ 
 
 o 
 
 
 
 
 
 
 
 
 
 
 
 
 r 50 
 
 1500 
 
 100 
 
 40 
 
 1200 
 
 100 
 
 Al. 
 
 55 
 
 1650 
 
 no 
 
 44 
 
 1320 
 
 no 
 
 
 60 
 
 1800 
 
 120 
 
 48 
 
 1440 
 
 120 
 
 
 65 
 
 1950 
 
 130 
 
 52 
 
 1560 
 
 130 
 
 An. 
 
 70 
 
 2100 
 
 140 
 
 56 
 
 1680 
 
 140 
 
 
 I 75 
 
 2250 
 
 150 
 
 60 
 
 1800 
 
 150 
 
 
 80 
 
 2400 
 
 160 
 
 64 
 
 1920 
 
 160 
 
 Aiii. 
 
 85 
 
 2550 
 
 170 
 
 68 
 
 2040 
 
 170 
 
 
 87 
 
 2625 
 
 175 
 
 70 
 
 2100 
 
 175 
 
 
 90 
 
 2700 
 
 180 
 
 72 
 
 2160 
 
 180 
 
 Aiv. 
 
 95 
 
 2850 
 
 I go 
 
 76 
 
 2280 
 
 190 
 
 
 100 
 
 3000 
 
 200 
 
 80 
 
 2400 
 
 200 
 
 125 
 
 3750 
 
 250 
 
 100 
 
 3000 
 
 250 
 
 Etc. 150 
 
 4500 
 
 300 • 
 
 120 
 
 3600 
 
 300 
 
 175 
 
 5250 
 
 350 
 
 140 
 
 4200 
 
 350 
 
 200 
 
 6000 
 
 400 
 
 160 
 
 4800 
 
 400 
 
 225 
 
 6750 
 
 450 
 
 180 
 
 5400 
 
 450 
 
 250 
 
 7500 
 
 500 
 
 200 
 
 6000 
 
 500 
 
 275 
 
 8250 
 
 550 
 
 220 
 
 6600 
 
 550 
 
 Etc. 300 
 
 9000 
 
 600 
 
 240 
 
 7200 
 
 600 
 
 325 
 
 9750 
 
 650 
 
 260 
 
 7800 
 
 650 
 
 350 
 
 10500 
 
 700 
 
 280 
 
 8400 
 
 700 
 
 375 
 
 1 1 250 
 
 750 
 
 300 
 
 9000 
 
 750 
 
 400 
 
 12000 
 
 800 
 
 320 
 
 9600 
 
 800 
 
 425 
 
 12750 
 
 850 
 
 340 
 
 10200 
 
 850 
 
 450 
 
 13500 
 
 900 
 
 360 
 
 10800 
 
 900 
 
 475 
 
 14250 
 
 950 
 
 380 
 
 1 1400 
 
 950 
 
 500 
 
 15000 
 
 1000 
 
 400 
 
 12000 
 
 1000 
 
 Quanti 
 
 ties between 1360 and 
 
 500 or 1 100 and 1200 are 
 
 accepted as normal. 
 
352 
 
 TABLES. 
 
 TABLE II. 
 
 RATIO OF DAY URINE TO NIGHT URINE. 
 
 The author having collected his urine for the 24 hours, day and night, separ- 
 ately, during 28 successive days, found the lowest ratio of day to night to be 1,7 
 to I, the highest 7 to I. On 12 days out of the 28 the ratio was 3 to i. On 4 days 
 the ratio was between 2 and 3 to i. On only 3 days was it below 2 to i, and on 
 S days it was from 4 up to 7 to i. I have, therefore, adopted 3 to i as a basis on 
 which to reckon percentage, 
 
 DESCENDING SCALE. 
 
 
 Per cent. 
 
 
 Per cent. 
 
 3 to I . 
 
 100 
 
 1.50 to I 
 
 .... 50 
 
 2.8s to I . . 
 
 95 
 
 1.35 to I ... 
 
 • 45 
 
 2.70 to I . . 
 
 . 90 
 
 1.20 to I . . 
 
 40 
 
 2.55 to I 
 
 85 
 
 1.05 to I 
 
 35 
 
 2.40 to I . . 
 
 .... 80 
 
 0.90 to I 
 
 .30 
 
 2.25 to I . . 
 
 75 
 
 0.75 to I ... 
 
 ■ • • 25 
 
 2.10 to I 
 
 70 
 
 0. 60 to I ... 
 
 20 
 
 1.95 to I . . 
 1.80 to I . . 
 
 .... 65 
 
 60 
 
 55 
 
 0.4^ to I ... 
 
 TC 
 
 "■to ""^ ^ ... 
 
 0.30 to I ... 
 
 ^0 
 
 10 
 
 1.65 to I . . 
 
 0.15 to I . . 
 
 5 
 
 TABIvE III. 
 
 TOTAI, SOWDS IN THE URINE. 
 
 Conversion of grains to grammes and relation to normal averages for a 
 weight of 145 pounds. (See al^o page 32.) 
 
 DESCENDING SCALE. 
 
 Grains. Grammes. Per cent. 
 
 95 
 90 
 
 85 
 80 
 
 899. 
 
 58. 
 
 854-05 
 
 55 I 
 
 809.10 
 
 52.2 
 
 764-15 
 
 49-3 
 
 719.2 
 
 46-4 
 
 674.25 
 
 43-5 
 
 629.30 
 
 40,6 
 
 584-35 
 
 37-7 
 
 539-4 
 
 34-8 
 
 494-45 
 
 31-9 
 
 449-5 
 
 29. 
 
 404-55 
 
 26.1 
 
 359-6 
 
 23.2 
 
 314-65 
 
 20.3 
 
 269.7 
 
 17-4 
 
 22475 
 
 14-5 
 
 179-8 
 
 11.6 
 
 134-85 
 
 8.7 
 
 89.9 
 
 5-8 
 
 44-95 
 
 2-9 
 
 22.475 
 
 1-45 
 
 75 
 70 
 
 65 
 60 
 
 55 
 50 
 45 
 40 
 
 35 
 30 
 
 25 
 20 
 
 15 
 10 
 
 5 
 
 ASCENDING SCALE 
 
 Grains. 
 
 899. 
 
 943-95 
 988.9 
 
 1033-85 
 
 1078.8 
 
 1122.75 
 
 1168.7 
 
 1213.65 
 
 1258.6 
 
 1303-55 
 
 1348-5 
 
 1393-45 
 
 1438.4 
 
 1483-35 
 
 1528.3 
 
 1573-25 
 
 1618.2 
 
 1663.15 
 
 1708. 1 
 
 1753-05 
 
 1798. 
 
 2022.75 
 
 rammes. 
 
 Per cent 
 
 58. 
 
 100 
 
 60. 9 
 
 105 
 
 63.8 
 
 110 
 
 66.7 
 
 115 
 
 69.6 
 
 120 
 
 72.5 
 
 125 
 
 75-4 
 
 130 
 
 783 
 
 135 
 
 81.2 
 
 140 
 
 84.1 
 
 145 
 
 87. 
 
 150 
 
 89.9 
 
 155 
 
 92.8 
 
 160 
 
 95-7 
 
 165 
 
 98.6 
 
 170 
 
 101.5 
 
 175 
 
 104.4 
 
 180 
 
 107.3 
 
 185 
 
 110.2 
 
 190 
 
 113.1 
 
 195 
 
 116. 
 
 200 
 
 130.5 
 
 225 
 
D 
 
 Ai. 
 
 An. 
 
 Ani. 
 
 Aiv. 
 
 Etc. 
 
 Etc. 
 
 
 APPENDIX. 
 
 
 353 
 
 
 TABLE IV. 
 
 
 
 
 GRAINS 
 
 PER FLUID OUNCE AND GRAMMES PER LITER. 
 
 
 MALES. 
 
 
 
 FEMALES. 
 
 
 Grains 
 
 
 %of 
 
 Grains 
 
 
 %of 
 
 jer fluid- 
 
 Grammes 
 
 normal 
 
 per fluid- 
 
 Grammes 
 
 normal 
 
 ounce. 
 
 • per liter. 
 
 av'ge. 
 
 ounce. 
 
 per liter. 
 
 av'ge. 
 
 10.09 
 
 21.50 
 
 100 
 
 8.924 
 
 19.00 
 
 100 
 
 9-56 
 
 20.42 
 
 95 
 
 8.478 
 
 18.05 
 
 95 
 
 9.008 
 
 19-35 
 
 90 
 
 8.003 
 
 17.10 
 
 90 
 
 8.589 
 
 18.28 
 
 85 
 
 7-585 
 
 16.15 
 
 85. 
 
 8.007 
 
 17.10 
 
 80 
 
 7-139 
 
 15-20 
 
 80 
 
 7-571 
 
 l6.I2 
 
 75 
 
 6.692 
 
 14.25 
 
 75 
 
 7.068 
 
 15-05 
 
 70 
 
 6.246 
 
 13-30 
 
 70 
 
 6.566 
 
 13-98 
 
 65 
 
 5.800 
 
 12-35 
 
 65 
 
 6.059 
 
 12.90 
 
 60 
 
 5-354 
 
 11.40 
 
 60 
 
 5-556 
 
 11.83 
 
 55 
 
 4.908 
 
 10.45 
 
 55 
 
 5-049 
 
 10.75 
 
 50 
 
 4.162 
 
 9-50 
 
 50 
 
 4-546 
 
 9.68 
 
 45 
 
 4015 
 
 8-55 
 
 45 
 
 4.036 
 
 8.60 
 
 40 
 
 3-560 
 
 7.60 
 
 40 
 
 3-532 
 
 7-52 
 
 35 
 
 3-123 
 
 6.65 
 
 35 
 
 3-332 
 
 6-45 
 
 30 
 
 2.919 
 
 5-70 
 
 30 
 
 2.527 
 
 5-38 
 
 25 
 
 2.231 
 
 4-75 
 
 25 
 
 2.019 
 
 430 
 
 20 
 
 1.784 
 
 3-8o 
 
 20 
 
 1-517 
 
 3-23 
 
 15 
 
 1-338 
 
 2-85 
 
 15 
 
 1.009 
 
 2-15 
 
 10 
 
 0.892 
 
 1.90 
 
 10 
 
 0.507 
 
 1.08 
 
 5 
 
 0.445 
 
 0.95 
 
 5 , 
 
 0.256 
 
 0.54 
 
 ^% 
 
 0.225 
 
 0.48 
 
 2>^ 
 
 10.821 
 
 23-04 
 
 100 
 
 10.427 
 
 22.2 
 
 100 
 
 11.362 
 
 24. 192 
 
 105 
 
 10.948 
 
 23-31 
 
 105 
 
 11.904 
 
 25-344 
 
 110 
 
 11.47 
 
 24.42 
 
 110 
 
 12.445 
 
 26.496 
 
 "5 
 
 11.991 
 
 25-53 
 
 115 
 
 12.986 
 
 27.648 
 
 120 
 
 12.512 
 
 26.64 
 
 120 
 
 13-527 
 
 28.8 
 
 125 
 
 13-034 
 
 27-75 
 
 125 
 
 14.068 
 
 29.952 
 
 130 
 
 13-555 
 
 28.86 
 
 130 
 
 14-609 
 
 31.104 
 
 135 
 
 14.076 
 
 29-97 
 
 135 
 
 15-150 
 
 32.256 
 
 140 
 
 14-598 
 
 31-08 
 
 140 
 
 15.691 
 
 33-408 
 
 145 
 
 15-119 
 
 32.19 
 
 145 
 
 16.232 
 
 34-56 
 
 150 
 
 15-640 
 
 33-3 
 
 150 
 
 16.773 
 
 35-712 
 
 155 
 
 16.162 
 
 34-41 
 
 15s 
 
 17-314 
 
 36.864 
 
 160 
 
 16.683 
 
 35-52 
 
 160 
 
 17-856 
 
 38.016 
 
 165 
 
 17-205 
 
 36-63 
 
 165 
 
 18-397 
 
 39.168 
 
 170 
 
 17.726 
 
 37-74 
 
 170 
 
 18.938 
 
 40.32 
 
 175 
 
 18.247 
 
 38-85 
 
 175 
 
 19-479 
 
 41.472 
 
 180 
 
 18.769 
 
 39-96 
 
 180 
 
 20.020 
 
 42.624 
 
 185 
 
 19.290 
 
 41.07 
 
 185 
 
 20.561 
 
 43-776 
 
 190 
 
 19.811 
 
 42.18 
 
 190 
 
 21.102 
 
 44.928 
 
 195 
 
 20.333 
 
 43-29 
 
 195 
 
 21.643 
 
 46.08 
 
 200 
 
 20.854 
 
 44-4 
 
 200 
 
 24-349 
 
 51.84 
 
 225 
 
 23.461 
 
 49.95 
 
 225 
 
 27-054 
 
 57-6 
 
 250 
 
 26.068 
 
 55-5 
 
 250 
 
 29.760 
 
 63-36 
 
 275 
 
 28.675 
 
 61.05 
 
 275 
 
 32-465 
 
 69.12 
 
 300 
 
 3^-^!o 
 
 66.6 
 
 300 
 
 35-171 
 
 74-88 
 
 325 
 
 33-888 
 
 72-15 
 
 325 
 
 37.876 
 
 80.64 
 
 350 
 
 36.495 
 
 77-7 
 
 350 
 
 40.582 
 
 86.4 
 
 375 
 
 49. 102 
 
 83-25 
 
 375 
 
 43-287 
 
 92.16 
 
 400 
 
 51-709 
 
 88.8 
 
 400 
 
354 
 
 A 
 
 D 
 
 Al. 
 
 All. 
 
 Am. 
 
 Aiv. 
 
 Av. 
 
 Avi. 
 
 
 
 TABLES. 
 
 
 
 
 
 
 TABLE V 
 
 
 
 
 UREA IN GRAINS AND GRAMMES PER 
 
 24 HOURS. 
 
 
 MALES. 
 
 
 
 
 FEMALES. 
 
 
 Grains. Gram's. Approx. % 
 
 . Grains. Gram's. Approx. % 
 
 410.75 
 
 26.50 
 
 27 
 
 100 
 
 312.75 « 
 
 20.50 21 
 
 100 
 
 390.29 
 
 25.18 
 
 25 
 
 95 
 
 301.94 
 
 19.48 19 
 
 95 
 
 369-675 
 
 23.85 
 
 24 
 
 90 
 
 285.975 
 
 18.45 18 
 
 90 
 
 349-215 
 
 22.53 
 
 23 
 
 85 
 
 270.165 
 
 17-43 17 
 
 85 
 
 328.60 
 
 21.20 
 
 21 
 
 80 
 
 254.20 
 
 16.40 16 
 
 80 
 
 307-83 
 
 19.88 
 
 20 
 
 75 
 
 238.39 
 
 15-38 15 
 
 75 
 
 287.525 
 
 18.55 
 
 19 
 
 70 
 
 222.425 
 
 14-35 14 
 
 70 
 
 267.065 
 
 17.23 
 
 17 
 
 65 
 
 206.615 
 
 13-33 13 
 
 65 
 
 246.45 
 
 15-90 
 
 16 
 
 60 
 
 190.65 
 
 12.30 12 
 
 60 
 
 225.99 
 
 14.58 
 
 15 
 
 55 
 
 174.84 
 
 11.28 II 
 
 55 
 
 204.875 
 
 13-25 
 
 13 
 
 50 
 
 158.875 
 
 10.25 10 
 
 50 
 
 184.915 
 
 11-93 
 
 12 
 
 45 
 
 143.065 
 
 9-23 9 
 
 45 
 
 164.30 
 
 10.60 
 
 11 
 
 40 
 
 127.10 
 
 8.20 8 
 
 40 
 
 143-84 
 
 9.28 
 
 9 
 
 35 
 
 111.29 
 
 7-18 7 
 
 35 
 
 123.225 
 
 7-95 
 
 8 
 
 30 
 
 95-325 
 
 6.15 6 
 
 30 
 
 102.765 
 
 6.63 
 
 7 
 
 25 
 
 79-515 
 
 5-13 5 
 
 25 
 
 82.15 
 
 5-30 
 
 5 
 
 20 
 
 63-55 
 
 4.10 4 
 
 20 
 
 61.69 
 
 3-98 
 
 4 
 
 15 
 
 47-74 
 
 3-08 3 
 
 15 
 
 41-075 
 
 2.65 
 
 3 
 
 10 
 
 31-775 
 
 2.05 2 
 
 10 
 
 20.46 
 
 1.32 
 
 1 
 
 , 5 , 
 
 15-965 
 
 1.03 I 
 
 , 5 , 
 
 10.23 
 
 0.66 
 
 2 
 / 
 
 i 2'4 
 
 8.215 
 
 0-53 'A 
 
 : 2>^ 
 
 Grains. 
 
 Grammes. Percent. 
 
 Grains. 
 
 Grammes. Percent. 
 
 514.6 
 
 33-^. 
 
 
 100 
 
 412.3 
 
 26.6 
 
 100 
 
 540.33 
 
 34.86 
 
 
 105 
 
 432-915 
 
 2793 
 
 105 
 
 566.06 
 
 36.52 
 
 
 IIO 
 
 453-53 
 
 29.26 
 
 110 
 
 591-79 
 
 38.18 
 
 
 115 
 
 474-145 
 
 30-59 
 
 115 
 
 617.52 
 
 39-84 
 
 
 120 
 
 494-76 
 
 31.92 
 
 120 
 
 643-25 
 
 41-5 
 
 
 125 
 
 515-375 
 
 33-25 
 
 125 
 
 668.98 
 
 43-16 
 
 
 130 
 
 535 99 
 
 34-58 
 
 130 
 
 694.71 
 
 44.82 
 
 
 135 
 
 556.605 
 
 35-91 
 
 135 
 
 720.44 
 
 46.48 
 
 
 140 
 
 577-22 
 
 37-24 
 
 140 
 
 746.17 
 
 48.14 
 
 
 145 
 
 597-835 
 
 ' 38-57 
 
 145 
 
 771.9 
 
 49.80 
 
 
 150 
 
 618.45 
 
 39-90 
 
 150 
 
 797-63 
 
 51.46 
 
 
 155 
 
 639.065 
 
 41-23 
 
 155 
 
 823.36 
 
 53-12 
 
 
 160 
 
 65968 
 
 42.56 
 
 160 
 
 849.09 
 
 54.78 
 
 
 165 
 
 680.295 
 
 43-89 
 
 165 
 
 874.82 
 
 56.44 
 
 
 170 
 
 700.91 
 
 45.22 
 
 170 
 
 900.65 
 
 58.10 
 
 
 175 
 
 721-525 
 
 46.55 
 
 175 
 
 926.28 
 
 59.76 
 
 
 180 
 
 742.14 
 
 47.88 
 
 180 
 
 952.01 
 
 61.42 
 
 
 185 
 
 762.755 
 
 49.21 
 
 185 
 
 977-74 
 
 63.8 
 
 
 190 
 
 78337 
 
 50.54 
 
 190 
 
 1003.47 
 
 6474 
 
 
 195 
 
 803.98s 
 
 51.87 
 
 195 
 
 1029.2 
 
 66.40 
 
 
 200 
 
 824.6 
 
 53-2 
 
 200 
 
 1157.85 
 
 74.7 
 
 
 225 
 
 927.675 
 
 59-85 
 
 225 
 
 1286.50 
 
 83. 
 
 
 250 
 
 1030.75 
 
 66.5 
 
 250 
 
 1415-15 
 
 94.3 
 
 
 275 
 
 1134-825 
 
 73-15 
 
 275 
 
 1543-80 
 
 99.6 
 
 
 300 
 
 1236.9 
 
 79-8 
 
 300 
 
 Those examining urine in Chicago and vicinity will find the figures in the 
 upper half of the page far more common than those in the lower. 
 
APPENDIX. 
 
 355 
 
 
 
 TABLE 
 
 VI. 
 
 
 
 
 
 {a.) 
 
 
 
 
 
 URIC ACID RELATIVE TO WATER. 
 
 
 
 
 DESCENDING 
 
 SCALE, 
 
 
 
 
 MALE PATIENTS. 
 
 FEMALE PATIENTS, 
 
 
 Grains per 
 
 Grammes 
 
 
 Grains per 
 
 Grammes 
 
 
 fluid 02. 
 
 per liter. 
 
 Per cent. 
 
 fluid oz. 
 
 per liter. 
 
 Per cent. 
 
 0.173 
 
 0.37 
 
 100 
 
 0.191 
 
 0,407 
 
 100 
 
 0.164 
 
 0.3s 
 
 95 
 
 0,181 
 
 0.386 
 
 95 
 
 0.155 
 
 0.33 
 
 90 
 
 0.172 
 
 0.366 
 
 90 
 
 0.147 
 
 0.31 
 
 85 
 
 0,162 
 
 0.345 
 
 85 
 
 0.138 
 
 0,296 
 
 80 
 
 0.153 
 
 0.325 
 
 80 
 
 0.129 
 
 0.277 
 
 75 
 
 0.143 
 
 0.305 
 
 75 
 
 0.121 
 
 0.259 
 
 70 
 
 0.133 
 
 0.285 
 
 70 
 
 O.II2 
 
 0.24 
 
 65 
 
 0.124 
 
 0,264 
 
 65 
 
 0.103 
 
 0.22 
 
 60 
 
 Q.II5 
 
 0,244 
 
 60 
 
 0095 
 
 0.20 
 
 55 
 
 0.105 
 
 0,224 
 
 55 
 
 0.086 
 
 0.185 
 
 50 
 
 0.095 
 
 0.203 
 
 50 
 
 0.077 
 
 0.166 
 
 45 
 
 0.086 
 
 0.183 
 
 45 
 
 0.069 
 
 0.148 
 
 40 
 
 0.076 
 
 0.163 
 
 40 
 
 0.060 
 
 0.129 
 
 35 
 
 0.066 
 
 0.142 
 
 35 
 
 0.052 
 
 O.IIl 
 
 30 
 
 O.OS7 
 
 0,122 
 
 30 
 
 0.042 
 
 0,092 
 
 25 
 
 6.047 
 
 0.102 
 
 25 
 
 0.034 
 
 0.074 
 
 20 
 
 0,038 
 
 0.08 
 
 20 
 
 0.026 
 
 0.055 
 
 15 
 
 0.028 
 
 0.06 
 
 15 
 
 0.017 
 
 0.037 
 
 10 
 
 0.019 
 
 0.04 
 
 10 
 
 0.008 
 
 0.018 
 
 5 
 
 0.009 
 
 0.02 
 
 5 
 
 0.004 
 
 0.009 
 
 2>^ 
 
 0.004 
 
 0.01 
 
 2>^ 
 
 In this table the average of Parkes is chosen, since it 
 
 is lower than that of 
 
 Yvon-Berlioz. But in order to make the average for female patients, 
 
 the ratio 
 
 of male to female in the Yvon-Berlioz average is taken. 
 
 
 
 
 
 {.b.) 
 
 
 
 
 
 
 ASCENDING 
 
 SCALE, 
 
 
 
 0.232 
 
 0.500 
 
 100 
 
 0.255 
 
 0.550 
 
 100 
 
 0.244 
 
 0.525 
 
 105 
 
 0.267 
 
 0.577 
 
 105 
 
 0-255 
 
 0.550 
 
 110 
 
 0.280 
 
 0.605 
 
 no 
 
 0.267 
 
 0,575 
 
 "5 
 
 0.293 
 
 0.632 
 
 115 
 
 0.278 
 
 0.600 
 
 120 
 
 0.306 
 
 0.660 
 
 120 
 
 0.290 
 
 0.625 
 
 125 
 
 0.319 
 
 0.687 
 
 125 
 
 0.302 
 
 0,650 
 
 130 
 
 0.331 
 
 0.715 
 
 130 
 
 0.313 
 
 0.675 
 
 135 
 
 0.344 
 
 0.742 
 
 135 
 
 0.325 
 
 0.700 
 
 140 
 
 0.357 
 
 0.770 
 
 140 
 
 0.336 
 
 0.725 
 
 145 
 
 0.369 
 
 0.797 
 
 145 
 
 0.348 
 
 0.750 
 
 150 
 
 0.382 
 
 0.825 
 
 150 
 
 0-359 
 
 0.775 
 
 155 
 
 0.395 
 
 0.852 
 
 155 
 
 0.371 
 
 0.800 
 
 160 
 
 0.408 
 
 0.880 
 
 160 
 
 0.383 
 
 0.825 
 
 165 
 
 0,420 
 
 0.907 
 
 165 
 
 0.394 
 
 0.850 
 
 170 
 
 0.433 
 
 0.935 
 
 170 
 
 0.406 
 
 0.875 
 
 175 
 
 0.446 
 
 0.962 
 
 175 
 
 0.418 
 
 900 
 
 180 
 
 0.459 
 
 0,990 
 
 180 
 
 0.429 
 
 0.925 
 
 185 
 
 0.472 
 
 1.017 
 
 185 
 
 0.441 
 
 0.950 
 
 190 
 
 0.484 
 
 1,045 
 
 190 
 
 0.452 
 
 0.975 
 
 195 
 
 0.497 
 
 1,072 
 
 195 
 
 0.464 
 
 1. 000 
 
 200 
 
 0.510 
 
 I.ICO 
 
 200 
 
 0.522 
 
 1.125 
 
 225 
 
 0.573 
 
 1.237 
 
 225 
 
 0.580 
 
 1.250 
 
 250 
 
 0.637 
 
 1.375 
 
 250 
 
 0.638 
 
 1.375 
 
 275' 
 
 0.701 
 
 1. 512 
 
 275 
 
 0.696 
 
 1.500 
 
 300 
 
 0.765 
 
 1.650 
 
 300 
 
 0.754 
 
 1.625 
 
 325 
 
 0.828 
 
 1.787 
 
 325 
 
 0.812 
 
 1.750 
 
 350 
 
 0.892 
 
 1.92s 
 
 350 
 
 0.870 
 
 1.875 
 
 375 
 
 0.956 
 
 2.062 
 
 375 
 
 0.928 
 
 2.000 
 
 400 
 
 1.020 
 
 2.200 
 
 400 
 
356 TABLES. 
 
 
 
 TABLE VII. 
 
 
 
 {a.) 
 
 
 
 TOTAI, URIC ACID IN 24 HOURS. 
 
 
 
 DESCENDING 
 
 SCALE. 
 
 
 MALE PATIENTS 
 
 
 FBMAL 
 
 Grains. 
 
 Grammes, 
 
 Per cent. 
 
 Grains. Gi 
 
 8.600 
 
 0.555 
 
 100 
 
 8.17 
 
 8.170 
 
 0.527 
 
 95 
 
 7.76 
 
 7.740 
 
 0.499 
 
 T 
 
 7-35 
 
 7.310 
 
 0.472 
 
 85 
 
 6.94 
 
 6.880 
 
 0.444 
 
 80 
 
 6.54 
 
 6.450 
 
 0.416 
 
 75 
 
 6.13 
 
 6.020 
 
 0.388 
 
 70 
 
 5.72 
 
 5-590 
 
 0.361 
 
 65 
 
 5-31 
 
 5.160 
 
 0.333 
 
 60 
 
 4.90 
 
 4730 
 
 0.305 
 
 55 
 
 4-49 
 
 4.300 
 
 0277 
 
 50 
 
 4.08 
 
 3.870 
 
 0.250 
 
 45 
 
 3-67 
 
 3-440 
 
 0.222 
 
 40 
 
 ^■v. 
 
 3.010 
 
 0.194 
 
 35 
 
 2.86 
 
 2.580 
 
 0.166 
 
 30 
 
 2.45 
 
 2.150 
 
 0.139 
 
 25 
 
 2.04 
 
 1.710 
 
 O.III 
 
 20 
 
 1.63 
 
 1.290 
 
 0.083 
 
 15 
 
 1-23 
 
 0.860 
 
 0.055 
 
 10 
 
 0.82 
 
 0.430 
 
 0.028 
 
 5^ 
 
 0.40 
 
 0.021 
 
 0.014 
 
 2^ 
 
 0.02 
 
 9-30 
 
 9.76 
 
 10.23 
 
 10.69 
 II. 16 
 11.62 
 12.09 
 
 12.55 
 13.02 
 
 13-48 
 1395 
 14.41 
 14.88 
 
 15-34 
 15-81 
 16.27 
 16.74 
 17.20 
 17.67 
 
 18.13 
 18.60 
 
 
 (*•) 
 
 
 
 ASCENDING 
 
 SCALE. 
 
 0.60 
 
 100 
 
 8.80 
 
 0.63 
 
 105 
 
 9.24 
 
 0.66 
 
 HO 
 
 9.68 
 
 0.69 
 
 115 
 
 IO.I2 
 
 0.72 
 
 120 
 
 10.56 
 
 0.75 
 
 125 
 
 11.00 
 
 0.78 
 
 130 
 
 11.41 
 
 o.8i 
 
 135 
 
 11.88 
 
 0.84 
 
 140 
 
 12.32 
 
 0.87 
 
 145 
 
 12.76 
 
 0.90 
 
 150 
 
 13.20 
 
 0-93 
 
 155 
 
 13.64 
 
 0.96 
 
 160 
 
 14.08 
 
 0.99 
 
 165 
 
 14-52 
 
 1.02 
 
 170 
 
 14.96 
 
 1.05 
 
 175 
 
 15.40 
 
 1.08 
 
 180 
 
 15.84 
 
 I. II 
 
 185 
 
 16.28 
 
 1.14 
 
 190 
 
 16.72 
 
 1.17 
 
 195 
 
 17 17 
 
 1.20 
 
 200 
 
 17.60 
 
 0.527 
 
 100 
 
 0.501 
 
 95 
 
 0.474 
 
 90 
 
 0.448 
 
 85 
 
 0.422 
 
 80 
 
 0.396 
 
 75 
 
 0.370 
 
 70 
 
 0.343 
 
 65 
 
 0.316 
 
 60 
 
 0.290 
 
 55 
 
 0.263 
 
 50 
 
 0.237 
 
 45 
 
 0.211 
 
 40 
 
 0.184 
 
 35 
 
 0.158 
 
 30 
 
 0.132 
 
 25 
 
 0.105 
 
 20 
 
 0.079 
 
 IS 
 
 0.053 
 
 10 
 
 0.026 
 
 5 , 
 
 0.001 
 
 ^Yz 
 
 0.57 
 
 100 
 
 0.59 
 
 105 
 
 0.62 
 
 HO 
 
 0.65 
 
 "5 
 
 0.68 
 
 120 
 
 0.71 
 
 125 
 
 0.74 
 
 130 
 
 0.77 
 
 135 
 
 0.79 
 
 140 
 
 0.S2 
 
 145 
 
 0.85 
 
 150 
 
 0.88 
 
 155 
 
 0.91 
 
 160 
 
 0.94 
 
 165 
 
 0.97 
 
 170 
 
 1.00 
 
 175 
 
 1.03 
 
 180 
 
 1.05 
 
 185 
 
 1.08 
 
 190 
 
 I. II 
 
 195 
 
 1. 14 
 
 200 
 
APPENDIX. 
 
 357 
 
 
 
 
 TABLE VIII. 
 
 
 
 
 PHOSPH 
 
 ORIC ACID IN GRAINS PER FI,UID OUNCE AND GRAMMES 
 
 
 
 
 PER LITER. 
 
 
 
 
 
 
 MALES. 
 
 
 
 FEMALES. 
 
 
 
 Grains 
 
 
 
 Grains 
 
 
 
 
 per fluid- 
 
 Grammes 
 
 Per 
 
 per fluid- 
 
 Grammes 
 
 Per 
 
 
 ounce. 
 
 per liter. 
 
 cent. 
 
 ounce. 
 
 per liter. 
 
 cent. 
 
 
 1. 174 
 
 2.5 
 
 100 
 
 1. 127 
 
 2.40 
 
 100 
 
 Al. 
 
 I.I17 
 
 2.38 
 
 95 
 
 1.070 
 
 2.28 
 
 95 
 
 
 1.058 
 
 2.25 
 
 90 
 
 1.014 
 
 2.16 
 
 90 
 
 
 1.004 
 
 2.13 
 
 85 
 
 0,958 
 
 2.04 
 
 85 
 
 A 
 
 0.939 
 
 2.00 
 
 80 
 
 0.901 
 
 1.92 
 
 80 
 
 
 . 0.883 
 
 1.88 
 
 75 
 
 0.845 
 
 1.80 
 
 75 
 
 
 ■ 0.821 
 
 1-75 
 
 70 
 
 0.789 
 
 1.68 
 
 70 
 
 
 0.76s 
 
 1.63 
 
 65 
 
 0.732 
 
 1.56 
 
 65 
 
 B 
 
 0.704 
 
 1.50 
 
 60 
 
 0.676 
 
 1.44 
 
 60 
 
 
 0.648 
 
 1.38 
 
 55 
 
 0.66 
 
 1.32 
 
 55 
 
 
 . 0.587 
 
 1.25 
 
 50 
 
 0.563 
 
 1.20 
 
 50 
 
 
 ' 0.530 
 
 1.13 
 
 45 
 
 0.507 
 
 1.08 
 
 45 
 
 
 0.469 
 
 1. 00 
 
 40 
 
 0.450 
 
 0.96 
 
 40 
 
 C 
 
 0.413 
 
 0.88 
 
 35 
 
 0.394 
 
 0.84 
 
 35 
 
 
 0.352 
 
 0.75 
 
 30 
 
 0.338 
 
 0.72 
 
 30 
 
 
 . 0.295 
 
 0.63 
 
 25 
 
 0.381 
 
 0.60 
 
 25 
 
 
 ' 0.234 
 
 0.50 
 
 20 
 
 0,225 
 
 0.48 
 
 20 
 
 
 0.178 
 
 0.38 
 
 15 
 
 0.169 
 
 0.36 
 
 15 
 
 D 
 
 0.II7 
 
 0.25 
 
 10 
 
 0.112 
 
 0.24 
 
 10 
 
 
 0.061 
 
 0.13 
 
 5 
 
 0.059 
 
 0.12 
 
 5 , 
 
 
 . 0.032 
 
 0.07 
 
 2^ 
 
 0.028 
 
 0.06 
 
 ^'A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■ 0.986 
 
 2.1 
 
 100 
 
 0.939 
 
 2.0 
 
 100 
 
 A 
 
 1.035 
 
 2.205 
 
 105 
 
 0.986 
 
 2.1 
 
 105 
 
 1. 083 
 
 2.31 
 
 no 
 
 1.030 
 
 2.2 
 
 no 
 
 
 . I- 134 
 
 2.415 
 
 115 
 
 1.080 
 
 2.3 
 
 115 
 
 Al. < 
 
 f I.183 
 
 2.52 
 
 120 
 
 1. 127 
 
 2.4 
 
 120 
 
 I 1.233 
 
 2.625 
 
 125 
 
 1. 174 
 
 2.5 
 
 125 
 
 
 ' 1.282 
 
 2.73 
 
 130 
 
 1. 221 
 
 2.6 
 
 130 
 
 
 I-33I 
 
 2.835 
 
 135 
 
 r.268 
 
 2.7 
 
 135 
 
 All. 
 
 1.380 
 
 2.94 
 
 140 
 
 1.315 
 
 2.8 
 
 140 
 
 
 1.430 
 
 3.045 
 
 145 
 
 1.362 
 
 2.9 
 
 145 
 
 
 L 1.479 
 
 3-15 
 
 150 
 
 1.409 
 
 3.0 
 
 150 
 
 
 ' 1.528 
 
 3.255 
 
 155 
 
 1.456 
 
 3.1 
 
 155 
 
 
 1.578 
 
 336 
 
 160 
 
 1.503 
 
 3-2 
 
 160 
 
 Am. - 
 
 1.627 
 
 3.465 
 
 165 
 
 1.55 
 
 3.3 
 
 165 
 
 
 1.676 
 
 3-57 
 
 170 
 
 1.596 
 
 3.4 
 
 170 
 
 
 1.726 
 
 3.675 
 
 175 
 
 1.643 
 
 3-5 
 
 175 
 
 
 1-775 
 
 3.78 
 
 180 
 
 1.690 
 
 3.6 
 
 180 
 
 
 1.824 
 
 3.885 
 
 185 
 
 1.737 
 
 H 
 
 185 
 
 Aiv. 
 
 1.874 
 
 3.99 
 
 190 
 
 1.784 
 
 3.8 
 
 190 
 
 
 1. 921 
 
 4.095 
 
 195 
 
 ^•l^l 
 
 3.9 
 
 195 
 
 
 2.003 
 
 4.2 
 
 200 
 
 1.878 
 
 4.0 
 
 200 
 
 
 2.220 
 
 4.725 
 
 225 
 
 2. 113 
 
 4-5 
 
 225 
 
 
 2.465 
 
 5.25 
 
 250 
 
 2.348 
 
 5.0 
 
 250 
 
 Etc. 
 
 2.712 
 
 5.775 
 
 275 
 
 2583 
 
 5.5 
 
 275 
 
 
 2.950 
 
 6.3 
 
 300 
 
 2.818 
 
 6.0 
 
 300 
 
 
 3.205 
 
 6.825 
 
 325 
 
 3.053 
 
 6.5 
 
 325 
 
 
 3.452 
 
 7-35 
 
 350 
 
 3.287 
 
 7.0 
 
 3SO 
 
 Etc. 
 
 3.698 
 
 7.875 
 
 375 
 
 3.522 
 
 7-5 
 
 375 
 
 
 3.90 
 
 8.4 
 
 400 
 
 3.757 
 
 8.0 
 
 400 
 
 Note.— 
 
 -In the writer's experience the lower half of this page is of little value. 
 
 •When tl 
 
 le figures 
 
 exceed 2.40 
 
 or 2.5, which IS 
 
 rare, calculate by dividing tne 
 
 figure found by 2.4 or 2.5. 
 
358 
 
 TABLES. 
 
 TABLE IX. 
 
 PHOSPHORIC ACID IN GRAINS PER 24 HOURS AND GRAMMES. 
 
 D 
 
 Al. 
 
 An. 
 
 Am. 
 
 Aiv. 
 
 Etc. 
 
 Etc. 
 
 MALBS. 
 
 Grains. Grammes, 
 49.60 
 47.12 
 44.64 
 42.16 
 39.68 
 37.20 
 
 35-72 
 32.24 
 29.76 
 27.28 
 24.80 
 22.32 
 19.84 
 17-36 
 14.88 
 12.40 
 9.92 
 
 7-44 
 4.96 
 2.58 
 1.24 
 
 49-6 
 52.08 
 
 54-56 
 57-04 
 59-52 
 62.00 
 64.48 
 66.96 
 
 69-44 
 71.92 
 
 74-4 
 
 76.88 
 
 79-36 
 
 81.84 
 
 84-32 
 
 86.80 
 
 89.28 
 
 91.76 
 
 94.24 
 
 96.72 
 
 99.20 
 III. 60 
 124.00 
 136.40 
 148.80 
 161.20 
 173.60 
 186.00 
 198.40 
 
 FEMALES. 
 
 Grains. Grammes, Per cent. 
 
 3.20 
 
 100 
 
 3-04 
 
 95 
 
 2.88 
 
 90 
 
 2.72 
 
 85 
 
 2.56 
 
 80 
 
 2.40 
 
 75 
 
 2.24 
 
 70 
 
 2.08 
 
 65 
 
 1.92 
 
 60 
 
 1.76 
 
 55 
 
 1.60 
 
 50 
 
 1.44 
 
 45 
 
 1.28 
 
 40 
 
 1. 12 
 
 35 
 
 0.96 
 
 30 
 
 0.80 
 
 25 
 
 0.64 
 
 20 
 
 0.48 
 
 IS 
 
 0.32 
 
 10 
 
 0.16 
 
 5 
 
 0.08 
 
 2^ 
 
 3-2 
 
 100 
 
 3-36 
 
 105 
 
 3-52 
 
 no 
 
 3.68 
 
 U5 
 
 3-84 
 
 120 
 
 4.00 
 
 125 
 
 4.16 
 
 130 
 
 432 
 
 135 
 
 4.48 
 
 140 
 
 4.64 
 
 145 
 
 4.80 
 
 150 
 
 4.96 
 
 155 
 
 5-12 
 
 160 
 
 5-28 
 
 165 
 
 5-44 
 
 170 
 
 5-6 
 
 175 
 
 5-76 
 
 180 
 
 5.92 
 
 185 
 
 6.08 
 
 190 
 
 6.24 
 
 195 
 
 6.40 
 
 200 
 
 7.20 
 
 225 
 
 8.00 
 
 250 
 
 8.80 
 
 275 
 
 9.60 
 
 300 
 
 10.40 
 
 325 
 
 11.20 
 
 350 
 
 12.00 
 
 375 
 
 12.80 
 
 400 
 
 40.30 
 38.285 
 
 36.27 
 
 34-255 
 
 32.24 
 
 30.225 
 
 28.21 
 
 26.195 
 
 24.18 
 
 22.165 
 20.15 
 
 -18.135 
 
 16.12 
 
 14.105 
 
 12.09 
 10.075 
 8.06 
 6.045 
 4-03 
 2-015 
 1-085 
 
 40.3 
 
 42-3'5 
 
 44-33 
 
 46.345 
 
 48.36 
 
 50.375 
 
 52.39 
 
 54-405 
 
 56.42 
 
 58.435 
 60.45 
 62.465 
 64.48 
 66.495 
 68.51 
 70.525 
 72.54 
 74-555 
 76.57 
 78.585 
 80.6 
 90.675 
 100.75 
 110.825 
 120.9 
 
 130.975 
 141.05 
 151-125 
 161.2 
 
 2.60 
 2.47 
 
 2.34 
 2.21 
 2.08 
 
 1-95 
 1.82 
 1.69 
 1.56 
 
 1-43 
 1.30 
 1.17 
 1.04 
 0.91 
 0.78 
 0.65 
 0.52 
 
 0.39 
 0.26 
 
 0.13 
 0.07 
 
 2.6 
 
 2.73 
 2.86 
 
 2-99 
 3.12 
 
 3-25 
 
 3-38 
 
 3-51 
 
 3-64 
 
 3-77 
 
 3-9 
 
 4-03 
 
 4.16 
 
 4.29 
 
 4-42 
 
 4-55 
 
 4.68 
 
 4.81 
 
 4-94 
 
 5-07 
 
 5-2 
 
 5-85 
 
 6.50 
 
 7-15 
 7.80 
 
 8.45 
 9.10 
 
 9-75 
 10.40 
 
 95 
 90 
 
 85 
 80 
 
 75 
 70 
 
 65 
 60 
 
 55 
 50 
 45 
 40 
 
 35 
 30 
 25 
 20 
 
 IS 
 10 
 
 s 
 100 
 
 los 
 no 
 
 115 
 120 
 
 125 
 130 
 
 135 
 140 
 
 145 
 150 
 155 
 160 
 
 165 
 170 
 
 175 
 180 
 
 185 
 190 
 
 19s 
 200 
 225 
 250 
 
 275 
 300 
 
 325 
 350 
 375 
 400 
 
APPENDIX. 
 
 359 
 
 TABLE X. 
 
 RATIO OF URBA TO PHOSPHORIC ACID. 
 
 (Yvon-Berlioz, 
 
 8. to 
 7.6 to 
 7.2 to 
 6.8 to 
 6.4 to 
 6.0 to 
 5-6 to 
 5.2 to 
 4.8 to 
 4.410 
 4.0 to 
 3-6 to 
 3.2 to 
 2.8 to 
 2.4 to 
 2.0 to 
 
 T.6tO 
 1.2 to 
 
 0.8 to 
 0.4 to 
 0.2 to 
 
 Per cent. 
 100 
 
 95 
 90 
 
 85 
 80 
 
 75 
 70 
 
 65 
 60 
 
 55 
 50 
 45 
 40 
 
 35 
 30 
 25 
 20 
 
 15 
 10 
 
 5 
 
 (Parkes.) 
 
 10. to I 
 10.5 to I 
 
 II.O to I 
 
 11.5 to I 
 12.0 to I 
 12.5 to I 
 13.0 to I 
 13-5 to I 
 14.0 to I 
 14.5 to I 
 15.0 to I 
 15-5 to I 
 16.0 to I 
 16.5 to I 
 17.0 to I 
 17.5 to I 
 18.0 to I 
 18.5 to I 
 19.0 to I 
 19.5 to I 
 20.0 to I 
 22.5 to I 
 25.0 to I 
 
 TABLE XI. 
 
 RATIO OF UREA TO URIC ACID. 
 
 40 to I is normal according to Yvon-Berlioz and 33 to r according to Haigs. 
 The writer believes that, when the clinical instruments are used for urea and 
 the Heintz process for uric acid, anything below 40 to i must be regarded as 
 indicating relative excess of uric acid. 50 to i may be taken as normal. 
 
 Per cent. 
 100 
 105 
 
 no 
 
 115 
 
 120 
 
 125 
 130 
 
 135 
 
 140 
 
 145 
 150 
 155 
 
 160 
 
 165 
 
 170 
 
 175 
 180 
 
 185 
 
 190 
 
 195 
 
 200 
 225 
 250 
 
 
 TABLE XII. 
 
 
 
 RATIO OF UREA TO SAI,TS. 
 
 
 Urea. Salts. Per cent. Urea. Salts. Per cent 
 
 0.85 
 
 I 100 1.33 
 
 I TOO 
 
 0.8075 
 
 95 1-396+ 
 
 105 
 
 0.765 
 
 90 1.463 
 
 no 
 
 0.7225 
 
 85 1.529+ 
 
 115 
 
 0.68 
 
 80 1.596 
 
 120 
 
 0.6375 
 
 75 1.662+ 
 
 125 
 
 0.595 
 
 70 1.729 
 
 130 
 
 0.5525 
 
 65 1-795+ 
 
 135 
 
 0.51 
 
 60 1.862 
 
 140 
 
 0.4675 
 
 55 1.928+ 
 
 145 
 
 0.425 
 
 50 1.995 
 
 150 
 
 0.3825 
 
 45 2.061+ 
 
 155 
 
 0.34 
 
 40 2.128 
 
 160 
 
 0.2975 
 
 35 2.194-1- 
 
 165 
 
 0.255 
 
 30 2.261 
 
 170 
 
 0.2125 
 
 25 2.327+ 
 
 175 
 
 0.17 
 
 20 2.394 
 
 180 
 
 O.I27.S 
 
 15 2.46+ 
 
 185 
 
 0.085 
 
 10 2.527 
 
 190 
 
 0.0425 
 
 5 2.593+ 
 
 195 
 
 0.02125 
 
 lYz 2.66 
 
 200 
 
 
 2.992+ 
 
 225 
 
 
 - • 3-325+ 
 
 250 
 
 . . . 
 
 • • 3-657+ 
 
 275 
 
 
 - • 3-99 
 
 300 
 
INDEX. 
 
 PAGE 
 
 Acetone 232 
 
 Albumoses 195-201 
 
 Allantoin 104 
 
 AUoxuric bodies 247 
 
 Ammonia 161 
 
 Animal gum 128 
 
 Animal bases in urine . . . 245 
 Aromatic compounds . . . 109 
 Albumin, chemistry of . . 162 
 " significance of ... 189 
 " quantitative determi- 
 nation , ... 1S4 
 
 " tests 162 
 
 " " acetic acid and 
 
 heat 176 
 
 ;■ " acidulated brine 181 
 " " chromic acid . . 181 
 ," " clinical test . ■., . 164 
 " " ferrocyanic test . 178 
 " " heat and acetic 
 
 acid 175 
 
 " " heat and nitric 
 
 acid 174 
 
 " " JoUes' 183 
 
 " " metaphosphoric 
 
 acid .... r. 181 
 " " Millard's ... 183 
 " " nitric acid .... 169 
 " " nitro-magnesian 173 
 " " perchloride of 
 
 mercury . . 182 
 " " phenlc-acetic . . 181 
 " " picric acid ■ . 181 
 " " platinocyanide . 182 
 " " potassio-mercuric 
 
 iodide .... 181 
 " " Sharp's .... 183 
 " " sodium tungstate 183 
 " " Spiegler's ... 182 
 " " sulpho-salicylic 182 
 " " sulphocyanide . 182 
 " " Tanret's .... 183 
 " " trichloracetic. . 179 
 Benzoyl-carbohydrate . . . 128 
 
 Bile in urine 236 
 
 Biliary acids 238 
 
 Bilirubin 287 
 
 PAGE 
 
 Blood pigments 236 
 
 Calcium 161 
 
 Carboluria 121 
 
 Cane sugar 231 
 
 Carbohydrates in urine . . 230 
 
 " abnormal 207 
 
 " normal 128 
 
 Carbon 161 
 
 Carbonic acid 161 
 
 Chlorides 151 
 
 " chemistry of. . .151-152 
 
 " physiology 152 
 
 " pathology ... 153 
 " microscopical appear- 
 ance 156 
 
 Cholesterin .... 286 
 
 Chromogens 124 
 
 Coloring matters . . . •, . : . 236 
 " '■ abnormal . 236 
 
 " " normal . ...122 
 
 Colors of urine • 240 
 
 ';' due to drugs 241 ' 
 
 Color of urine ....... 43 
 
 Collection of urine .... 19 
 
 Conjugate sulphates . . 111-115 
 Consistency of urine ... 38 
 
 Cumarin no 
 
 Cystin 267 
 
 Day urine 18 
 
 Dextrin 230 
 
 Diacetic acid 233 
 
 Diastase . . 130 
 
 Diazo reaction 242 
 
 Ehrlich's reaction . . . 245 
 Ethereal sulphates . . .111-112 
 
 Enzymes 130 
 
 Fibrin 203 
 
 Filtration 48 
 
 Fluorine 161 
 
 Fatty acids . 126 
 
 Gases in urine 41 
 
 Glucosazon 128 
 
 Glycero-phosphoric acid . 127 
 
 Glycuronic acid 231 
 
 Glycuronic acid compounds no 
 
 Globulin 193 
 
 Hsematoporpbyrin . . 123, 236 
 
362 
 
 INDEX. 
 
 PAGE 
 
 Haematoidin 2S7 
 
 Haemoglobin 201 
 
 Hippuric acid 109 
 
 Histon .• ■ • 205 
 
 Hydroparacumaric acid . . no 
 
 Hydroquinone 121 
 
 Indican 116-121 
 
 Inosite 128 
 
 Iron 161 
 
 Kreatin .... ... 104 
 
 Kreatinin 104 
 
 lL,actic acid 126 
 
 Lactose 129 
 
 Laiose 231 
 
 IvCvulose 230 
 
 Leucin 269 
 
 Leucomains 245 
 
 Maltose 230 
 
 Melanin 240, 287 
 
 Mucus 130 
 
 Night urine 18 
 
 Nitric acid 161 
 
 Nitrogen 161 
 
 Nucleo-albumin .... 203-205 
 
 Odor of urine 40-44 
 
 Oxalic acid 126 
 
 Oxybutyric acid 235 
 
 Oxygen . 161 
 
 Oxypheuylacetic acid . . . no 
 
 Paracresol 121 
 
 Paraxanthin 106 
 
 Pathologic urobilin .... 238 
 
 Pentose 231 
 
 Pepsin 130 
 
 Peroxide of hydrogen . . . 161 
 
 Phenol 121 
 
 Phosphates 131-150 
 
 •' detection of . . . 137-139 
 " determination of . 147-150 
 " pathology of. 140-145 
 
 " physiology of . .135-137 
 Physical characteristics of 
 
 urine 28 
 
 Ptomains .... . 130, 245 
 
 Pyrocatechin 121 
 
 Quantity of urine in twenty- 
 four hours . . .20, 21, 23, 24 
 Reaction of urine . . 37, 45, 52 
 
 Rennet 130 
 
 Sediments 253 
 
 " ammonio-magnesium 
 
 phosphate . . . 273 
 
 " bacteria 315 
 
 " blood 289, 293 
 
 " calcium carbonate 278, 282 
 
 PAGE 
 
 Sediments, calcium sulphate 
 
 268, 271 
 " connective tissue . . 314 
 " crystalline calcium 
 
 phosphate .... 280 
 " crystalline magnesium 
 
 phosphate .... 283 
 
 " cystin 267 
 
 " earthy phosphates . . 277 
 " epithelium .... 299, 302 
 ' ' extraneous obj ects 308-309 
 
 " fat 285 
 
 " hippuric acid .... 268 
 
 " indigo 284 
 
 " kreatinin 269 
 
 ' ' leucin and tyrosin . . 270 
 " oxalate of lime . . . 264 
 
 " parasites 317 
 
 "pus 294, 298 
 
 " soaps of lime and 
 
 magnesia 283 
 
 " spermatozoa . . . . 314 
 ' ' triple phosphate ... 273 
 " tube casts .... 303, 313 
 
 " urates 260 
 
 " uric acid 257 
 
 " xanthin 272 
 
 Sulphates 157 
 
 " preformed 157 
 
 " physiology of . . . . 158 
 " pathology of ... . 159 
 
 " conjugate 159 
 
 Skatoxyl 120 
 
 Specific gravity 45 
 
 Succinic acid 126 
 
 Sugar, quantity of ... . 220 
 " significance of . . 228-230 
 
 Sugar 207 
 
 " Allen's test 217 
 
 " bismuth test . .214-227 
 " Briicke's test .... 227 
 " Carwardine's test . . 222 
 " chemistry of . . 207 
 
 " clinical test . . . 207-211 
 
 " cupric test 221 
 
 " Fehling'stest . . . 212 
 " fermentation test . . 215 
 " Haines' test . . . . 207 
 " indigo-carmine test . 219 
 " Nylander's test . . 214 
 " picric acid test . . . 222 
 " phenylhydrazin test . 217 
 " polariraetric test . . 222 
 " Purdy's quantitative 
 
 test 221 
 
INDEX. 
 
 363 
 
 PAGE 
 
 Sugar quantitative fertnent- 
 
 ation method . 220, 227 
 " Trommer's test 217,226 
 Sugar, Whitney's test . . . 223 
 Toxicity of urine . 249-252 
 Typhoid reaction . . . 242 
 Total solids in urine . . . 30, 51 
 
 Tyrosin 269 
 
 Urea 54-70 
 
 " physiology of . . . 71-74 
 " pathology 74-83 
 
 Uric acid, chemistry 
 
 of 
 
 
 85-92, 
 Uric acid, physiology of 
 " " pathology of 
 Urinometer .... 
 
 100-103 
 
 ■ 93-97 
 98-100 
 
 • 29 
 
 Urochrome . . 
 
 
 
 
 
 122 
 
 Urohsematin . 
 
 
 
 
 
 124 
 
 Uroerythriu . , . 
 Uroroseinogen . . . 
 Urospectrin . . . 
 Xanthin, sediment of 
 
 
 
 123 
 
 125 
 123 
 272