^^WlH^tM1>M^-' 
 
 Practical Notes on Mmm Anal 
 
 
 By William B. Canfield, A 
 
LIBRARY OF CONGRESS, 
 
 ^XB?^ ■' — 
 
 Shelf..LZ% 
 
 UNITED STATES OF AMERICA. 
 
 T^ 
 
GASTRIC DERANGEMENTS. 
 
 HORSFORD'S ACID PHOSPHATE. 
 
 Unl ke all oiher forms of phosphorus in combination, such as dilute 
 phosphoric acid, glacial phosphoric acid, neutral phosphate of lime, hypo- 
 phosphites, etc., the phosphates in this product are in solution, and readily 
 assimilable by the system, and it not only causes no trouble with the 
 digestive organs, but promotes in a marked degree their healthful action. 
 
 In certain forms of dyspepsia it acts as a specific. 
 
 Dr. H R. Merville, Milwaukee, Wis., says: " I regard it as val- 
 uable in the treatment of gastric derangements affecting digestion." 
 
 Dr. E. Osborne. Mason City, la., says: " I consider it a valuable 
 addition to the remedies in use for the relief of gastr c disorders depend- 
 ent on enervation." 
 
 Dr. Albert Day, Superintendent of the Washington Home, Bos- 
 ton, says: " For several years I have used it in cases of alcoholism and 
 gastric irritation. It is of special value." 
 
 Dr. T. G CoMSTOCK, of the Good Samaritan Hospital, St. Louis, 
 says: ' For so ;j3e years we have used it in a variety of derangements 
 characterized by debility, as also in chronic gastric ailments. It is ap- 
 proved of, unanimously, by the medical staff of this Hospital." 
 
 Dr. G. W. Whitney, Marshall, Minn., says: "I have used it in 
 debility of the nervous system, and deranged condition of all the secre- 
 tory organs. I esteem it highly." 
 
 Send for descriptive circular. Physicians who wish to test it will be 
 furnished a bottle on application, without expense, except express 
 charges. 
 
 Prepared under the direction of Prof. E. N. Horsford, by the 
 
 RUMFORD CHEMICAL WORKS, Providence, R. I. 
 
 Beware of Substitutes and Imitations. 
 
 CAUTION:— Be sure the word '' Sors ford's " is Printed on, the label. 
 All others are spurious. Never sold in bulk. 
 
Practical Notes 
 
 Urinary Analysis 
 
 — BY — 
 
 WILLIAM B. CANFIELD, A.M, M.D., 
 
 Chief of Chest Clinic, and Lecturer on Clinical Medicine, Uni- 
 versity of Maryland; Visiting Physician to the Union Pro- 
 testant Infirmary, Bay Vietv Hospital, Baltimore, etc. 
 
 iysj~)y 
 
 1S91. 
 GEORGE S. DAVIS. 
 
 DKTROIT, MICH. 
 
 N- 
 
rr 
 
 Copyrighted by 
 GEORGE S. DAVIS. 
 
 1891. 
 
 ^t> 
 
TABLE OF CONTENTS. 
 
 Preface v, 
 
 CHAPTER I. Page. 
 
 General Characteristics of the Urine, i. — Quantity. 2. 
 — Color. 3. — Smell. 4. — Transparency. 5. — Reac- 
 tion. 6. — Specific Gravity i 
 
 CHAPTER H. 
 
 Normal Constituents of the Urine, A. — Organic: i. — 
 Urea. 2. — Uric Acid. 3. — Oxalic Acid. 4. — Indi- 
 can. B — Inorganic Constituents of the Urine: i. — 
 Chlorides. 2. — Phosphates 13 
 
 CHAPTER HI. 
 
 Abnormal Constituents of the Urine, i. — Albumen. 
 2. — Sugar. 3. — Blood. 4. — Pus. 5. — Bile 30 
 
 CHAPTER IV. 
 
 Sediment, i. — Mucous and Pus Cells. 2. — Blood Cor- 
 puscles. 3. — Epithelium. 4. — Casts. 5. — Sperma- 
 tozoa. 6. — Bacteria. 7. — Papilloma Cells. 8. — Par- 
 asites. Unorganized Sediment 61 
 
 CHAPTER V. 
 
 The Urine in Disease. Fever. — Acute Nephritis. — Chronic 
 Nephritis. — Contracted Kidney. — Amyloid Kidney. — 
 Diabetes Mellitus. — Diabetes Insipidus. — Uraemia. — 
 Cystitis . — Calculi 83 
 
 CHAPTER VI. 
 Reagents and Apparatus 86 
 
 CHAPTER VII. 
 
 Order of Analysis 88 
 
 Index gi 
 
LIST OF ILLUSTRATIONS. 
 
 Vogel's Color Scale Frontispiece. 
 
 Urinometer 8 
 
 Crystals of Nitrate of Urea 14 
 
 Lyon's Ureometer 17 
 
 Nitric Acid Test for Albumen 33 
 
 Colored and Colored Blood Corpuscles 55 
 
 Crenated Red Blood Corpuscles in Urine 56 
 
 Epithelium 71 
 
 Hyaline Casts 73 
 
 Waxy Casts 74 
 
 Blood Casts 75 
 
 Hyaline and Granular Casts 76 
 
 Epithelial Casts and Compound Granular Cells 77 
 
 Oil Casts and Fatty Epithelium 78 
 
 Urinary Sediment 
 
PREFACE. 
 
 The importance of a knowledge of urinary analysis 
 need not be pointed out here. It is generally admitted that 
 in every case of doubtful diagnosis the urine should be ex- 
 amined. The science, (if it may be so called), of urinary 
 analysis has been, however, carried to such a refinement, 
 that an expert chemist alone is able to master it in all its 
 detail. The busy practitioner has no time to search through 
 manuals and make elaborate tests. In the light of many 
 advances made in this department several old tests have 
 shown themselves trustworthy and many new ones have 
 been added. 
 
 The object of these notes will be, after reviewing the 
 general character of the urine, to endeavor to show the 
 tried and reliable tests for detecting normal and abnormal 
 substances in the urine, and at the same time to try to 
 point out the little errors that may creep in in such an 
 undertaking, and to guard against certain mistakes by 
 clearly stating the important and carefully avoiding the 
 superfluous. Besides drawing largely from his own experi- 
 ence, the writer has unhesitatingly made use of the litera- 
 ture on the subject. 
 
 W. B. C. 
 loio North Charles Street, Baltimore. 
 
Table of Colors of the trine 
 
 Pale Yellow. 
 
 5, Yei lowish Red, 
 
 9. Brownish Black 
 
PMOTIOAL NOTES ON URINARY 
 ANALYSIS. 
 
 CHAPTER I. 
 
 GENERAL CHARACTER OF THE URINE. 
 
 I.— QUANTITY. 
 
 The amount of urine passed daily by a healthy 
 man is from 40 to 60 fluidounces (1500 to 2000 c. c), 
 and by a healthy woman 30 to 40 fluidounces (1000 
 to 1500 c. c). This, however, is subject to great 
 variations in health depending upon different circum- 
 stances, to be stated below, so that any amount under 
 15 fluidounces (500 c. c.) or over 90 fluidounces 
 (3000 c. c), may be considered pathological. 
 
 In order to measure the exact amount of urine 
 passed in 24 hours, the bladder is emptied at a fixed 
 hour (say 8 a. m.), and all the urine passed up to 
 8 A. M. the next day collected in one vessel and 
 measured. Although most writers advocate saving 
 one day's urine for testing, it is only in hospital and 
 exceptional private cases that such a procedure is 
 practicable; for aside from the fact that it is not easy 
 to get the patient or attendants to save so much urine, 
 the decomposition and fermentation of that passed in 
 the first part of the 24 hours, especially in_ warm 
 
weather, would so contaminate the rest, that the 
 results would be vitiated. Hence, in practice (except 
 in certain cases of diabetes, nephritis, etc., where the 
 the amount is extremely large or small), we generally 
 satisfy ourselves with a single specimen from each 
 day, and preferably the urine passed on rising, as 
 that is less apt to be affected by food or drink, and is 
 what has been called the "blood urine." Occasion- 
 ally it is well to secure specimens of urine passed in 
 the forenoon and afternoon as well as at night. The 
 most urine is passed in the afternoon, and the least at 
 night. 
 
 The amount of urine may be temporarily increased 
 in health: 
 
 a. By drinking large quantities of liquid, 
 
 b. By diminished skin activity, as in cold or 
 damp weather. 
 
 c. By taking diuretics. 
 
 This amount may be diminished: 
 
 a. By drinking little liquid. 
 
 b. By rest. 
 
 c. By profuse perspiration. 
 Pathologically the amount is increased: 
 
 a. In diabetes mellitus and insipidus. 
 
 b. In granular atrophy of the kidney. 
 
 c. In pyelitis. 
 
 d. By the absorption of dropsical fluids from 
 the body. 
 
 e. In convalescence from acute diseases. 
 
Pathologically the amount is diminished: 
 
 a. In fever. 
 
 b. In the acute and chronic forms of parenchy- 
 matous nephritis. 
 
 c. In cholera or other diarrhtDeal diseases. 
 
 d. In the formation of dropsical fluids. 
 
 e. In those heart troubles where the blood- 
 pressure is diminished. 
 
 In life-insurance examinations, it is important 
 that the urine be passed in the presence of the medi- 
 cal examiner. 
 
 2. COLOR. 
 
 Normal urine may vary in color from a pale yel- 
 low to a brownish black according to its concentra- 
 tion, depending in part on the action of the skin and 
 the amount of fluid taken. 
 
 The color of the urine, which depends on the 
 presence of urobilin and other substances, should be 
 noted at the bedside. It gets darker on standing. A 
 light clear urine [urina spastica) would show absence 
 of acute fever, and a possible presence of polyuria; 
 while a dark-colored urine would denote not only a 
 fever, but might signify a variety of affections of the 
 spleen or liver, a hearty meal, active exercise, etc. 
 Reddish or reddish-brown or smoky urine would point 
 to blood, black urine to the presence of the pigment 
 of melanotic cancer (melanuria). Green or brownish- 
 green urine would indicate bile. 
 
— 4 — 
 
 To avoid the confusion of describing the color, 
 Vogel's scale of colors is usually referred to. Flint 
 used to paste gummed, colored paper slips on the 
 record to show the color of the urine. 
 
 Different drugs have a decided effect on the color 
 of the urine; for example, rhubarb (chrysophanic 
 acid), senna, and santonin, make it intensely yellow, 
 or a greenish or brownish yellow. Further, logwood, 
 strong coffee, turpentine, carbolic acid, tar, creasote, 
 folia uvse ursi, gallic acid, tannic acid, indican, kairin, 
 and fuchsin, all color the urine. It is not probable 
 that the presence of albumen can be suspected by the 
 color. 
 
 3. SMELL. 
 
 The smell of normal urine is slightly aromatic. 
 When concentrated it is strong, when ammoniacally 
 decomposed it is stronger and even putrescent. In 
 certain forms of dyspepsia and liver trouble the urine 
 has a pathognomonic odor. Mineral acids interfere 
 with the normal odor; fixed alkalies make it aromatic. 
 Urine containing blood has a slightly putrid odor re- 
 sembling that of high game. It is affected by certain 
 drugs. Turpentine gives it the odor of violets. The 
 odor of cubebs, copaiba, sandal-wood, castoreum, val- 
 erian, is imparted to urine after administration by the 
 mouth. Also, after eating certain vegetables, such as 
 garlic, asparagus, cauliflower, etc., the urine has a 
 peculiar smell. In diabetes mellitus it may have a 
 sweet smell, due to the acetone. 
 
— 5 — 
 
 4. TRANSPARENCY AND CONSISTENCY. 
 
 Normal urine is always clear when first passed, 
 and shows, on standing, a slight cloudiness (nubecula) 
 more noticeable in the urine of women. Microscopi- 
 cally a few epithelial and other cells are always pres- 
 ent, and in the case of females, vaginal epithelium. 
 Pathologically the presence of the earthy phosphates 
 of lime and magnesium, of the urates, pus, mucus, 
 blood, etc., causes cloudy nrine. The bacteria of 
 decomposition also render it turbid. Normally 
 urine is aqueous. Pathologically the presence of 
 mucds or pus (from gonorrhoea, cystitis, etc.) may 
 cause it to be viscid; and also chyle in the urine 
 (chyluria), as observed in the tropics, gives it a turbid 
 and thick appearance. The foam which normally so 
 quickly disappears from urine, may remain in the 
 presence of sugar, albumen, or blood. 
 
 It is well to bear in mind that because a speci- 
 men of urine is clear and transparent, it is not neces- 
 sarily normal. 
 
 5. REACTION. 
 
 The reaction of normal urine is generally acid. 
 The cause of this is not certain although it is very 
 likely due to the presence of the acid phosphate of 
 sodium (N^H^PO^^) and other salts. The reaction 
 is tested by means of litmus paper. It is slightly acid 
 when first passed, becomes more acid on standing and 
 then becomes alkaline. 
 
— 6 — 
 
 Acid urine turns blue litmus paper red and alka- 
 line urine turns red litmus paper blue. Normally the 
 urine may be alkaline immediately after meals. The 
 acidity is greater: 
 
 a. In concentrated urine after perspiration. 
 
 b. After fasting. 
 
 c. After eating much animal food. 
 
 d. After exercise. 
 
 e. In fever. 
 
 /. In rheumatism and gout. 
 
 g. After taking benzoin and the mineral acids. 
 
 The urine is only faintly acid or even alkaline: 
 
 a. Just after meals, from a vegetable diet. 
 
 b. When very dilute. 
 
 c. After taking certain mineral waters and other 
 alkalies. 
 
 d. After repeated vomiting. 
 Pathologically the urine is alkaline in cystitis and 
 
 by decomposition after it has left the bladder. 
 
 The alkalinity may be due to a fixed (potassium 
 or sodium) or a volatile (ammonia) alkali. In the 
 former case the litmus paper made blue by the alkali 
 remains blue on drying; in the latter case the blue 
 fades away. 
 
 The alkalinity from fixed alkalies causes the pre- 
 cipitation of the earthy phosphates rendering the 
 urine a white, turbid color. Ammoniacal alkalescence 
 brings about the formation of triple phosphates. Yel- 
 low turmeric paper is turned brown by alkaline urine, 
 
— 7 — 
 but it has no special advantage over the Htmus paper 
 except to test urine which it is desirable to keep alka- 
 line. In typhoid fever the acidity of the urine is in 
 direct ratio to the fever; in rheumatism, with the 
 pain; while in pneumonia, pleurisy, emphysema, etc., 
 the urine is very acid. The urine may be alkaline 
 from fever, nervous affections, anaemia, debility and 
 in affections of the genito-urinary apparatus, brain, 
 spinal cord, etc. 
 
 6. SPECIFIC GRAVITY. 
 
 In taking the specific gravity of urine the pro- 
 portion between its watery and solid constituents is 
 measured. Like the color, this depends on the skin 
 action and on the amount of fluid taken, etc. The 
 specific gravitjT^ is measured by means of a urino- 
 meter, which consists of a glass tube loaded at its 
 lower end with mercury and with a bulb blown in the 
 middle. The stem, the external diameter of which is 
 as regular as possible, is hollow and the scale is 
 marked upon it. A urinometer when immersed in 
 pure distilled water at a temperature of 60° F. should 
 register at 1000. As the ordinary urinometer is not 
 sufficiently accurate, it should be tested carefully 
 once before using. The specific gravity of urine thus 
 measured is normally between 1015 and 1021 for 40 
 to 50 ounces per day, and pathologically may vary 
 from 1002 to 1040 and even more. These extremes 
 occur at times without any pathological change. 
 
8 — 
 
 Fig. I. — Urinometer. 
 
— 9 — 
 
 Normally the specific gravity is in inverse proportion 
 to the amount passed in twenty-four hours. 
 
 In order to take the specific gravity of a given 
 specimen of urine, a large test tube or cylinder should 
 be about three-fourths filled with urine and after the 
 bubbles have disappeared or have been removed by 
 bibulous paper, and the urine cooled off to the sur- 
 rounding temperature, the dry urinometer should be 
 gently dipped into the urine and allowed to float with- 
 out touching the sides of the vessel, and after all mo- 
 tion has ceased the figures may be read off from the 
 stem of the urinometer. In taking the specific grav- 
 ity, the total amount passed in 24 hours should be 
 known, when possible. 
 
 As the ordinary urinometer is too fragile an in- 
 strument to be carried safely, in place of it Parke, 
 Davis & Co. of Detroit, Mich., make a set of specific 
 gravity beads, marked respectively 5, 10, 15, 20, 25 
 and 30, the figures being the last two of the specific 
 gravities, water being 1000. 
 
 The beads, arranged in regular succession, the 
 heaviest at the bottom, are contained in a small tube 
 having a hole in the bottom. This constitutes an im- 
 proved form of urinometer, sufficiently accurate for 
 ordinary clinical observations. To use it, fill the 
 larger tube nearly full of the urine, and plunge 
 slowly into this the tube containing the beads. As 
 the fluid enters the tube, some of the beads will float, 
 while the remainder will remain at the bottom. If 
 
lO 
 
 three beads float, we know that the specific gravity of 
 the fluid is between 1015 and 1020. 
 
 To ascertain the specific gravity more exactly, 
 add water, drop by drop, to the urine, testing it re- 
 peatedly with the urinometer until two only of the 
 beads are floated, the third being in a state of indif- 
 ferent equilibrium. If two fluidrachms of urine were 
 taken to begin with, and 20 minims of water were re- 
 quired to bring the third bead to the point of sinking, 
 then 120: i2o-|-i2o:: 15: X. The value of X is found 
 to be 17.5, and the specific gravity of the urine is 
 therefore 10175. 
 
 Rule. — Multiply the figure on the bead which is 
 made to sink by the total amount of fluid, water and 
 urine, and divide the product by the amount of urine; 
 the quotient wili be the figures in (second and) third 
 decimal places of the specific gravity. 
 
 The temperature of the urine must be about 60° 
 Fah. (15.6^0.) If higher than this, to obtair^ an 
 exact result, add to the figure obtained one unit for 
 every 8° F. (4.5°C.) in excess of the standard tem- 
 perature. 
 
 Ordinarily it is sufficient to observe how many of 
 the beads float; the exact specific gravity is of impor- 
 tance only when the whole amount of urine voided 
 during 24 hours is examined; for clinical purposes a 
 rough approximation is all that is generally necessary, 
 and this is all, moreover, that the ordinary urinometer 
 as commonly used affords. 
 
If all the beads float, dilute the urine with an 
 equal body of water, take the specific gravity of the 
 mixture, and multiply the fractional portion of the 
 figure obtained by two. 
 
 One great advantage of these specific gravity 
 beads, is that the specific gravity can be taken with as 
 little as two drachms of urine, and we know that it is 
 frequently impossible to get the two or three ounces 
 necessary to tioat the ordinary urinometer, not to 
 speak of the inconvenience of carrying about several 
 large specimens of urine. 
 
 The specific gravity is not affected by the pres- 
 ence of albumen, as it is by sugar. If the last two 
 figures of the specific gravity be multiplied by 2 
 (2.33 to be more accurate), the amount or solids 
 per 1000 is given. Normally, when the amount of 
 urine is temporarily increased in health, the specific 
 gravity is less, and vice versa. Pathologically, the 
 specific gravity is high and the amount of urine passed 
 low: 
 
 a. In acute febrile diseases. 
 
 b. In some forms of heart trouble. 
 
 In diabetes mellitus the specific gravity is gener- 
 ally high and the amount passed abundant and clear. 
 Exceptionally, cases of diabetes mellitus have been 
 reported with abundant urine and low specific grav- 
 ity. Generally a low specific gravity with abundant 
 secretion of urine is observed in many constitutional 
 afebrile diseases, such as 
 
a. Chlorosis. 
 
 b. Hysteria. 
 
 c. Contracted kidney. 
 
 d. Diabetes insipidus. 
 
 It is hardly safe to accept a candidate for life 
 insurance if the specific gravity be below loio. 
 
 The morning urine has a greater specific gravity 
 than that passed later in the day. If the specific 
 gravity be very high, the urine may be diluted with 
 one-half the volume of water and the addition allowed 
 for. For the connection between the specific gravity 
 and the amount of urea present, the reader is referred 
 to another section. 
 
CHAPTER II. 
 
 NORMAL CONSTITUENTS OF THE URINE, 
 
 A. ORGANIC. — I. UREA. 
 
 Urea forms the most important product of de- 
 composition of the albuminous bodies, and the 
 amount excreted is dependent upon the amount of 
 albumen in the food. Adults produce about 20 to 40 
 grammes (300 to 600 grains) of urea a day and child- 
 ren proportionately more. Urea is eliminated as a 
 nitrogenous compound. 
 
 As about one-half of the solid constituents of the 
 urine consist of urea, we may most readily determine 
 approximate variations in the amount of the latter by 
 means of the specific gravity. There are many tests 
 quantitative and qualitative for the detection of the 
 presence of urea in human urine, but the most con- 
 venient is the microscopic test. A drop of urine is 
 put on a glass slide and a drop of nitric acid added, 
 and the whole gently heated over the lamp and 
 allowed to cool. The hexagonal and quadrilateral 
 plates of the nitrate of urea, both single and in strata, 
 will be formed. They overlap each other like 
 shingles on a roof. In doubtful diagnosis between a 
 hydronephrosis and an ovarian cyst, the presence of 
 the crystals of the nitrate of urea in the former case, 
 and their absence in the fluid of an ovarian cyst, would 
 
— 14 — 
 
 be almost decisive. If the urine be free from sugar 
 and albumen, and contain the normal amount of the 
 chlorides, and its specific gravity be 1020-1024, then 
 it should contain normally 2 to 2.5 per cent, of 
 urea. If the specific gravity be 10 14 then i per cent, 
 of urea. If the specific gravity be 1030 then 3 per 
 cent, of urea. 
 
 Fig. 2. — Crystals of Nitrate of Urea. 
 
 As it is by far the most abundant solid constitu- 
 ent of the urine, the specific gravity of the urine may 
 become a means of estimating approximately the 
 amount of urea present, under the conditions named. 
 
 The amount of urea is increased^ 
 
 a. In an exclusively animal diet. 
 
 b. In an increased breaking up of the body 
 albumen; as in diabetes mellitus, in fevers before 
 the crisis, in posphorus poisoning, in dyspnoea. 
 
— 15 — 
 
 The amount of urea is di?ninished, 
 
 a. In a non-nitrogenous diet and in inanition. 
 
 b. In ursemia. 
 
 d. In acute yellow atrophy of the liver. 
 
 d. In chronic diseases. 
 
 There are many methods of estimating the 
 amount of urea in the urine, and their principle de- 
 pends on a decomposition of the urine by means of 
 chlorinated soda, into nitrogen and carbon dioxide, 
 and measuring either the volume of the gas evolved 
 or the specific gravity lost by the decomposition. As 
 it is often important to know the amount of urea 
 present, particularly in gout and rheumatism, and in 
 the pre-albuminuric stage of chronic nephritis, vari- 
 ous means have been suggested to measure the urea. 
 All are complicated. Probably Lyon's apparatus, as 
 made by Parke, Davis & Co., of Detroit, affords the 
 most simple means of estimating the amount of urea 
 present in a given specimen of urine. 
 
 The amount of urea excreted by a patient in a 
 given time furnishes the physician information of the 
 greatest importance as bearing upon diagnosis, prog- 
 nosis, and treatment. It is in general an mdex of the 
 manner in which the various physiological functions 
 of the organism are performed, and, in particular, in 
 certain kidney diseases, .it enables the physician to 
 foresee and guard against danger. 
 
 Medical men have, however, been deterred from 
 attempting estimations of urea from the expensive- 
 
— i6 — 
 
 ness of the apparatus required, and still more from 
 want of confidence in their ability to make any intelli- 
 gent use of the apparatus if they were to purchase it. 
 This new ureometer is an apparatus which does not 
 require the skillful manipulations of a chemist to ob- 
 tain with it results which for practical purposes may 
 be considered exact. 
 
 No new principle is involved in this ureometer. 
 The urea is decomposed as usual by the action of an 
 alkaline solution of chlorine or bromine, and de- 
 termined by the volume of gas (nitrogen) generated 
 in the reaction. The original features in the appa- 
 ratus are (a) the form of the receiver in which the 
 gas is collected and measured, and (b) the gradua- 
 tion of this receiver in such a way that the results are 
 read off directly in percentages of urea. 
 
 The apparatus, as illustrated in the cut, consists of: 
 
 1. A bottle, provided with perforated rubber 
 cork and delivery tube; in this the decomposition of 
 the urea is affected. 
 
 2. A small test tube to contain the urine, grad- 
 uated to hold 4 c. c, the quantity employed in each 
 experiment. 
 
 3. A graduated jar for measuring the gas 
 evolved. This jar is provided at the bottom with an 
 " overflow " tube, and at the top with a vent tube 
 closed with a rubber cap, to secure accurate adjust- 
 ment of the level of the fluid in the jar at the com- 
 mencement of the experiment. 
 
— 17 — 
 
 The process is as follows: Put into the bottle 20 
 c. c. of a solution of sodium hypobromite (formula 
 given below); fill the test tube exactly to the mark (4 
 c. c.) with the urine to be examined, and lower it 
 into the bottle by means of a thread, or by the aid of 
 a pair of dressing-forceps, taking care that none of its 
 contents are spilled in the operation. Fill the gradu- 
 ated jar with water (which must be of the same tem- 
 perature as the air of the room) to a point a little 
 
 Fig. 3. — Lyon's Ureometer. 
 
 above the 0° of the scale, supporting the extremity of 
 the overflow tube so that no water can escape. Re- 
 move the rubber cap from the vent-tube, and connect 
 the apparatus, pressing in the rubber corks firmly so 
 as to make the joints air-tight. Finally put on the 
 rubber cap, drawing it down so as to force a little 
 water out of the overflow tube, and bring the level of 
 the water remaining exactly to the 0° mark, the ori- 
 
— I« — 
 
 fice of the overflow tube being on the same level. A 
 little practice will make this easy. 
 
 To make sure that the connections are all per- 
 fectly air-tight, lower the end of the overflow tube a 
 few inches; a few drops of water will escape from 
 diminished pressure, but if the joints are perfect there 
 will be no further dropping. If there is any leakage 
 the defective joint must be found and the difficulty 
 corrected before proceeding further with the experi- 
 ment. Having made sure that the connections are 
 perfect, catch the curved end of the overflow tube 
 over the edge of a measuring graduate, as shown in 
 the illustration (an ordinary bottle or any other re- 
 ceiver may be used in place of the graduate). Now, 
 by canting the bottle, cause the urine to flow out of 
 the test tube and mix with the hypobromite solution. 
 Effervescence is at once produced, and the gas 
 evolved forces a corresponding volume of water out 
 of the overflow tube. Shake the bottle occasionally 
 to promote the escape of the gas. When the action 
 appears to be at an end, pour into the measuring 
 graduate water enough to reach above the opening of 
 the overflow tube, in order that cooling of the gas 
 evolved, which is at first quite warm, may not draw 
 air into the apparatus. Let the apparatus stand fifteen 
 or twenty minutes to cool, then shake the bottle con- 
 taining the urine once more, and proceed to read off 
 the result. To do this, it is necessary to bring the 
 opening at the end of the overflow tube just to the 
 
— 19 — 
 
 same level as that of the fluid remaining in the gradu- 
 ated cylinder, since raising or lowering the tube 
 slightly affects the volume of the gas to be measured. 
 The percentage of urea is read off without need of 
 any calculation from the scale of the instrument. An 
 accompanying table will enable the physician to ascer- 
 tain from the percentage amount of urea in the speci- 
 men examined, what is the absolute amount of that 
 compound excreted during the day, provided, of 
 course, the whole of the urine passed during the 
 twenty-four hours has been collected together and 
 carefully measured. 
 
 For exact estimations, the temperature of the 
 room in which the experiment is made must be about 
 70° F. (21° C). A variation from this temperature of 
 20° will, however, make a difference in the result of 
 only about o.i per cent., so that the temperature cor- 
 rection may be regarded as unimportant. 
 
 The solution of sodium hypobromite is made by 
 dissolving 10 parts of caustic soda in 45 parts of 
 water, allowing this solution to stand until impurities 
 have subsided, and pouring off for use the clear por- 
 tion, which must be kept in well-stopped bottles. 
 When an estimation is to be made, mix with 20 c. c. 
 (5 fluidrachms) of this solution of soda, i c. c. (15 
 minims) of bromine, and allow the mixture to cool to 
 the temperature of the air. 
 
 In place of the hypobromite solution prepared in 
 this manner, the physician will find it convenient to 
 
TABLES TO FACILITATE CALCULATIONS 
 
 UREOMETER. 
 
 IN THE USE OF THE 
 
 Table I. 
 
 Per cent, of Quantity of urea 
 
 urea by in grains 
 
 ureometer. in i fluidounce. 
 
 O.I 4^6 
 
 0.2 911 
 
 0.3 1-367 
 
 0.4 .1-823 
 
 0.5 2 279 
 
 0.6 2.734 
 
 0.7 3-190 
 
 0.8. 3-646 . 
 
 0.9 4.101 
 
 i-o 4 557 
 
 I.I 5-013 
 
 12 5-468 
 
 1-3 5-924 
 
 1.4 6.3S0 
 
 1.5 6.836 
 
 1.6 7.291 
 
 1-7 7-747 
 
 1.8 8.203 
 
 1.9 8.658 
 
 2.0 9-II4 
 
 2.1 9-570 
 
 2.2 10.025 
 
 2.3 10.481 
 
 2.4 10.937 
 
 25 ri 393 
 
 2.6 11.848 
 
 2.7 12.304 
 
 28 12.760 
 
 2.9 13215 
 
 3-0 z3 671 
 
 3 1 14-127 
 
 3-2 14582 
 
 3-3 15038 
 
 3-4 15-494 
 
 3-5 16.950 
 
 To ascertain the quantity of urea 
 excreted by a patient in 24 hours, col- 
 lect the whole of the urine for the 24 
 hours, mix and measure it; then esti- 
 mate with the ureometer the percent- 
 age of urea it contain. Take out from 
 Table I. the quantity of urea per fluid- 
 ounce corresponding to this percent- 
 age, and multiply this by the number 
 of fluidounces of urine excreted. 
 
 Example. — The patient has passed 
 24 fluidounces of urine, found to con- 
 tain 24 per cent, of urea. The total 
 urea excreted will therefore be 10.937 
 (from the table) X 24=262 488 grains. 
 The quantity of urea normally excreted 
 varies greatly with the diet, averaging 
 about three grains per pound of body- 
 weight in healthy adults on a mixed 
 diet. 
 
 By Table II. an approximate figure 
 can be readily found. 
 
21 
 
 Table II. 
 
 Per 
 cent. 
 
 by 
 ureo- 
 meter. 
 
 10 
 
 fl. oz. 
 urine 
 contain 
 g^rains 
 urea. 
 
 ' 15 
 : fl. oz. 
 1 urine 
 contain 
 grains 
 urea. 
 
 20 
 
 fl. oz. 
 
 urine 
 contain 
 grains 
 
 urea. 
 
 2; 
 fl. oz. 
 urine 
 contain 
 grains 
 urea. 
 
 30 
 fl. oz. 
 urine 
 contain 
 grains 
 urea. 
 
 '.35 
 1 fl. oz. 
 1 urine 
 contain 
 [ grains 
 { urea. 
 
 . 40 
 fl. oz. 
 urine 
 contain 
 grains 
 urea. 
 
 ^ 45 
 fl. oz. 
 urine 
 contain 
 grains 
 urea. 
 
 50 55 
 fl. oz. fl. oz. 
 urine urine 
 contain contain 
 grains grains 
 urea. urea. 
 
 60 
 fl. oz. 
 
 urine 
 contain 
 grains 
 
 urea. 
 
 X 
 
 II. 4 
 
 17. 1 
 
 22.8 
 
 28. 5 
 
 34.2 
 
 39-9 
 
 45.6 
 
 |..3 
 
 57 
 
 . 63. 
 
 68 
 
 
 K 
 
 22.8 
 
 i 34-2 
 
 45.6 
 
 57-0 
 
 68.4 
 
 79 7 
 
 91 I 
 
 102.5 
 
 114 
 
 . 125. 
 
 137 
 
 
 Ya 
 
 34-2 
 
 51-3 
 
 68.4 
 
 85-4 
 
 102.5 
 
 119. 6 
 
 136.7 
 
 153.8 
 
 171 
 
 . 188. 
 
 205 
 
 
 12 
 
 45-6 
 
 68.4 
 
 91. 1 
 
 II3-9 
 
 136.7 
 
 159-5 
 
 182.3 
 
 205.1 
 
 228 
 
 - 251. 
 
 273 
 
 
 IX 
 
 57-0 
 
 85-4 
 
 II3-9 
 
 142.4 
 
 170.9 
 
 199.4 
 
 227.9 
 
 256.3 
 
 285 
 
 - 313- 
 
 342 
 
 
 IK 
 
 68.4 
 
 102.5 
 
 ■ 
 
 136.7 
 
 170.9 
 
 205.1 
 
 239-2 
 
 273-4 
 
 307-6 
 
 342 
 
 376. 
 
 410 
 
 
 ^Ya 
 
 79-7 
 
 119. 6 
 
 159-5 
 
 199.4 
 
 239-2 
 
 279.1 
 
 319.0 
 
 358.9 
 
 399 
 
 439- 
 
 478 
 
 
 2 
 
 91. 1 
 
 136.7 
 
 182.3 
 
 227.9 
 
 273-4 
 
 319.0 
 
 364-6 
 
 410. I 
 
 456 
 
 501. 
 
 547 
 
 
 23^ 
 
 I02.5 
 
 153-8 
 
 205.1 
 
 256.3 
 
 307-6 
 
 358.9 
 
 410. 1 
 
 461.4 
 
 513 
 
 564. 
 
 615 
 
 
 2|^ 
 
 II3-9 
 
 170.9 
 
 227.9 
 
 284.8 
 
 341-8 
 
 398.7 
 
 455.7 
 
 512.7 
 
 570 
 
 627. 
 
 684 
 
 
 ^Ya 
 
 125-3 
 
 188.0 
 
 250.6 
 
 313-3 
 
 376-0 
 
 438.6 
 
 501.3 
 
 563.9 i 
 
 627. 
 
 689. 
 
 752. 
 
 
 3 
 
 136.7 
 
 205.1 
 
 273-4 
 
 341.8 
 
 410. 1 
 
 47S.5 
 
 546.8 
 
 615 2 
 
 684. 
 
 752. 
 
 820. 
 
 
 3^ 
 
 I4«.i 
 
 222.2 
 
 296.2 
 
 370.3 
 
 444-3 
 
 518.4 
 
 592-4 
 
 666.5 
 
 741. 
 
 815. 
 
 S89. 
 
 
 3K 
 
 159-5 
 
 239-2 
 
 319.0 
 
 398.7 
 
 478.5 
 
 558.1 
 
 638.0 
 
 717-7 
 
 797. 
 
 877. 
 
 957- 
 
 
 Example —Patient has passed 42 fl. oz. of urine, shown by ureometer to contain 2.6 per cent. 
 urea. By the table we find that 45 fl. oz. containing 2^ per cent, urea would contain ^12.7 grains 
 nrea, and this figure is near enough to the truth for all practical purposes for the ph^'sician. By 
 lable I. the exact figure is found to be 497.6 grains. 
 
22 
 
 use the U. S. P. solution of chlorinated soda, which 
 can be kept for a considerable length of time, and can 
 be obtained, freshly prepared, from time to time, of 
 any competent druggist. Keep also on hand a solu- 
 tion of potassium bromide, 90 grains to the fluidounce. 
 Of this solution place in the ureometer 5 c.c. (75 min- 
 ims), then 25 c.c. (14 fiuidrachms) of the solution of 
 chlorinated soda. The mixture gives more uniform 
 and trustworthy results than those obtained with the 
 chlorinated soda alone, which is recommended by Dr. 
 Squibb. It is in fact identical in its action with the 
 hypobromite solution, without the great inconvenience 
 of handling bromine. A few minutes must be allowed 
 to elapse after the mixture is made before mixing the 
 urine with it, but this need occasion no delay, since 
 the mixture can be put into the bottle before filling 
 the cylinder and making the connections. 
 
 The activity of the solution of chlorinated soda 
 can be easily tested by adding to a little of it in a test 
 tube a few drops of the solution of potassium bro- 
 mide, and then a little muriate of ammonia, which 
 should cause brisk effervescence. If this is not the 
 case, it is too much deteriorated for use. 
 
 In some rare instances it will happen that the 
 urine contains a larger proportion of urea than the 
 ureometer is capable of indicating. When this is the 
 case, and in general when the specific gravity of the 
 urine exceeds 1030 sugar being absent, it will be best 
 to dilute the urine with an equal volume of water be- 
 
fore making the test. Four c.c. of the diluted urine 
 will then be used as usual in the experiment, but the 
 percentage given by the reading of the instrument 
 must be multiplied by two. 
 
 It will be found in practice that an estimation of 
 urea by this apparatus consumes very little time, and 
 results for all practical purposes are as accurate as 
 could be wished. 
 
 2. URIC ACID. 
 
 Uric acid is in the urine almost always combined 
 with potassium, ammonia, calcium, magnesium, sodium, 
 in the form of the urates. 
 
 These being bibasic salts, we have the neutral and 
 the acid salts. The neutral urates are soluble in 
 water and rarely met with when the acid urates are 
 precipitated and crystallized. Uric acid and the 
 urates appear in the form of rhombic plates, whet- 
 stones, barrel, envelop, spear, fan, comb, dumb-bell, 
 etc. They are generally colored reddish. Sodium 
 and potassium urate or brick dust sediment is easily 
 soluble in warm water and with difficulty soluble in 
 the cold. It disappears on heating; it adheres to the 
 pot or glass and is more often seen in cold weather, in 
 concentrated urine and when the urine is strongly 
 acid. 
 
 Uric acid and the urates are increased. 
 
 a. In rich animal food with little exercise. 
 
 b. In fevers. 
 
— 24 — 
 
 c. In leucaemia with enlarged spleen and in per- 
 nicious anaemia. 
 
 d. In the so-called uric acid diathesis. 
 
 e. In all diseases of the heart and lungs and in 
 fact in all conditions (abdominal tumors, liver trouble, 
 etc.) where the function of the diaphragm is interfered 
 with. 
 
 Uric acid and the urates are dimi7iished. 
 
 a. In chronic diseases. 
 
 b. During an attack of gout. 
 
 The microscopical tests are the most convenient, 
 but require skill. When the red granulated crystals 
 on the bottom and side of the vessel disappear on 
 heating and appear in the cold and disappear on ad- 
 ding caustic potash or soda solution we may presume 
 they are the urates. 
 
 Uric acid may be detected by the 7?iurextd test by 
 mixing a small portion of the sediment supposed to 
 be uric acid with a few drops of nitric acid and then 
 evaporating on a porcelain or platinum plate over a 
 moderate heat to dryness. If uric acid be present, 
 the addition of a drop of ammonia water will cause a 
 beautiful purple-red color of murexid to appear. 
 
 By pouring nitric acid upon urine highly charged 
 with urates, a ring much like the ring of albumen in 
 Heller's test, is seen. It disappears on standing or 
 heating, which albumen does not do. The urates 
 show themselves by high temperature, strong concen- 
 tration and marked acidity of urine 
 
— 25 — 
 
 3- OXALIC ACID. 
 
 The presence of the oxalate of lime crystals as 
 envelop-shaped and dumb-bell crystals is scarcely of 
 practical importance. They are present in large 
 numbers in so-called oxaluria, and in some calculi. 
 As a slight diminution in the acid phosphate of 
 sodium in the urine causes a precipitate of oxalate of 
 lime crystals'their presence can be of little diagnostic 
 importance. 
 
 The ingestion of rhubarb often causes the oxal- 
 ate of lime crystals to appear in the urine. They are 
 seen as dumb-bell crystals, and may be the principal 
 ingredient of the mulberry calculi. They are present 
 principally. in imperfect oxidation or retarded meta- 
 bolism, and are found in mal-assimilation as in dys- 
 pepsia. 
 
 4. INDICAN. 
 
 A positive or negative result in testing for this 
 substance is of equal value in a urinary examination. 
 It was found that a certain substance, indol, was ab- 
 sorbed during digestion and converted in the blood 
 into indican, but during normal intestinal digestion 
 very little indol was produced while in faulty diges- 
 tion and allied troubles more was produced and 
 appeared in the urine. Thus indican is increased: 
 
 a. In all obstructive diseases of the bowel. 
 
 b. In pyelitis. 
 
— 26 — 
 
 c. In diseases of the spinal cord and nervous 
 system. 
 
 d. In urina spastica. 
 
 e. After eating. 
 /. After cholera. 
 
 g. In cancer of the liver. 
 
 h. In maUgnant tumors. 
 
 /. In Addison's disease. 
 
 j. In cancer of the stomach. 
 
 k. In acute peritonitis. 
 
 Indican is present in increased amount particu- 
 larly in typhoid fever and in cancer of the liver and 
 stomach. 
 
 The most convenient test is by Jaffe. Equal 
 quantities of clear urine and concentrated pure hy- 
 drochloric acid are mixed in a test tube, and then a 
 perfectly fresh concentrated solution of the calcic 
 hyphophosphite is added drop by drop until a blue 
 color is observed. If desired, afterward about a 
 drachm of chloroform may be added and the whole 
 shaken, by which the chloroform takes up the color 
 and shows its intensity. 
 
 B. INORGANIC CONSTITUENTS OF THE URINE. 
 
 I. CHLORIDES. 
 
 The chlorides are present in the healthy urine 
 principally as the chloride of sodium with traces of 
 the chlorides of potassium, ammonia, and calcium. 
 
— 27 — 
 
 The amount varies normally according to the amount 
 of common salt taken with the food. The most con- 
 venient test for detecting the presence of the chlor- 
 ides, is the chemical test with the nitrate of silver. If 
 to a given specimen of urine a few drops of nitric 
 acid are first added to keep the phosphates in solu- 
 tion, and then a solution of the nitrate of silver be 
 added, a white, and in healthy urine, thick flocculent 
 cloud of the insoluble chloride of silver will be pre- 
 cipitated, thus proving the presence of the chloride of 
 sodium in the urine thus: Na [Cl-j-Ag] NOg^Na 
 N03-fAgCl. 
 
 The absence of the chlorides in urine is regarded 
 as a very grave symptom, and in watching a case of 
 the acute febrile diseases, particularly of pneumonia, 
 it is important to test the urine daily or more often 
 with a nitrate of silver solution, and as the crisis ap- 
 proaches the chlorides will be seen to diminish, and 
 may even disappear for a few hours; and after the 
 crisis they begin to reappear. By taking the same 
 amount of urine daily and a silver nitrate solution of 
 known strength, the disease can be watched carefully 
 from day to day. 
 
 The chlorides are increased^ 
 
 a. When much salt is ingested. 
 
 b. After active bodily or mental exercise. 
 
 c. During a malarial chill. 
 
 d. In diabetes insipidus. 
 
 e. When dropsies are removed by diuresis. 
 
The chlorides are diminished^ 
 
 a. In rest. 
 
 b. In all acute febrile diseases (exactly the re- 
 verse of urea) e. g. in pneumonia when they may be 
 entirely absent at the crisis, a grave omen. 
 
 c. In some chronic diseases. 
 
 d. In renal diseases with albuminuria and ana- 
 sarca. 
 
 2. PHOSPHATES. 
 
 The phosphates consist of the alkaline and the 
 earthy phosphates. The former consist of combina- 
 tions of phosphoric acid with the bases sodium, potas- 
 sium, etc., are insoluble in water and are not precipi- 
 tated by alkalies, and need not be further considered. 
 The latter earthy phosphates consist of combinations 
 of phosphoric acid with calcium, magnesium, etc., and 
 are shown to be present in urine by adding any alkaU 
 which causes a white precipitate, which precipitate, 
 however, is colored by blood, bile, vegetable coloring 
 matter or any other such pathological constituent of 
 «the urine. The phosphates are increased in the urine 
 in all diseases of the bones such as rachitis, osteo- 
 malacia. There is, however, not necessarily an ex- 
 cess of phosphates in the urine simply because they 
 are precipitated, as the alkalinity of the urine or an ap- 
 plication of heat as in testing for albumen may cause 
 them to appear. 
 
 The triple phosphates when formed in the 
 bladder may give rise to concretions. The phos- 
 
— 29 — 
 
 phates may be precipitated by heat alone, and in this 
 case may be mistaken for albumen. The addition of 
 acid will decide. A knowledge of the amount of 
 phosphates present in the urine is of no diagnostic 
 importance, their condition is the important point. 
 When the phosphates are persistently thrown down, 
 there is reason to fear the formation of a stone. 
 When the purulent urine of cystitis undergoes bac- 
 terial fermentation, the alkalinity causes the precipi- 
 tation of the earthy phosphates. 
 
CHAPTER III. 
 
 ABNORMAL CONSTITUENTS OF THE URINE. 
 
 I. ALBUMEN. 
 
 Albumen is the most important abnormal con- 
 stituent of the urine. Without going into the theory 
 of urinary secretion and excretion it may be sufficient 
 to state that the most generally accepted view of 
 albuminuria is that of Hcidenhain which is founded 
 upon the supposition that w^henever the continuous 
 epithelial layer on the outside of the convoluted ves- 
 sels in the glomeruli is in a pathological condition the 
 albumen escapes in the urine. In general, albumen 
 is present in form of serum-albumin, but practically it 
 makes no difference in what form it appears. 
 
 It is not easy or practicable to distinguish be- 
 tween serum-albumin and serum- globulin. 
 
 Physiologically albumen may be found in the 
 urine of: 
 
 a. Infants before the urinary secretion has fairly 
 begun. 
 
 b. Weak and delicate children at the age of 
 puberty. 
 
 c. Adults after exertion, etc. 
 Pathologically it may occur from numberless 
 
 causes, but its presence is always to be considered as 
 of grave importance. It is hardly possible to state 
 
— Sl- 
 avery cause that may give rise to albuminuria. 
 Aside from the so-called accidental albuminuria, in 
 which the albumen does not come from the kidneys, 
 but from the ureters, bladder or urethra we have renal 
 or true albuiiiinuria: 
 
 a. In the febrile and infectious diseases. 
 
 b. In diseases of the heart and lungs. 
 
 c. In actual disease of the kidney. 
 
 The tests for the detection of albumen in the 
 urine are various and often complicated. There are 
 at least ten proteids or bodies which may be precip- 
 itated by the albumen tests, but practically it is not 
 necessary to make the fine distinction of separating 
 these bodies. When testing a specimen of urine for 
 another physician it is well to know something of the 
 patient's condition. 
 
 The following tests are the simplest and most easy 
 of execution and reliable. In all tests the urine should 
 be clear, and if not clear, filtered. 
 
 If the urine is too old to be cleared by filtering, 
 add acetic acid and lime water, shake the urine with 
 some magnesia, or add a few drops of a magnesia 
 sulphate solution and the carbonate of sodium and 
 shake. This precipitates the filtrate without affecting 
 the test. 
 
 HEAT AND NITRIC ACID TEST. 
 
 A test tube is filled two-thirds full with the 
 urine, and then a few drops of diluted acetic acid 
 added to hold the phosphates in solution. The tube 
 
— 32 — 
 
 should be held obliquely over the flame, and the 
 upper layer heated to the boiling point. If a cloudi- 
 ness appear which ten to twenty drops of strong 
 nitric acid do not dissolve, but increase, then albu- 
 men is present. In case a slight amount of albumen 
 only be present, the precipitate does not appear for a 
 few minutes. This test may be carried out by first 
 heating the urine, and if the precipitate which occurs 
 be redissolved by strong nitric acid no albumen is 
 present, but if the urine remains cloudy after the 
 addition of the acid, then albumen is present. As an 
 excess of strong nitric acid redissolves a small amount 
 of albumen, the acid should be added drop by drop, 
 and not more than twenty drops to the amount of 
 urine stated. Be careful not to add too much acid. 
 The test tube should be held against the coat-sleeve 
 or a dark background, and allowed to stand for five 
 minutes before a decision is made. 
 
 The nitric acid test is a very delicate one, and the 
 heat and nitric acid tests are the accepted ones by the 
 best American life insurance companies. In examin- 
 ing the urine for life insurance it is more common to 
 find disease in its incipiency if found at all, hence 
 great care should be taken in using any tests. 
 
 heller's test. 
 
 This is by far the most reliable and convenient 
 test offered. About two inches of clear urine are 
 poured into a test tube, which is held obliquely while 
 
— 33 — 
 strong nitric acid is poured down the side of the glass 
 and allowed to flow below the urine without being 
 mixed with it; or the acid may be poured in first, and 
 the urine carefully poured down the side of the tube 
 by rotating the pipette. In using Heller's test, to 
 bring the urine and acid in contact, draw up the urine 
 
 Fig. 4. — Nitric Acid Test for Albumen. 
 
 in a pipette, and then rotate the pipette so as to let 
 the urine out as slowly as possible. At the junction 
 of the two fluids the slightess trace of albumen will 
 cause a cloudy ring of albumen. Instead of a test 
 tube, a conical glass may be used. Of course the 
 result will be the same if the urine be carefully poured 
 
 3 TT 
 
— 34 — 
 upon the acid, or if the latter be passed through the 
 urine by means of a pipette. A well defined ring- 
 shaped cloudiness may also be caused by urea and 
 uric acid (in which case it is higher up), or by certain 
 resinous substances as in cubebs, copaiba, turpentine, 
 etc. (in which case the cloudiness is at once redissolved 
 by alcohol). 
 
 PICRIC ACID TEST. 
 
 A few drops of a saturated watery solution of 
 picric acid are added to clear urine, and if albumen 
 be added a slight cloudiness will show itself at once. 
 Any cloudiness which may appear later need not 
 necessarily be due to albumen. 
 
 TRICHLORACETIC ACID. 
 
 Raabe's trichloracetic test has been recently 
 highly praised for its delicacy by Dr. D. Meredith 
 Reese of the Johns Hopkins Hospital, but Penzold 
 says it is not reliable. 
 
 In an emergency boiling the urine with vinegar 
 and concentrated salt solution is worth mentioning as 
 a test. 
 
 Great care is necessary in carrying out all these 
 tests and in many cases it is only after testing urine 
 from a patient at several different times that a decis- 
 ion can be reached. In carrying out the first test the 
 phosphates should not be taken for albumen merely 
 because they are precipitated by heat. Again the 
 
— 35 — 
 presence of a small amount of albumen may be redis- 
 solved if too much nitric acid be added. In using the 
 heat test on albuminous urine which contains a cloudy 
 precipitate of the acid urates, a very striking contrast 
 may be observed by slightly warming the middle part 
 of the urine until the urates here are redissolved and 
 heating the upper layer to a boiling point until not 
 only the urates have been redissolved, but the 
 albumen has been precipitated; then the urine in the 
 test tube will be clear in the middle while the lower 
 layer will contain a precipitate of the acid urates and 
 the upper part a precipitate of albumen. It is ad- 
 visable to test urine as soon as possible after the 
 specimen has been passed, for at all seasons, but 
 especially in warm weather, the urine becomes decom- 
 posed and alkaline and large amounts of the carbon- 
 ates (of ammonia) and uncombined carbonic acid gas 
 are present. This also the case when the patient has 
 been drinking certain alkaline mineral waters. When 
 such urine is examined for albumen and nitric acid is 
 added a lively effervescence takes place and carbonic 
 acid gas is set free. It is often difficult to decide 
 whether such urine contains albumen or not, for if the 
 albumen be present in a small quantity it is liable to 
 be redissolved by the large amount of acid necessarily 
 aded until the all effervescence ceases. It is some- 
 times desirable to compare the amount of albumen in 
 the urine of the same patient from day to day. The 
 process of precipitating the albumen filtering and 
 
- 36 - 
 
 weighing the filtrate (the weight of the filter paper 
 being known) is too time-wasting for a busy man. 
 Approximately the amount percent, may be estimated 
 by taking test tubes of equal size, filling them daily 
 to the same point (two-thirds full) and adding the 
 same amount of nitric acid (about twenty drops) and 
 letting the tube stand a few minutes. 
 
 There is great carelessness and uncertainty of 
 expression in noting the percentage of albumen pres- 
 ent. Some writers speak of 25 and 50 per cent 
 This is by bulk. In reality 3 per cent, of albumen is 
 rarely found and % per cent, is a large amount. 
 
 In general we may say that when the amount of 
 albumen is 2 per cent, to 3 per cent., the whole fluid 
 is completely coagulated. When there is i per cent, 
 of albumen present, the coagulum in the test tube 
 reaches half-way up to the level of the urine. 
 
 When 0.5 per cent. ^ the way up. 
 0.25 " % " " 
 0.1 " yV " ^^^ " 
 
 " 0.05 " the curved part of the tube 
 is barely filled with albumen, and when there is less 
 than o.oi per cent, present, there is a slight cloudi- 
 ness, but no precipitate. 
 
 CYCLIC ALBUMINURIA. 
 
 A very common form of albuminuria is this so- 
 called "cyclic" or "physiological" albuminuria, 
 which has been the subject of so much discussion on 
 
— 37 — 
 
 the part of English and German writers. Although 
 so much has been written on this subject, there seems 
 to be a tone of uncertainty as to what form of albu- 
 men this is, and what the result of such conditions is. 
 Clinicians are beginning to look upon such conditions 
 as entirely compatible with health, and yet it is im- 
 possible to say that such albuminuria is not the first 
 warning of a serious renal trouble. Even the careful 
 and conservative medical directors of the largest life- 
 insurance corporations keep on hand two sets of 
 opinions — one opinion which appears in medical 
 literature that such conditions are not necessarily 
 dangerous, and such an albuminuria is perfectly com- 
 patible with health. The other opinion is expressed 
 when a case of cyclic albuminuria occurs in an appli- 
 cant for life insurance. Then, if nothing else can be 
 found against the applicant, he is postponed, and if 
 albuminuria still continue for several weeks, there is a 
 very large chance for rejection; indeed, examiners 
 claim to have followed up such rejected cases and to 
 have found that most if not all of them have eventually 
 succumb to some renal disease or kindred trouble. 
 The trouble is that the insurance companies will not 
 take the risk. The pathology of the incipiency of 
 renal disease will have to be understood much better 
 than it is now before such cases can be justly judged. 
 As the use of acids and corrosives is always at- 
 tended with inconvenience in the office and more 
 especially at the bedside. Dr. G. Oliver, of Harro- 
 
- 3^- 
 gate, England, suggested that these tests be put up in 
 the shape of test papers impregnated with the test 
 substance, or as compressed tablets of the test sub- 
 stance. These papers and tablets are prepared by 
 Parke, Davis & Co., of Detroit, who put them up in 
 neat and convenient cases containing either the 
 papers or tablets with directions for use. 
 
 Four different reagents for albumen are furnished 
 in this series of test papers. 
 
 1. Potassio-mercuric iodide. 
 
 2. Sodium tungstate. 
 
 3. Potassium ferrocyanide. 
 
 4. Picric acid. 
 
 These reagents are all used in connection with 
 citric acid. Put into a test tube 30 minims of the 
 urine with a citric acid paper (or if the specimen be 
 alkaline, more than one acid paper) and allow a few 
 moments for the acid to become dissolved. If a 
 cloudiness is produced by the acid, it is due to mucin, 
 or uric acid, or rarely to oleo-resm, as where balsam 
 copaiba has been taken medicinally. The urates dis- 
 solve on warming the urine, mucin remains, being 
 distinguished by this behavior from any other con- 
 stituent of the urine. The oleo-resinous precipitate 
 clears up by boiling, but quickly returns while the 
 urine is yet warm. 
 
 After observing the effect of the acid alone, add 
 the albumen precipitant — one of the four named 
 
— 39 — 
 above. As the reagent dissolves, albumen, if present, 
 is precipitated in the form of a distinct cloud, soon 
 resolving itself into flakes. If any cloudiness is pro- 
 duced, the urine must be heated, when, if the reac- 
 tion is due to albumen, the precipitate remains undis- 
 solved. A precipitate cleared up by heat may con- 
 sist of peptones, or of compounds of vegetable alka- 
 loids. 
 
 It a very large quantity of albumen be present, it 
 may happen that the paper will become coated with 
 the precipitate which forms instantaneously on its 
 surface, and no cloudiness appear in the urine. Such 
 a contingency could very rarely occur, and applica- 
 tion of heat would be sure to reveal the presence of 
 the albumen. 
 
 Another method of using the papers is thus de- 
 scribed by Dr. Oliver: " Those who prefer to de- 
 velop a zone of precipitation along the plane of con- 
 tact of a test solution and the urine can do so with 
 these papers as follows: Put the reagent paper with 
 15 minims of water into one test tube, and a similar 
 quantity of the urine with a citric acid paper into an- 
 other. When the reagent is dissolved a portion of 
 the solution is taken up with a pipette and allowed to 
 trickle down the side of the tube, in which it will 
 either glide over the urine, or collect below it." Dr. 
 S. C. Smith, of Halifax, suggests as a still better way 
 to bend the papers into a circle so as to fit the inside 
 of the test tube, and push them down, say within an 
 
— 40 — 
 
 inch of the bottom of the tube, which is then to be 
 filled with the urine. If albumen be present, the 
 whole of the urine below the papers becomes opaque, 
 while that above them remains transparent and un- 
 changed. The advantage of observing separately the 
 effect of the citric acid is, however, lost in this mode 
 of applying the tests. 
 
 POTASSIO-MERCURIC IODIDE. 
 
 This is the most sensitive of all the tests for albu- 
 men, and in general should be the first test tried, since 
 if this fails albumen is surely absent. The reagent 
 precipitates peptones, and vegetable alkaloids; the 
 precipitate of peptones is cleared up by heat, but re- 
 turns as the urine cools. The precipitate of alkaloids 
 forms a diffused cloudiness which does not break up 
 into flocculi. On applying heat, it clears up, and it is 
 soluble also in alcohol. In case albumen and alka- 
 loids are present together, the fluid will partially clear 
 on heating. 
 
 SODIUM TUNGSTATE. 
 
 This reagent will detect one part of albumen in 
 20,000 of urine; it is therefore nearly as sensitive as 
 the potassio-mercuric iodide. It has the advantage 
 over the latter that it does not precipitate alkaloids. 
 It does however, precipitate peptones, the precipitate 
 redissolving on applying heat. 
 
— 41 — 
 
 PICRIC ACID, 
 
 This test equals in sensitiveness that just named, 
 and has this advantage that it may be used to detect 
 either sugar or albumen. It precipitates like the 
 potassio-mercuric iodide, peptones and vegetable alka- 
 loids, and also throws down oleo-resins, and occasion- 
 ally uric acid. The discrimination of the albuminous 
 precipitate is, however, made with certainty by the ap- 
 plication of heat which dissipates all other precipitates. 
 
 POTASSIUM FERROCYANIDE. 
 
 This test is less sensitive than others in the series, 
 but is capable of detecting albumen where present in 
 the proportion of i part in 12,000 of fluid. It is 
 therefore comparable in the range of its indications 
 with nitric acid. It does not precipitate peptones or 
 the vegetable alkaloids which one is likely to meet 
 with in the urine. It is therefore not liable to lead 
 to false conclusions in the hands of careless observers, 
 and it is selected on this account by Dr. Oliver and 
 by Dr. Purdy as likely to be of the most service to 
 medical men who have not had much experience in 
 applying chemical tests. 
 
 QUANTITATIVE ESTIMATION OF ALBUMEN BY THE 
 METHOD OF DR. OLIVER. 
 
 Twenty minims of the urine are placed in the 
 smaller test tube, a mercuric and a citric acid paper 
 introduced into it, and the tube is shaken during one 
 
— 42 — 
 
 minute, so that the whole of the albumen is precipi- 
 tatee. The opacity produced in the fluid is directly 
 proportional to the quantity of albumen present, and 
 this is determined by the aid of the printed test lines 
 which are provided for the purpose. The fine lines 
 are just discernable when the urine contains i-io per 
 cent, of albumen. The dark lines are rendered in- 
 distinct if there is more than 0.2 per cent, present. 
 If the fine lines are not distinguishable, add water a 
 little at a time, until they can just be discerned 
 through the centre of the tube. 
 
 If it require five times the original volume of the 
 urine to reduce the opacity to this extent, the urine 
 contains 5X0.1 per cent., i.e., one-half of one per 
 cent. If the quantity of albumen is greater than this, 
 it is best to dilute a portion of it two, four, or eight 
 times with pure water before precipitating the albu- 
 men, and multiply the result obtained by the factor 
 representing the degree of dilution of the urine. 
 
 The quantitative test for albumen may be made 
 with Eshbach's albuminometer. It seems hardly 
 worth while to discuss the other proteids found in the 
 urine, such as serum-globulin, globulin, paraglobulin, 
 peptones, etc. Some cases of cyclic or so-called 
 physiological albuminuria may be due to these pro- 
 teids. 
 
 The report of the Albumen Tests Committee 
 from the Clinical Society of London, while not very 
 conclusive, is on the whole quite satisfactory. Of the 
 
— 43 — 
 eight tests used, they decided that a solution of 
 potassio-mercuric iodide with citric acid, particularly 
 when used after Heller's method, gives the most 
 delicate and clearly marked reaction. The objection 
 to this test is that the citric acid precipitates the 
 urates which may be mistaken for albumen. The 
 nitric acid test used by Heller's method is of great 
 delicacy, and generally sufficiently trustworthy in 
 spite of the fact that the acid is not easily portable. 
 Anyone who may devote himself to the thorough use 
 of one of the tests will be able to decide the presence 
 or absence of albumen in urine, as minutely as all 
 practical need demands. The papers, and particu- 
 larly the pellets, have the great disadvantage of un- 
 dergoing change through the absorption of water 
 from the atmosphere — in short, they are hygros- 
 copic. As mentioned above, trichloracetic acid, as 
 used by Boymond, Raabe, and Reese, is very deli- 
 cate, but concentrated urine must first be diluted, 
 otherwise the urates are precipitated and mistaken 
 for albumen. 
 
 2. SUGAR. 
 
 Although various kinds of sugars are pathologic- 
 ally present in the urine, such as sugar of milk (lac- 
 tose) in the urine of lying-in women, also occasionally 
 inosite and levulose, still these are of minor import- 
 ance and when we speak of sugar in the urine we 
 generally refer to glycosuria, meaning the presence of 
 grape sugar (glucose, dextrose) in the urine. Such 
 
— 44 — 
 urine is much increased in quantity, pale, of high 
 specific gravity, 1030 to 1045. 
 
 Von Briicke and Bence Jones claimed against 
 Seegen, George Johnson and others several years ago 
 that a trace of grape sugar was present in all normal 
 human urine, but in such small amount that it escapes 
 the ordinary tests and hence this needs only a men- 
 tion here. One reason that laboratory tests do not 
 furnish reliable data from which to draw conclusions, 
 is that such tests are usually made not with urine con- 
 taining sugar but with distilled water to which has 
 been added anhydrous glucose in certain fixed pro- 
 portions. It may be easily seen that urine contain- 
 ing sugar and innumerable other things which chem- 
 ists do not yet understand will not react like the 
 above test solution. 
 
 Just as the mistake is so often made of saying 
 that a person with albumen in the urine has Bright's 
 disease, so one with sugar in the urine is often said to 
 have diabetes mellitus and hence with the disappear- 
 ance (practically speaking) of these two abnormal in- 
 gredients of the urine, hopeless cases of Bright's dis- 
 ease or diabetes mellitus have been said to be cured. 
 
 Pathologically sugar may appear in the urine as 
 a (a) transitory or a (b) permanent condition. 
 
 As a transitory condition it is described as 
 
 a. Glycosuria. 
 
 As a more lasting or permanent condition when 
 associated with other symptoms it is called: 
 
— 45 — 
 b. Diabetes mellitus. 
 
 a. Glycosuria may occur after taking certain 
 poisons or drugs and in consequence of disturbances 
 of the digestion or nervous system. 
 
 b. If the glycosuria continue it may bring cer- 
 tain other symptoms with it and then we have a 
 diabetes mellitus. 
 
 The tests for detecting the presence of sugar are 
 so numerous that it is no easy matter to be master of 
 them all. In carrying out these tests, however, it 
 must be remembered that if albumen be present it 
 should first be precipitated and removed by filtration 
 before the sugar test is made. 
 
 Before testing for sugar the specific gravity of 
 the urine should be taken. If it is 1 030 the presence of 
 sugar should be suspected, if 1035 and over," the sus- 
 picion of sugar should be very strong. Further, if 
 the urine be very pale and exceed 50 ounces per day, 
 with high specific gravity, sugar is almost sure to be 
 present. It should not be forgotten, however, that 
 many cases of glycosuria with large quantity of urine 
 and with low specific gravity have been reported. 
 
 Although a large number of sugar tests have 
 been suggested and most of them depend on the same 
 principle, it is a sad fact that no test is strictly reliable. 
 Investigators have found again and again unknown 
 substances in the urine that reduce the copper just as 
 sugar does. Indeed, it is no uncommon thing, after 
 cases of arsenic poisoning to find arsenic in the urine 
 
- 46 - 
 
 and this substance answers to all the sugar tests 
 with a striking similarity. However, until more 
 reliable tests are offered the following are given as 
 the best. 
 
 moore's or heller's test. 
 
 This is a favorite test in Germany. A small 
 quantity of urine is heated with one-third of its vol- 
 ume of a concentrated caustic potash solution in a 
 test-tube, and if sugar be present the urine turns a 
 yellow-brown or brown color according to the amount 
 of sugar present. This test is not reliable when the 
 sugar contained is 0.5 per cent, or less. The urine 
 must be boiled for several hours. The presence of 
 rhubarb or senna in the urine may cause a similar re- 
 action. Although not a delicate test, still it is a 
 reliable one if it yield a negative result, and hence it 
 is good as a preliminary test. 
 
 copper tests. 
 
 These all depend upon the power which grape 
 sugar possesses of reducing the oxide of copper, and 
 are therefore called reduction tests. 
 
 trommer's test. 
 
 As in the first test, to a quantity of urine one- 
 third its volume of caustic potash or soda solution is 
 added, then a sulphate of copper solution (1:10, or 
 even weaker) is added drop by drop until there is 
 
— 47 — 
 only a small part left undissolved on shaking the 
 tube. If this mixture be then heated, the presence of 
 sugar will cause, before the boiling point is reached, 
 a yellow-red precipitate of cuprous oxide (CugO). If 
 no sugar be present the fluid will show a greenish 
 hue. If a precipitate does not form at once on heat- 
 ing the tube, the test has no value. Occasionally 
 certain drugs in the urine are capable of reducing the 
 copper, and it is possible that these are in the urine. 
 Many reducing agents which the chemists do not yet 
 understand make this test of doubtful value. If the 
 sulphate of copper solution be boiled first and then 
 added, the test is strengthened, or if the sulphate 
 of copper solution be added in the cold, and the test- 
 tube be set aside for twenty-four hours, the test is 
 more reHable, since sugar is probably the only sub- 
 stance which reduces copper in the cold. 
 
 The other copper tests of Fehling and Pavy are 
 both reduction tests and not as convenient as the 
 last. Pavy's pellets are also convenient for bedside 
 tests, but they are apt to change and become unreli- 
 able. 
 
 fehling's test. 
 
 Fehling's test is considered sufficiently accurate 
 for all practical purposes, and is recommended by the 
 best American life-insurance companies. Fehling's 
 solution may be prepared in two parts and mixed 
 when wanted, as it does not otherwise keep. 
 
• - 48 - 
 
 No. I. — Cupric sulphate, C.P., 34.64 grammes (520 grains). 
 Water. q. s. ad 500 c. c. (15 ounces). 
 
 No. 2. — Rochelle salt (crystallized). . 173 grammes (5| ozs.). 
 Solution of caustic sodd, sp. 
 
 gr. 1.34 loo c. c. (3 ounces). 
 
 Water, q. s. ad 500 c. c. (15 ounces). 
 
 For use mix equal parts and use as m Trom- 
 mer's test. One c. c. (15 drops) of this is exactly re- 
 duced by 0.005 gramme (^^^ grain) of - grape sugar. 
 Dr. Charles W. Purdy has devised a new formula for 
 the detection of glucose, both qualitative and quanti- 
 tative. It seems to be a good and fairly reliable test, 
 but it is too early yet in the stage of probation to be 
 generally adopted. Its principle is the same as all 
 the copper tests. It is very carefully and satisfac- 
 torly prepared by Messrs. Hynson and Westcott, 
 legitimate pharmacists of Baltimore. 
 
 boettger's bismuth test. 
 
 This is a simple and reliable, but not delicate 
 test. The urine is made alkaline by adding equal 
 parts of liq. potassae or sodae and then a pinch of sub- 
 nitrate of bismuth, and boiling for a few minutes. If 
 sugar be present it reduces the bismuth, and the 
 black metal will be deposited on the sides of the test 
 tube. 
 
 FERMENTATION TEST. 
 
 The fermentation test is very reliable, but not 
 delicate, and entails a long wait. A small piece of 
 ordinary baker's yeast is put into the bottle contain- 
 
— 49 — 
 ing the suspected urine, and this is immersed neck 
 downward in the same urine. If sugar be present, 
 the evolution of carbonic acid gas by the yeast will 
 be shown by the displacement of the urine. 
 
 PHENYLHYDRAZIN TEST. 
 
 The phenylhydrazin test is the latest, and proba- 
 bly most sensitive and reliable test for glucose. It 
 was introduced by Emil Fischer in 1883, and since 
 that time has been carefully studied and modified by 
 V. Jaksch, of Graz. Two pinches of the muriate of 
 phenylhydrazin, and four pinches of the acetate of 
 sodium, are put into a test tube with water and heated, 
 then an equal quantity of urine is added, aud the 
 whole is again heated and set aside to cool. If sugar 
 is abundant it falls down in delicate yellow cr5^stals. 
 If only a small amount is present the delicate yellow 
 crystals of phenylglucoazone may be recognized under 
 the microscope. This test is a very satisfactory one, 
 but takes more time in case a small amount of sugar 
 is present. Since its introduction, there have been 
 raised plausible objections to its reliability. Aside 
 from this, any test that requires the careful use 
 of the microscope for the detection of a very delicate 
 crystal, will hardly find general acceptance. 
 
 As in the case of albumen, so with sugar, it is 
 best to become thoroughly acquainted with one good 
 test and use it always, but understand the others suf- 
 ficiently well to resort to them in case of doubt. 
 
— so — 
 
 Test papers and tablets have also been prepared 
 for the detection of sugar. They have given satisfac- 
 tion, and are of great convenience when more elabor- 
 ate means are not at hand. They are put up by 
 Messrs. Parke, Davis & Co., of Detroit. 
 
 Two tests are furnished in this series: 
 
 1. Indigo carmine. 
 
 2. Picric acid. 
 
 These reagents are both used in connection with 
 sodium carbonate in the manner described under the 
 individual heads following. 
 
 The diagnosis of glycosuria may be made with 
 certainty by means of these test papers, and an ap- 
 proximate estimation made of the quantity of sugar 
 present. 
 
 The presence of albumen and of uric acid in the 
 urine does not interfere with either of these tests, 
 which are capable of detecting the smallest quantities 
 of sugar that can be considered pathological. 
 
 INDIGO CARMINE. MULDER's TEST FOR SUGAR. 
 
 This is an exceedingly sensitive test for diabetic 
 sugar, and its indications may be accepted as infal- 
 lible. 
 
 Place in a test tube 30 minims of water with an 
 indigo and a sodium carbonate paper. Heat the 
 tube gently until the indigo is dissolved. [The solu- 
 tion should be of only a pale blue color. A portion 
 of one of the iudigo papers may suffice, but the 
 
— 51 — 
 whole of the soda paper should be used.] Add to 
 the blue solution from a pipette one drop of the urine 
 to be tested, ond keep the fluid at a boiling point, 
 without, however, permitting active ebullition, for 
 sixty seconds. If no change is produced add a sec- 
 ond drop of the urine, and heat once more. If any- 
 notable quantity of sugar is present, the fluid will be 
 observed to change from pure blue to violet, then to 
 purple and red, and only a trace of sugar, the color 
 will merely change to one of the intermediate shades. 
 
 DI^^Normal urine itself produces a reaction if 
 added in sufficient quantity, 5 to 8 drops generally 
 being sufficient to change the color to purple or red. 
 If, however, no more than one drop of the urine is 
 employed in the test, a change in color is proof that 
 sugar is present in abnormal quantity. 
 
 I^^If the tube is agitated during the experi- 
 ment so that the fluid is brought in contact with the 
 oxygen of the air, the reaction is retarded. Indeed 
 the blue color of the solution may be momentarily 
 restored even in presence of a large excess of sugar 
 by vigorously shaking the tube, and the color can be 
 discharged and restored repeatedly, by the alternate 
 action of the sugar and the oxygen of the air. 
 
 QUANTITATIVE ESTIMATION OF SUGAR BY INDIGO 
 CARMINE, 
 
 The test papers may be made to yield approxi- 
 mate quantitative results by observing that the color 
 of 30 minims of a pafe blue solution of indigo is 
 
— 52 — 
 
 changed to yellow by heating one minute with one 
 minim of a urine containing ten grains of sugar to 
 the fluidounce, or by heating two minutes with one 
 minim of a urine containing five grains to the fluid- 
 ounce. For exact work, it is necessary of course to 
 have papers especially prepared, containing a definite 
 quantity of the reagent, but a rough approximation 
 to the truth may be based upon the statement just 
 made, and information of great value may be thus 
 obtained in observing the influence of remedies in a 
 case of diabetes. 
 
 If the quantity of sugar is smaller than that named, 
 the change of color will be only partial, but exact 
 quantitative estimations are of less importance in these 
 cases than where the amount is more considerable. 
 
 In case the urine contains more than ten grains 
 of sugar to the fluidounce, it will be necessajy to di- 
 lute it until it is reduced to that strength. If four 
 times its volume of water is required to effect the 
 change in one minute, the urine must contain 5 x 10= 
 50 grains of sugar to the fluidounce. The details of 
 this method can be best worked out by each individ- 
 ual for himself. 
 
 PICRIC ACID. — DR. GEO. JOHNSON's TEST FOR SUGAR. 
 
 When an alkaline solution of picric acid is boiled 
 with a little glucose, picramnic acid is formed, and 
 the color of the solution changes to a garnet red. 
 To apply the test to the urine, .put in a test tube one 
 
— 53 — 
 of the picric acid papers with 20 minims of water and 
 about 3 grains of sodium carbonate, add 10 minims 
 of the urine and boil sixty seconds if necessary. The 
 color of the mixture always darkens perceptibly, but 
 if sugar is present the change is much more prompt 
 and decided than in the case of normal urine. If the 
 color changes rapidly to a dark red, repeat the exper- 
 iment with 5, 3 and one minim successively, to form 
 an approximate estimate of the quantity of sugar 
 present. If one minim gives a strong reaction, dilute 
 fluid gives only a deep amber color with a distinct 
 shade, however, of red. In a diluted urine this reac- 
 tion will indicate the presence of about one grain of 
 sugar to the fluidounce. 
 
 About the same shade of color is generally pro- 
 duced by two minims of a normal urine, so that there 
 should be deducted from the result obtained about 
 half a grain to the fluidounce, as "normal sugar." 
 This test should always be confirmed by the indigo 
 carmine test, since there are other substances than 
 sugar— notably kreatinin — which react like glucose 
 with picric acid. 
 
 COMPARATIVE VALUE OF TESTS FOR SUGAR IX THE 
 URINE. 
 
 The copper test which is commonly employed, is 
 perhaps the least trustworthy for all the tests for glu- 
 cose. Among the normal constituents of the urine, 
 uric acid is capable of reducing copper compounds. 
 
— 54 — 
 and numerous substances which may be accidentally 
 present have a similar action. Kreatinin and many 
 other organic compounds prevent or retard the preci- 
 pitation of small quantities of cuprous oxide, so that 
 urine containing less than one grain of sugar to the 
 fluidounce fails to respond to the copper test, or gives 
 an indication only after half an hour or a longer time. 
 
 Picric acid is an exceeeingly sensitive reagent 
 for the detection of sugar, but a larger amount of 
 alkali must be used than can be put in the form of a 
 test paper, so that a supplementary supply of the al- 
 kali must be carried in the pocket case, if the test is 
 to be used at the bedside. The reagent is not affected 
 by uric acid, nor by most of the substances occas- 
 ionally present in the urine which reduce copper. 
 It does react, however, with kreatinin present in 
 normal urine, and with ferrous salts, tannin, and in- 
 osite which occasionally occur in the secretion. 
 Normal urine always shows a distinct reaction, as 
 though it contained as much as ^ grain in the fluid- 
 ounce of glucose. 
 
 Indigo is not affected by any known normal con- 
 stituents of the urine. Since normal urine always 
 produces a reaction with it, we must conclude either 
 that glucose (or inosite) is constantly present in urine 
 in small quantities, or else that there is a constituent 
 constantly present which has a similar action but is 
 yet unknown. Of the possible accidental constituents 
 of the urine, only ferrous salts and tannic acid affect 
 
— 55 — 
 indigo, so that we may regard this test as not only the 
 most sensitive, practically, of any yet proposed, but as 
 practically free from fallacies. Finally, unlike the 
 copper test, indigo carmine can be preserved un- 
 changed for years, especially in the convenient form 
 of these test papers. 
 
 Fig. 6. — Colored and (a) Colorless Blood Corpuscles of Var- 
 ious Forms. 
 
 3. BLOOD. 
 
 Blood occurs in the urine in two different forms. 
 
 a. As Hcematuria, when the blood-coloring mat- 
 ter is present in the urine in combination with blood 
 corpuscles, and 
 
- 56 - 
 
 b. As Hcemoglobimiria^ when very few or no 
 blood corpuscles are present and the blood is in solu- 
 tion in the urine. 
 
 In Hcematiiria the blood may come from the kid- 
 kneys, pelvis of the kidney, ureters, bladder, urethra 
 
 Fig. 7. — Cremated Red Blood Corpuscles in Urine, X350. 
 
 or vagina. The presence of blood may be suspected 
 by the brownish-red color of the urine and the reddish 
 sediment which appears on standing. Haematuria 
 may be normal in character. Blood from the kidneys 
 is generally well mixed with the urine, making it 
 
— 57 — 
 smoky; when from the bladder it is usually stringy 
 and clotty, and comes out at the end of micturition. 
 
 With a power of 300 diameters the blood corpus- 
 cles can be easily recognized either in their usual 
 bi- concave form or, if the urine be concentrated and 
 acid, they appear with crenated edges and much 
 shrunken. 
 
 heller's test. 
 
 This convenient and easy test is made by adding 
 a caustic soda solution to some urine in a test-tube 
 and heating. The precipitated phosphates are col- 
 ored reddish-brown by the blood-coloring matter and 
 fall in a thick cloud to the bottom of the tube. Test- 
 ing for hcEmin cystals is difficult for the inexperienced, 
 but may be necessary at times. If some blood, or 
 sediment supposed to contain blood, be heated to the 
 boiling point with glacial acetic acid and a trace of 
 common salt, and then slowly evaporated, there are 
 found brownish yellow rhombic crystals of haemin. 
 The preparation should be moistened with a little- 
 glycerin and examined with a high power under the 
 microscope. If hemorrhage occur in the urinary tu- 
 bules, casts or cylinders made up of blood corpuscles 
 are seen under the microscope. 
 
 a. Haemoglobinuria occurs in some fevers, nerv- 
 ous troubles from burns and after carbolic acid pois- 
 oning. So-called paroxysmal or periodic hcsmoglobi- 
 nuria has been lately described as a disease due to 
 sudden effects of cold on the skin and particularly the 
 
- 58 - 
 
 feet. It is often connected with syphilis. Albumen 
 is often present from the dissolution of the blood cor- 
 puscles. If Heller's test gives a positive result and 
 no blood corpuscles are visible under the microscope, 
 then we may conclude it is haemoglobinuria. 
 
 almen's test. 
 
 Add a few drops of a freshly made tincture of 
 guaiac to the suspected urine, and it will turn green. 
 Shake well and add a few drops of old oil of turpen- 
 tine. The haemoglobin will change the color of the 
 precipitate to blue. The most convenient and reliable 
 test is to examine this sediment microscopically. 
 
 4. PUS. 
 
 Purulent urine is cloudy, grayish-yellow, with a 
 heavy sediment which, in alkaline urine, has the ap- 
 pearance of a tough, stringy mucus-like mass. Thus 
 the chemical test for pus is to add a solution of caus- 
 tic potash to the urine and observe whether the sedi- 
 ment takes on the above described appearance. Much 
 more reliable is the microscopical test which shows at 
 once the presence or absence of the pus corpuscles. 
 On the addition of a drop of acetic acid, the nuclei 
 become distinct and the outline of the corpuscle has 
 a glassy appearance. Urine containing pus in large 
 amount generally contains albumen. It is not easy 
 to find the source of the pus. Pus in the urine may 
 resemble mucus. The latter, however, forms a light 
 
— 59 — 
 flocculent cloud, which remains suspended in the 
 urine for some time. Microscopically, the threads of 
 mucus and the cells are at once recognized, but as 
 the mucus and pus cells are microscopically identi- 
 cal we must also look for albumen, which in pyuria 
 is generally present and in mucinuria may be ab- 
 sent. Mucus is more often seen in the urine of fe- 
 males. 
 
 5. BILE. 
 
 A yellow urine which retains its foam a long time 
 after shaking, points to the presence of bile. The 
 clothes are often stained a decided yellow by such 
 urine. 
 
 gmelin's test. 
 
 A few drachms of fuming nitric acid are poured 
 down the side of a test-tube so that it passes below 
 the urine, just as in Heller's test for albumen. At the 
 point of contact of the two fluids, if bile be present, a 
 green ring is observed, and below it in order a blue, 
 violet, and finally a yellow ring. The green ring is 
 alone decisive. The presence of albumen does not 
 disturb the test. The same play of colors is observed 
 by putting a drop of the suspected urine on a clean 
 porcelain back ground and putting a few drops of 
 fuming nitric acid by it. 
 
 Chloroform as a test for bile in the urine is very 
 satisfactory. Agitate a few drops of chloroform with 
 
— 6o — 
 
 the suspected urine in a test-tube. If bile be present, 
 the chloroform becomes turbid and acquires a yel- 
 lowish hue, the depth of which is in proportion to 
 the amount of bile present; the test fluid remains 
 limpid. 
 
CHAPTER IV. 
 
 SEDIMENT. 
 
 Normal urine is generally clear when just passed. 
 Pathological urine may be passed cloudy or may 
 become cloudy on standing. 
 
 A microscopical examination of this cloud or 
 sediment forms the most important part of urinary 
 analysis. For this a knowledge of the use of the 
 microscope is absolutely indispensable; and not only 
 this, but certain foreign substances, such as bits of 
 animal fibres from wearing apparel, hair, oil, starch, 
 granules from food, etc., etc., are so often found in 
 the urine, that they should be familiar objects. 
 Scratches and marks in the slide may be mistaken for 
 sediment. It may not be out of place here to give a 
 warning against unclean vessels and bottles in which 
 urine is saved and brought for examination. It seems 
 almost needless to state that cleanliness is very impor- 
 tant in saving urine for examination. It has happened 
 that spermatozoa have been found in female urine and 
 vaginal epithelium in male urine. But more often 
 from the female do we get foreign substances in the 
 urine, and therefore it is well to request women to 
 use a Davison syringe before the water is passed, or 
 to pass the first part in one chamber and the rest in a 
 clean chamber for examination. 
 
If the sediment be abundant, a drop of it may at 
 once be drawn up with a pipette, dropped on a slide 
 and examined microscopically. If the sediment 
 should be scanty, the urine should be well shaken 
 and then poured into a conical glass to allow the 
 sediment, to fall to the bottom and be collected. All 
 urine contains more or less sediment, which sinks rap- 
 idly to the bottom or floats for a long time, or even 
 remains adherent to the sides of the vessel, according 
 to its specific gravity. As an improvement on the 
 conical glass, it has been suggested to allow such 
 urine with scanty sediment to stand for twelve to 
 twenty-four hours in a vessel with straight sides, such 
 as a cylinder or test-tube with a foot. When the sedi- 
 ment has collected at the flat bottom, a pipette is in- 
 troduced with the finger on the top and the lower 
 stratum of urine and sediment drawn up and this 
 pipette is allowed to stand in the cylinder, the whole 
 being covered with paper or raw cotton, until this 
 scanty sediment collects at the lower end of the 
 pipette, when it is drawn out and dropped on a slide, 
 carefully covered with a cover glass, and examined. 
 
 In a paper read before the Medical and Chirur- 
 gical State Faculty of Maryland in 1888, the writer 
 collected e. few hints on the microscopical examina- 
 tion of urinary sediment, and at the risk of repetition 
 they are reproduced here: 
 
 Physicians now generally recognize the fact that 
 an examination of the urine forms an important part 
 
- 63 - 
 
 in making the diagnosis of any disease. In many- 
 cases negative results may satisfy, as excluding cer- 
 tain diseases. It is a matter of common occurrence 
 that one physician not being successful in the treat- 
 ment of a case, a consultant or another physician is 
 tried, who, carefully examining the urine, a thing 
 which the first adviser had failed to do, finds enough 
 to throw considerable light on the malady and its 
 treatment. In urinary analysis, an examination both 
 chemical and microscopical should be made in all 
 doubtful cases. The former is a matter not difficult 
 for the majority of physicians, and there are few phy- 
 sicians who cannot make the ordinary tests for albu- 
 men, sugar, etc. The microscopical examination, 
 however, is a matter not so simple. There are plenty 
 of practitioners who cannot make a microscopical ex- 
 amination of the urinar)'' sediment in a manner satis- 
 factory to themselves. This part of the subject, 
 though old and often discussed, may be repeated 
 with advantage, even at the risk of uttering remarks 
 well known and trite to many here. 
 
 First, as to the techniqice. The patient or attend- 
 ant should be impressed every time with the impor- 
 tance of saving clean specimens of urine. The bottles 
 and vessels in which the urine is collected and pre- 
 served should be scrupulously cleansed and dried. 
 The urine obtained should be passed in the morning 
 on rising and in the afternoon, so that two different 
 samples may be examined. This is necessary, among 
 
- 64 - 
 
 other reasons, because the urine may be free from al- 
 bumen in the morning and loaded in the afternoon. 
 These specimens should be examined as soon as pos- 
 sible after receiving them, and in case of keeping 
 them, they should be preserved in a cool place, and 
 some such substance as salicylic acid may be added 
 which will not affect the examination. 
 
 Difficulties present themselves when the urine 
 contains very much or very little sediment. When 
 very little, it is the general custom to let it stand for 
 twenty-four hours in a cool place in a conical glass, 
 so that the sediment may drop to the bottom of the 
 vessel. Casts when not abundant may remain sus- 
 pended for a longer time in the urine, and owing to 
 their lightness they may stick to the sloping sides of 
 the glass and thus escape detection. Sometimes bet- 
 ter results may be obtained by letting the urine stand 
 in a cylindrical glass for twenty-four hours and then 
 drawing up the bottom layer of fluid with a pipette 
 and examining it. I have turned the bottle upside 
 down for one day and then examined the sediment 
 which had collected on the cork, but this is not usu- 
 ally satisfactory. For the microscope it is well to 
 have a thick slide with a concavity ground in it. 
 
 When there is much sediment, it is not easy to 
 separate the important from the unimportant matters. 
 In this case it is better to let the urine stand in a cool 
 place in a conical glass for six or twelve hours, and 
 then pipette off the supernatant fluid and let that 
 
- 65 - 
 
 Stand in a second glass. Casts will be found in the 
 second glass, and in the first, pus, blood, epithelium 
 and inorganic matter. 
 
 There is a great difference between the urine of 
 the male and female as regards sediment. Urine 
 from the female generally contains large flakes of 
 epithelium from the vagina, blood corpuscles, etc. 
 This excess of sediment may be excluded by having 
 the urine drawn off with a clean catheter, or by di- 
 recting the patient to syringe out the vagina and 
 genitals with warm water before urinating. 
 
 Red blood corpuscles are of no clinical signifi- 
 cance unless present in large numbers. They may 
 occasionally be mistaken for air or oil globules. Stray 
 leucocytes are rarely absent, and are only to be con- 
 sidered when they are present in large numbers, as 
 from a cystitis or rupture of some abscess in the 
 genito-urinary-renal tract. Bladder epithelium, and, 
 in the female, vaginal epithelium, is always present. 
 Some of the bladder and vaginal cells so strongly re- 
 semble each other that they at times cannot be distin- 
 guished, and indeed vaginal epithelial cells have been 
 described as being present in the male urine occasion- 
 ally. Again, some cells from the bladder so much 
 resemble epithelium from the ureter or renal pelvis 
 that I always have trouble in distinguishing them. 
 Renal epithelium, when it has not undergone fatty or 
 other degeneration, is not difficult to recognize. 
 
 The principal object of the microscopical exami- 
 
— 66 — 
 
 nation of the urine is to see if casts are present or ab- 
 sent. Although they are found in some of the acute 
 diseases, and at times without sufficient explanation, 
 still their continual presence cannot fail to be alarm- 
 ing. They should be looked for whether albumen be 
 present or not. Albumen is often absent at the time 
 of the microscopical examination, it having appeared 
 at an earlier stage of the disease. Albuminuria with- 
 out casts is said to be more common than it really is, 
 and the majority of investigators agree in believing 
 that casts are present though they can not always be 
 found. This was deduced from autopsies. In an in- 
 teresting case* of cyclic or physiological albuminuria, 
 I was never able to find casts although I looked at 
 intervals. 
 
 I generally draw off a little of the sediment with 
 a pipette, and drop it on a hollow slide and examine 
 it with a low power. The sediment may be then seen 
 floating about. Most books warn against taking up 
 too much fluid on the slide; I find this an advantage. 
 I take up a large drop on an ordinary slide, and as 
 the fluid runs along the slide, an opportunity is offered 
 to review the sediment as it passes by, taking care, of 
 course, that it does not get on the stage of the micros- 
 cope. If casts are found, then another drop may be 
 taken, and, before putting on a cover glass, a small bit 
 
 * See author's article on " Cyclic Albuminuria," in the 
 Medical News, July 30, 1887. 
 
- 67 - 
 
 of broken cover glass or a hair is put by the prepara- 
 tion and then covered. This prevents the casts from 
 being crushed. I generally prefer to examine first 
 without a cover glass, because it is rarely necessary to 
 use such a high power that the objective comes near 
 the preparation. Some writers suggest that when 
 there is much sediment, to roll the cover glass back- 
 ward and forward with two fingers. I have done that 
 several times and succeeded in making casts when 
 there were none there. When a cover glass is used, 
 as little liquid as possible should be taken up; and as 
 this lessens the chance of finding them if few are 
 present, it is not always advisable. Staining is gene- 
 rally superfluous, but if desirable, it is better to drop 
 a little staining fluid in the urine, as staining under 
 the cover glass causes the sediment to fly across the 
 field at an alarming rate of speed and settle on the 
 outside of the glass. This may be prevented by al- 
 lowing the casts to dry on the slide and then staining; 
 but this is apt to change their appearance, and is not 
 advisable. The best way is to stain them before the 
 cover glass is put on. 
 
 Numerous substances, such as camphor, carbolic 
 acid, salicylic acid, borax, etc., etc., when added to 
 urine containing casts, preserve these casts indefinitely. 
 The urine may contain such a variety of sediment 
 that careful study is very necessary in recognizing 
 the various substances found. According as the 
 urine is acid, or alkaline, concentrated or dilute, the 
 
— 6S — 
 
 sediment varies, hence a reference to the following 
 table will assist in the examination. Some of these 
 substances are passed out with the urine from the 
 bladder, while others are formed after the urine has 
 been passed: 
 
 ORGANIZED MATTER. 
 
 1. Mucus and pus cells. 
 
 2. Blood corpuscles. 
 
 3. Epithelium. 
 
 4. Casts. 
 
 5. Spermatozoa: 
 
 6. Bacteria. 
 
 7. Papilloma cells. 
 
 8. Parasites. 
 
 UNORGANIZED MATTER. 
 
 Acid urine. 
 
 Alkaline urine. 
 
 AMORPHOROUS. 
 
 I. Urate of sodium and pot- ; i. Phosphate of calcium. 
 
 ash. j 2. Carbonate of calcium. 
 
 2. Fat. 
 
 CRYSTALLINE. 
 
 I. Uric acid.' 
 
 I. Urate of ammonium. 
 
 2. Oxalate of lime. 
 
 2. Triple phosphates. 
 
 3, Cystin. 
 
 3. Phosphate of calcium. 
 
 4, Leucin and Tyrosin, 
 
 4. Phosphate of magnesium 
 
• -69- 
 
 I. xMUCUS AND PUS CELLS 
 
 Are found in all urine, and it is only when they 
 are present in an especially large amount that they 
 are considered pathological. In alkaline urine they 
 swell up and take on a glassy appearance. When 
 they contain fat drops they are probably from some 
 abscess in the rectum, prostate, etc. In women they 
 come from the vaginal secretion. Acetic acid renders 
 the nucleus more distinct. Pus in the pelvis of the kid- 
 ney appears mixed with the urine. From the bladder 
 or prostate it is apt to be in plugs or threads — the 
 urine is then strongly alkaline. When a gonorrhoea 
 can be excluded, these masses of pus point almost 
 certainly to a prostatic trouble. 
 
 2. BLOOD CORPUSCLES. 
 
 Almost all urine from women contains a few 
 blood-corpuscles from the vagina, unless the urine be 
 drawn off with a catheter. It is not always easy to 
 say where the blood comes from, but if it be inti- 
 mately mixed with the urine but in small quantities it 
 is very likely from the kidneys, while if it appear in 
 strings or clots either at the beginning or end of mic- 
 turition, it is most probably from the bladder, pros- 
 tate or urethra. When much blood is present it may 
 thus be recognized. Such urine usually contains al- 
 bumen from the disorganization of the blood-corpus- 
 cles. Red blood-corpuscles may be recognized with 
 
— 70 — 
 
 a power of 300 diameters. They are bi-concave and 
 from this shape the centers appear dark when the 
 edges are clearly focused and the edges dark when 
 the centers are focussed. In dilute urine the corpus- 
 cles swell up, and may even become bi-convex. In 
 acid and concentrated urine they appear shrunken, 
 and have crenated or jagged edges. A few leuco- 
 cytes, or white blood-corpuscles, are present in all 
 urine. In larger numbers they may be present as 
 pus under such conditions as cystitis, gonorrhoea, va- 
 ginitis, or they may come from an abscess of the pros- 
 tate or rectum. Occasionally, the blood appears in 
 the urine in the form of cylinders or casts, which are 
 undoubtedly from the kidneys. This will be referred 
 to later. 
 
 3. EPITHELIUM. 
 
 The epithelium in the urine may come from the 
 bladder, ureter, pelvis of the kidney, kidney, vagina 
 or urethra. Epidermis cells often appear in the field 
 of the microscope when the fingers have come in con- 
 tact with the slide or preparation. It is probably im- 
 possible to distinguish cells of the ureters and renal 
 pelvis, and even those of the bladder. The large flat 
 vaginal epithelium may be recognized from its resem- 
 blance to the buccal epithelium. The bladder epithe- 
 lium is easily recognized when the superficial and deep 
 pear-shaped cells are seen floating together. Much 
 more important is the recognition of the renal epithe- 
 
Hum. These cells are polygonal -generally hexago- 
 nal — are smaller than the other cells and contain a 
 large nucleus. Their presence in the urine points to 
 grave pathological changes in the kidney. They may 
 appear singly, or adherent to casts. 
 
 
 Fig. 8. — {a) Epithelium from Human Urethra; (b) Vag- 
 ina; if) Prostrate; id) Cowper's Glands; ie) Littre's Glands; 
 (/) Female Urethra; {g) Bladder. 
 
 The small round epithelial cells from the urinife- 
 rous tubules may be distinguished from pus cells by 
 their size, and especially by their single nucleus clearly 
 
— 72 — 
 
 visible, while the pus cell often has a multiple or lobu- 
 lated nucleus, which is only visible on the addition of 
 acetic acid. The flat epithelial or squamous cells of 
 the bladder are not quite so large as those of the va- 
 gina, and do not usually appear in flakes or layers as 
 those of the vagina do, still it is not always safe to 
 attempt to distinguish between the two. When large 
 multinuclear epithelium cells are seen in the urine, 
 the presence of a cancerous (villous) growth may be 
 suspected. 
 
 4. CASTS. 
 
 Tube-casts or epithelial cylinders form by far the 
 most important pathological constituent of urinary 
 sediment. They are so called because they are sup- 
 posed to be moulds of the uriniferous tubules of the 
 kidney. After being thus moulded they shrink and 
 are carried out with the urine. They are supposed to 
 be formed by a coagulable substance in the blood or 
 by some morbid change of the renal epithelium. Ac- 
 cording to their appearance and composition they 
 have received different names. Their presence points 
 almost certainly to a diseased condition of the kid- 
 ney. Until recently they were supposed to be accom- 
 panied by albuminuria, but, as is now known, either 
 albumen or casts may be present without the other. 
 The way to find them in the urine has already been 
 mentioned. If the bottle of urine be placed upside 
 down for twelve hours or longer, enough sediment 
 
will be deposited on the cork to be examined. Re- 
 peated examinations of the urine are necessary before 
 a decision is reached. Urine containing casts should 
 be examined early after securing the specimen, as the 
 bacteria and alkaline fermentation soon destroy the 
 
 Fig. 9. — Hyalin Casts. 
 
 casts. A drop of carbolic acid is said to preserve the 
 integrity of the casts; and also other substances, such 
 as chloral, acetate of potassium, etc., have been sug- 
 gested, but the risk of precipitating the albumen 
 should always be avoided. 
 
 Dr. Charles H. Cockey, of Baltimore, uses a mix- 
 ture of salicylic acid 2 parts, borax i part and glycer- 
 ine 3 to 5 parts. 
 
— 74 — 
 According to their appearance and composition, 
 casts have received different names. If the mould of 
 coagulated fibrin pass out with the urine without blood 
 or cell, it is called a hyaline cast or waxy cast. Ac- 
 cording as epithelium, blood, fat drops, or granular 
 matter (the two last from degenerated epithelium) are 
 
 Fig, io. — Waxy Casts. 
 
 adherent to the moulds of fibrin, the casts are called 
 respectively epethelial, blood, fat, or granular casts. 
 These casts vary in diameter (from ^-^Vo ^^ tot i^-) 
 according to the part of the tubule from which they 
 come. Hyaline casts are naturally smaller than those 
 to which epithelium, blood, etc., are attached. Mucous 
 casts have also been described. Amorphous sediment 
 and crystals may adhere to casts, and they also some- 
 
— 75 — 
 times arrange themselves in a cylindrical form and 
 deceive the inexperienced. Casts of the urates and 
 of bacteria may be mentioned. In cleaning slides 
 and cover-glasses, bits of linen threads are left on the 
 glass and may be mistaken for the hyaline cast. 
 
 5. SPERMATOZOA 
 
 Are present in the urine occasionally, and are of in- 
 terest from a medico-legal standpoint when found in 
 the urine of women. 
 
 Fig. II. — Blood Casts. 
 
 6. BACTERIA. 
 
 Freshly passed normal urine contains no bacte- 
 ria; these are observed, however, in the alkaline fer- 
 mentation. The two micro-organisms which have 
 some diagnostic importance are the bacillus of tuber- 
 culosis and the gonococcus. In a suspected tubercu- 
 
- 76 - 
 
 lous ulceration of the genito-urinary tract, an examina- 
 tion of the sediment or ulcerating matter will often 
 decide the question. These bacilli are not so easy to 
 find here as in the sputum, but the method is ex- 
 actly the same. 
 
 Fig. 12. — Hyaline and Granular Casts, illustrating the 
 formation of the former at a. 
 
 This method is soon learned after a little practice 
 by one already familiar with the use of the microscope. 
 Others may not find it so easy, and there may be 
 danger of drawing too hasty conclusions by those not 
 versed in those matters. 
 
 A little of this sediment or ulcerating matter 
 from the urine is spread out on a clean cover-glass 
 with a sterilized platinum needle, or is taken up with 
 
• 77 — 
 bterilized forceps and put in the center of a clean 
 cover-glass upon which a second cover-glass is pressed, 
 and then the two are drawn apart and allowed to dry. 
 They are then passed through the alcohol or Bunsen 
 flame to coagulate the albuminous substance and fix 
 the layer on the glass. The principle of rendering 
 • the bacilli visible by staining them has been clearly 
 enunciated by Koch and modified, but not improved, by 
 
 Fig. 13. — Epithelial Casts and Compound Granular Cells. 
 
 a host of followers. This principle of all is about the 
 same, namely, to overstain the specimen and then 
 decolorize, experience having shown that the bacilli 
 retain their color better than the cells and other mat- 
 ter. The stains most commonly used are fuchsin or 
 magenta, properly called hydrochlorate of rosanilin, 
 and methyl-violet or gentian-violet. The coloring 
 fluid which I find most convenient and durable is 
 made up of — 
 
- 78 - 
 
 Fuchsin (by weight) 2 parts. 
 
 Absolute alcohol 10 " 
 
 Solution carbolic acid (5 p. c.) 100 " 
 
 This keeps better and longer than the ordinary 
 anilin solutions, which should be prepared fresh for 
 every examination. The cover-glass, with preparation 
 side downwards, may be floated on the staining solu- 
 
 FiG. 14. — Oil Casts and Fatty Epithelium. 
 
 tion in a watch glass which is held on a wire gauze 
 over the flame to hasten the coloring, or a few drops 
 of the stain may be dropped on the color-glass, which 
 is then cautiously held over the flame high above it 
 until bubbles break on the surface; the glass is then 
 dipped into diluted nitric acid (one to three or four), 
 until slightly decolorized, then directly into water, to 
 stop the decolorizing process, or some prefer to pass 
 
— 79 — 
 
 it from the acid into alcohol. For immediate exami- 
 nation it is laid on a slide, the excess of liquid taken 
 up by blotting paper and examined. An immersion lens 
 is generally used to find these bacilli, but good dry 
 lenses are made of sufficient strength and definition. 
 Indeed, the bacilli may be recognized with 350 diam- 
 eters, although it is not desirable to use less than 500. 
 
 The finding of the gonococus is easy, practicable 
 and of decided importance in an ordinary case of gon- 
 orrhoea. The number present and their gradual dis- 
 appearance in the discharge as the disease improves, 
 are of decided assistance. Aside from this, the fact that 
 some cases of salpingitis and other inflammatory con- 
 ditions of the tubes or ovaries have been traced to an 
 old gonorrhoea in the male, makes the search for the 
 gonococcus very important in these obscure troubles. 
 
 The method of examination is very simple. A 
 little of the pus is pressed between two cover-glasses, 
 which are then drawn apart. Then the glasses are 
 allowed to dry, and are quickly passed through the 
 Bunsen flame to coagulate the albumen and fix the 
 pus. Then a few drops of the ordinary methylene 
 blue or violet* are allowed to cover the specimen for a 
 few minutes and washed off. The specimen may at 
 once be examined in water or glycerin, or it may be 
 dried and mounted in balsam, which makes it more 
 
 *This is made by adding enough of a concentrated alco- 
 holic solution of methylene blue or violet to distilled or clear 
 water to give it a decided color. 
 
— 8o — 
 
 distinct. The gonococci are seen in pairs or fours, 
 apparently in the pus cells, while the contour of the 
 pus cells is seen to be very indistinct, due to the Abb6 
 illuminator. 
 
 The best way to confirm the discovery of a micro- 
 organism is by cultivation and inoculation. This, of 
 course, is not possible in every case of urethretis. 
 Another way is by a process of staining which shall 
 exclude every other micro-organism. Dr. Gabriel 
 Roux, of Paris, says that if the preparation be first 
 stained according to Gram* and then be examined, 
 and then be decolorized with alcohol and examined 
 again, the gonococci will be seen stained at the first 
 examination, and will be unstained after decoloriza- 
 tion with alcohol. Allen]; and Wendt heartily con- 
 firm this. So far, I have not been doubtful in examin- 
 ing them myself, but as I have only looked for the 
 gonococci in cases where gonorrhoea was undoubtedly 
 present, my experience is of little value. 
 
 7. PAPILLOMA CELLS. 
 
 A villous cancer of the bladder may be suspected 
 when bits of malignant growths in large multinuclear 
 cells are found in the sediment. 
 
 *Gram's method consists in staining first with methylene 
 blue or violet, fixing the color with a solution of iodine in 
 iodide of potash, and then decolorizing with alcohol. 
 
 f Journal of Cutaneous and Genito-urinary Diseases, 
 March, 1887. 
 
Fig. 15.— Urinary Sediment. — A, Uric acid; B, Acid ammonium urate; 
 C, Sodium urate; D, Urea pitrate; E, (i) Leucin and (2) tyrosin; F, Cystin; G, 
 Magnesium ammonium phosphate or triple phosphate; H, Calcium phosphate; 
 I, Calcium oxalate; J, Blood corpuscles; K, Mucus and pus; L, Hsemin crystals; 
 M, (1) Hyaline casts, (2) Granular casts; N, Epithelial casts and cells; O, (i) Waxy 
 casts, (2) Casts with blood corpuscles, (3) Casts with fat globules. 
 
5. PARASITES. 
 
 Parasites are not very common in this latitude, 
 although occasional cases of filaria sanguinis hominis 
 are reported. The distoma haematobium, and echino- 
 ococci, have been found. 
 
 UNORGANIZED SEDIMENT. 
 
 It is not. easy to recognize all the varied kinds of 
 unorganized sediment; but those that occur most 
 commonly may be studied, and their recognition will 
 be of decided importance. The amorphous matter has 
 little significance under the microscope. The same salt 
 occurs under different shapes — some rarely seen and 
 some to be found in nearly every specimen examined. 
 
 URIC ACID. 
 
 Uric acid is present either as a slight reddish 
 sediment at the bottom of the vessel, or, if abundant, it 
 may be seen adherent to the sides of the vessel as brick- 
 dust sediment, and when abundant is commonly called 
 "sand" or "gravel." Those crystals have been com- 
 pared in shape to a whetstone, barrel, envelope, spear, 
 fan, comb, dumbbell, etc. This sediment may be dis- 
 solved on heating, or by adding caustic potash in solu- 
 tion. 
 
 URATES. 
 
 The sodium urates appear as fine amorphous gran- 
 ules, or as spherules with spicules or spines. The am- 
 monium urates are in the shape of "thorn apples." 
 
 6 TT 
 
— 82 — 
 OXALATES. 
 
 The oxalates occur principally as the oxalate of 
 lime crystals, which are in the shape of octohaedra, or 
 envelope and dumb-bell crystals. These crystals 
 have no special significance, although they may point 
 to mal-assimilation, when present. 
 
 PHOSPHATES. 
 
 The earthy phosphates occur principally as the 
 triple phosphates in a large variety of shapes. They 
 are found in alkaline urine in some affections of the 
 bladder. 
 
 LEUCIN AND TYROSIN 
 
 are found in the urine in certain abnormal conditions 
 of the liver. They are easily recognized in the sedi-* 
 ment, or may be found on evaporating the urine. 
 
CHAPTER V. 
 
 THE URINE IN DISEASE. 
 
 FEVER. 
 
 Quantity diminished, acid, of high specific grav- 
 ity, dark color, abundant sediment of the urates. A 
 microscopical examination may show, in addition, 
 hyaline casts; albumen may be present. 
 
 Disturbance of circulation. 
 
 Much like the ^next condition, except that the 
 albuminuria may be more lasting. 
 
 ACUTE NEPHRITIS. 
 
 In the beginning of this disease the quantity is 
 diminished, acid, of high specific gravity, but not as 
 high as in the last condition named. The urine is 
 red from the presence of blood, and albumen is pres- 
 ent. In the sediment are found red blood-corpuscles, 
 leucocytes, renal and bladder epithelium, casts of 
 blood. 
 
 CHRONIC NEPHRITIS. 
 
 Urine slightly diminished in quantity, acid, of 
 normal specific gravity, much albumen. In the sedi- 
 ment are found epithelial cells, which have undergone 
 fatty degeneration, also different kinds of casts, but 
 
- 84 - 
 
 especially granular; aiso blood and epithelial casts 
 and casts covered with fat crystals. The presence of 
 these fat crystals and fatty cells points to chronic 
 nephritis. 
 
 CONTRACTED KIDNEY. 
 
 Urine increased in amount, acid, specific gravity 
 1008 to 1012 aud lower with startling exceptions, 
 color pale, little albumen and very little sediment, in 
 which diligent search will show the presence of a few 
 hyaline or slightly granular casts. 
 
 AMYLOID KIDNEY. 
 
 Urine much like the last condition. 
 
 DIABETES MELLITUS. 
 
 Quantity enormously increased, specific gravity 
 1030 and higher. Occasionally albumen. 
 
 DIABETES INSIPIDUS. 
 
 Quantity greatly increased, specific gravity very 
 low, often 1002. No albumen. No danger except 
 at rare intervals. 
 
 UR.^MIA. 
 
 The amount of urine is much decreased, often to 
 anuria, but in exceptional cases it may be normal in 
 amount but with low specific gravity. Albumen and 
 casts are usually present. 
 
- 8s - 
 
 CYSTITIS. 
 
 The urine is acid unless it lies in the bladder and 
 undergoes ammoniacal fermentation, when it is 
 strongly alkaline. It is cloudy and contains a heavy 
 sediment of fatty, swollen leucocytes and triple phos- 
 phate crystals. There is much pus, and layers of 
 bladder epithelium and also blood present. 
 
 CALCULI. 
 
 They may be suspected when intermittent haema- 
 turia occurs from the bladder and the blood is not 
 intimately mixed with the urine, but as a thick clot 
 or sediment lies at the bottom of the vessel. 
 
 Tuberculosis and gonorrhoea may both be recog- 
 nized by the staining methods already given. In di- 
 gestion troubles, and principally in carcinoma of the 
 stomach, the indican is increased in amount, but this 
 is by no means pathognomonic, for the same is true 
 in constipation. In certain cases of poisoning the 
 substance may be detected by careful tests, but such 
 tests are usually referred to the analytical chemist.' 
 The presence of certain drugs may be detected in the 
 urine, but their presence has little significance except 
 that they may affect the more common tests for sugar, 
 albumen, etc. For instance, arsenic in the urine is 
 said to act very much as sugar, reducing the copper 
 in Fehlng's test. 
 
CHAPTER VI. 
 
 4, REAGENTS AND APPARATUS. 
 
 In order to be able to examine urine with'^proper 
 care, the apparatus and reagents should always be 
 ready. To this end, the physician who makes any 
 pretensions to examining urine regularly should have 
 at one end of his office, preferably near running water, 
 a table or shelf large enough to hold a series of bot- 
 tles, a test-tube rack and all other necessities, and in 
 this table several small drawers in which extra appa- 
 ratus may be kept. Everything should be scrupul- 
 ously clean and cleaned after each using, and the re- 
 agent bottles should always be kept filled, ready for 
 use. It very often happens that a friend or physician 
 will call with a specimen of urine to be examined for 
 sugar or albumen at once. In such a case a bad im- 
 pression is made, and loss of such work is entailed, 
 if everything is not in proper order. Although the 
 •compact examining cases are very convenient at the 
 bedside or in an emergency, the office-testing with 
 table and apparatus is much to be preferred. The 
 following are indispensable, other articles mentioned 
 in this work may be added: 
 
 Concentrated hydrochloric or muriatic acid C. P. 
 " nitric " " 
 
 " sulphuric " " 
 
 " acetic " " 
 
 Glacial acetic acid. 
 
- 87 - 
 
 Solution of caustic potash or caustic soda, i part to 2 of 
 water. 
 
 Solution of sodium carbonate, i part of water to 3 parts 
 sodium carbonate. 
 
 Liquor ammoniae. 
 
 Solution of sulphate of copper (i to 10 or 20). 
 silver nitrate, I to 8 of water. 
 
 Subnitrate of bismuth. 
 
 Chloroform. 
 
 Alcohol. 
 
 Common salt. 
 
 Apparatus. — Test-tubes, conical glasses, litmus 
 paper, urinometer and glass, spirit lamp or Bunsen 
 burner, microscope and lenses, filter paper, glass ves- 
 sels, rods, etc., etc. 
 
CHAPTER VII. 
 
 ORDER OF ANALYSIS. 
 
 The urine is collected in a large vessel, and after 
 standing for a few hours the upper part is poured off 
 and the sediment put aside for microscopical exami- 
 nation. After noting the amount in twenty-four hours, 
 color, consistency, transparency, smell, reaction, spe- 
 cific gravity and quantity of sediment, a little of the 
 clear urine is poured into a test-tube and heated to 
 the boiling point. If a cloudiness arise, it is due 
 either to albumen or to the earthy phosphates. Add 
 one or two drops of acetic acid, and if the cloudiness 
 disappear it was due to the phosphates; if it remain, 
 it is albumen. Then add one-half as much of a caus- 
 tic potash solution as there is urine in the test-tube, 
 and if albumen be present it will be dissolved, while 
 the earthy phosphates fall as a thick white cloud to 
 the bottom of the tube. If the earthy phosphates 
 become brown on heating, sugar is most probably 
 present; if red, blood-coloring matter. In the latter 
 case albumen is probably also present, and the pres- 
 ence of the hsemin crystals and the red blood-corpus- 
 cles may be demonstrated by the microscope. The 
 sediment should then be examined microscopically. 
 In making many examinations, it is generally more 
 convenient to have a blank form in which the results 
 
 ll 
 
- 89 - 
 
 may be systematically recorded for oneself or for 
 another physician. 
 
 The following will be found convenient: 
 
 EXAMINATION OF URINE. 
 For at the request of Dr 
 
 THYSICAL PROPERTIES, 
 
 Quantity in 24 hours Specific gravity 
 
 Color Quantity and character of 
 
 Reaction the sediment 
 
 Odor 
 
 ABNORMAL CONSTITUENTS IN SOLUTION. 
 
 Albumen Bile 
 
 Sugar * 
 
 SEDIMENT. 
 
 Casts Oil 
 
 Pus Crystals 
 
 Blood Date . . . 
 
 Nc 
 
y 
 
INDEX, 
 
 A. Page. 
 
 Albumen 30 
 
 Quantitative Estimation of 41 
 
 Tests for 31 
 
 Albuminuria, Cyclic 36 
 
 Amount of Urine i 
 
 B. 
 
 Bacteria 75 
 
 Bile , 59 
 
 Blood 55 
 
 Corpuscles 6g 
 
 Tests for 57 
 
 C. 
 
 Casts 72 
 
 Chlorides 26 
 
 Color of Urine 3 
 
 Cyclic Albuminuria 36 
 
 E. 
 
 Epithelium 70 
 
 I. 
 
 Indican 25 
 
 L. 
 
 Leucin and Tyrosin 82 
 
 M. 
 
 Mucous and Pus Cells 69 
 
— 92 — 
 
 N. Page. 
 
 Normal Constituents of the Urine 13 
 
 O. 
 
 Order of Analysis 88 
 
 Oxalates 82 
 
 Oxalic Acid 25 
 
 P. 
 
 Papilloma Cells 80 
 
 Parasites 81 
 
 Phosphates 28, 82 
 
 Pus 58 
 
 R. 
 
 Reaction 5 
 
 Reagents and Apparatus 86 
 
 s. 
 
 Sediment 61 
 
 Smell of Urine 4 
 
 Specific Gravity 7 
 
 Spermatozoa 75 
 
 Sugar 43 
 
 Comparative Value of Tests for 53 
 
 Quantitative Estimation of 51 
 
 Tests for 45 
 
 T. 
 
 Tables to Facilitate Calculations in the Use of the Ureo- 
 
 meter 20, 21 
 
 Transparency and Consistency 5 
 
 U. 
 
 Unorganized Sediment ^. 81 
 
 Urates 81 
 
 Urea 13 
 
 Crystals of Nitrate of 14 
 
— 93 — 
 
 Page. 
 
 Ureometer 17 
 
 Uric Acid 23, 81 
 
 Urine, Amount of i 
 
 Color of 3 
 
 in Disease 83 
 
 Reaction of 5 
 
 Smell of 4 
 
 Specific Gravity of 7 
 
 Transparency and Consistency 5 
 
 Urinometer 8 
 
PICHI. 
 
 AN EMOLLIENT, SEDATIVE, AND DIURETIC IN DISEASES 
 OF THE URINARY ORGANS. 
 
 Of the remedies which have recently been added to the materia 
 medica none so thoroughly as Pichi have been proved to possess specific 
 action in certain hitherto difficultly curable conditions. 
 
 Pichi is undoubtedly a valuable sedative and emollient in inflamma- 
 tion of the mucous membranes of urinary organs. It possesses also 
 considerable diuretic action. 
 
 In cases of vesical catarrh, acute or chronic, following a mechanical 
 cause, such as gravel or calculus, or a uric acid diathesis, this remedy 
 will quickly modify the urinary secretion, calm the irritability, and favor 
 the expulsion of the gravel and calculi that can be passed through the 
 urethra. 
 
 It favorably modifies also purulent mucous secretions. Its action in 
 affections of the liver must be attributed to its diuretic properties, though 
 it is recommended for icterus, hydropsy, and dyspepsia due to insufficient 
 biliary secretions. In this case the essential oil, when absorbed and 
 carried into circulation, acts as a stimulant of the secretory apparatus in 
 general, but the specific action of Pichi is directed without doubt upon 
 the organs of the urinary apparatus. 
 
 The pharmaceutical preparations of Pichi are as follows: 
 
 Fluid Extract and Powdered Extract Pichi, and Soluble Elastic Cap- 
 sules Pichi, each containing four grains of a specially prepared extract, 
 representing the active medicinal constituents of thirty grains of the 
 drug. 
 
 PARKE, DAVIS & CO., 
 
 DETROIT AND NEW YORK. 
 
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IN EXPLANATION 
 
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 We have made a new departure in the pubUcation of medical books. As you 
 no doubt know, many of the large treatises published, which sell for four or five or 
 more dollars, contain much irrelevant matter of no practical value to the physi- 
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 PRICE: PAPER, 25 CT?. PER COPY, $2.50 PER SET; CLOTH, 50 CTS. PER COPY, 
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 SEIMES I. 
 
 Inhalers. Inhalations and Inhalants. 
 By Beverley Robinson, M. D. 
 
 The Use of Electricity in the Removal of 
 Superfluous Hair and the Treatment of 
 Various Facial Blemishes. 
 By Geo. Henry Fox, M. D. 
 New Medications, Vol. 1. 
 
 By Dujardin-Beaumetz, M. D. 
 
 New Medications) Vol. 11. 
 
 By Dujardin-Beaumetz, M. D. 
 
 The Modern Treatment of Ear Diseases. 
 By Samuel Sexton, M. D. 
 
 The Modern Treatment of Eczema. 
 By Henry G. Piffard, M. D. 
 
 Antiseptic Midwifery. 
 
 By Henry J. Garrigues, M. D. 
 
 On the Determination of the Necessity for 
 Wearing Glasses. 
 
 By D. B. St. John Roosa, M. D. 
 The Physiological, Pathological and Ther- 
 apeutic Effects of Compressed Air. 
 By Andrew H. Smith, M. D. 
 GranularLidsandContagiousOphthalmia. 
 
 By W. F. Mittendorf, M. D. 
 Practical Bacteriology. 
 
 By Thomas E. Satterthwaite, M. D. 
 Pregnancy, Parturition, the Puerperal 
 State and their Complications. 
 By Paul F. Mundg, M. D. 
 
SERIES II. 
 
 The Diagnosis and Treatment of Haem- 
 orrhoids 
 By Chas. B. Kelsey, M. D. 
 
 Diseases of the Heart, Vol. I. 
 
 By Dujardin-Beaumetz, M. D. 
 
 Diseases of the Heart, Vol. li. 
 By Dujardin-Beaumetz, M. D. 
 
 The Modern Treatment of Diarrhoea and 
 Dysentery. 
 
 By A. B. Palmer, M. D. 
 Intestinal Diseasses of Children, Vol. I. 
 By A. Jacobi, M. D. 
 
 Intestinal Diseases of Children, Vol. II. 
 by A. Jacobi, M. U. 
 
 The Modern Treatment of Headaches. 
 By Allan McLane Hamilton, M. D. 
 
 The Modern Treatment of Pleurisy and 
 Pneumonia. 
 
 By G. M. Garland, M. D. 
 Diseases of the Male Urethra. 
 
 By Fessenden N. Otis, M. D. 
 The Disorders of Menstruation. 
 
 By Edward W. Jenks, M. D. 
 The Infectious Diseases, Vol. I. 
 
 By Karl Liebermeister. 
 
 The Infectious Diseases, Vol. II. 
 By Karl Liebermeister. 
 
 SERIES III. 
 
 Abdominal Surgery. 
 
 By Hal C. Wyman, M. D. 
 
 Diseases of the Liver- 
 
 By Dujardin-Beaumetz, M. D. 
 
 Hysteria and Epilepsy. 
 
 By J. Leonard Corning, M, D. 
 
 Diseases of the Kidney. 
 
 By Dujardin-Beaumetz, M. D. 
 
 The Theory and Practice of the Ophthal- 
 moscope. 
 
 By J. Herbert Claiborne, Jr., M. D. 
 
 Modern Treatment of Bright's Disease. 
 By Alfred L. Loomis, M. D. 
 
 Clinical-Lectures on Certain Diseases of 
 Nervous System. 
 
 By Prof. J. M. Charcot, M. D. 
 The Radical Cure of Hernia. 
 
 By Henrv O. Marcy, A M., M. D., 
 L. L. D. 
 Spinal Irritati en. 
 
 By William A. Hammond, M. D. . 
 Dyspepsia. 
 
 By Frank Woodbury, M. D. 
 The Treatment of the Morphia Habit. 
 
 By Erlenmeyer. 
 The Etiology, Diagnosis and Therapy of 
 Tuberculosis 
 
 By Prof. H. von Ziemssen. 
 
 SERIES IJl, 
 
 IMervous Syphilis. 
 
 ByH. C. Wood, M. D. 
 
 Education and Culture as correlated to 
 the Health and Diseases of Women. 
 By A. J. C.Skene, M. D. 
 
 Diabetes. _ 
 
 By A. H. Smith, M D. 
 
 A Treatise on Fractures. 
 
 By Armand Despres, M. D. 
 Some Major and Minor Fallacies concern- 
 ing Syphilis. 
 
 By E. L. Keyes, M .D. 
 Hypodermic Medication. 
 
 By Bourneviile and Bricon. 
 
 Practical Points in the Management of 
 Diseases of Children. 
 By L N. Love, M. D. 
 
 Neuralgia. 
 
 By E. P. Hurd, M. D. 
 Rheumatism and Gout. 
 
 By F. Le Roy Satterlee, M. D. 
 Electricity, Its Application in Med'cme. 
 
 By Wellington Adams, M.D. [Vol.I] 
 Electricity, Its Application In Medicine. 
 
 By Wellington Adams, M.D. [V'ol.II] 
 Auscultation and Percussion. 
 
 By Frederick C. Shattuck, M. D. 
 
SERIES IZ. 
 
 Taking Cold. 
 
 By F. W. Bosworth, M. D. 
 
 Practical Notes on Urinary Analy- 
 sis. 
 
 By William B. Canfield, M. D. 
 
 Practical Intestinal Surgery. Vol. I. 
 Practical Intestinal Surgery. Vol. II- 
 
 By F. B. Robinson. M. D. 
 Lectures on Tumors. 
 
 By John B. Hamilton, M, D., LL. D. 
 
 Pulmonary Consumption, a Ner- 
 vous Disease. 
 
 By Thomas J . Mays, M . D . 
 
 Lessons In the Diagnosis and 
 Treatment of Eye Diseases. 
 
 By Casey A. Wood, M. D. 
 
 Diseases of the Bladder and Pros- 
 tate. 
 
 By Hal C. Wyman, M. D. 
 
 Artificial Aneesthesia and Anaes- 
 thetics. 
 
 By DeForest Willard, M. D., and Dr. 
 Lewis H. Adler, Jr. 
 
 Cancer. 
 
 By Daniel Lewis, M. D. 
 
 The Modern Treatment of Hip Dis- 
 ease. 
 
 By Charles F. Stillman, M. D. 
 
 Insomnia and Hypnotics. 
 
 By Germain See. 
 
 Translated by E P. Hurd, M. D. 
 
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 FHTSICIANS' PERFECT VISITING LIST... 1.50 
 
 Bv G. Archie Stockwell, M. D. 
 A NEW TREATMENT OF CHRONIC METRITIS .50 
 
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 MICROSCOPICAL DIAGNOSIS 4.00 
 
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