NOTES ON THE Cl .> CLINICAL EXAMINATION OF THE BLOOD AND EXCRETA BY SIDNEY COUPLAND M.D., F.R.C.P. PHYSICIAN TO THE MIDDLESEX HOSPITAL, AND LECTURER ON PRACTICAL MEDICINE IN THE MEDICAL SCHOOL J LATE EXAMINER IN MEDICINE AT THE EXAMINING BOARD FOR ENGLAND LONDON H. K. LEWIS, 136, GOWER STREET, W. C. 1892 J N preparing the third edition of this little book I have endeavoured to make it more accurate in certain particu- lars without changing its character. I am indebted to Professor Tirard for some valuable suggestions in the sections on the Urine ; and to my house physician, Mr. E. Hill, for the description of the use of Dr. Johnson’s Picro-saccharimeter. S. C. London, October 1892 . ^3-^ 0,^0= CONTENTS PAGE THE BLOOD. Reaction — Specific Gravity 5 Estimation of Hemoglobin ... 6 Microscopical Examination . . 7 THE SPUTUM. General Characters and Composition . 12 Microscopical Examination . . .14 Method of Staining Tubercle Bacilli . 19 THE VOMIT. Characters 23 Examination — Microscopical . . .26 THE FAECES. Characters and Composition . . .27 Intestinal Worms 30 Microscopical Examination . . *32 THE URINE. General and Physical Characters . . 34 Sedimentary Deposits 38 Qualitative Analysis 39 Quantitative Analysis— 1. Urea 49 2. Sugar 54 3. Albumen 57 Microscopical Examination . . -58 Weights and Measures 63 Percentage Table 64 NOTES ON THE CLINICAL EXAMINATION OF THE BLOOD AND EXCRETA. THE BLOOD. For clinical purposes it is sufficient to examine a drop of blood obtained from a puncture of the finger, which should first be thoroughly cleansed. The puncture should be made with a perfectly clean needle, and, as far as possible, undue pressure of the finger should be avoided. Reaction. The degree of alkalinity varies. It may be determined by the use of specially prepared glazed litmus papers, previously treated by varying quantities of oxalic acid (Haycraft and Williamson). A drop of blood is allowed to remain for half a minute on a paper of medium acidity, and is then washed off. 6 Notes on the Clinical Examination Should it give a reaction, a stronger paper is tested with another drop until the limit is reached. If it gives no reaction, a paper of weaker acidity is taken, and so on. Specific gravity. A drop of blood is allowed to fall into tube containing a mixture of glycerine and water. When the mixture is of such a degree of dilution that its specific gravity is the same as that of the blood, the drop of latter will remain suspended in it. Or the same procedure may be followed in using a mixture of benzol and chloroform ; small additions of one or other of these liquids being made until the blood-drop is suspended. The specific gravity of the mix- ture will then correspond with that of the blood. Estimation of haemoglobin. The percentage amount of haemoglobin may be approximately arrived at by the use of Gowers’ haemoglobinometer. This consists of a small graduated tube (ioo divisions in 2 centimetres), which would, if filled up to that point (ioo) with 20 cub. mm. of normal blood and distilled water, give a tint corre- of the Blood and Excreta . / sponding to a standard (composed of glycerine jelly and picrocarmine) kept in a tube of the same calibre. Method . — From a puncture in the finger there is drawn into a pipette 20 cub. mm. of blood, which is carefully ejected into the gradu- ated tube. To this distilled water is added, and the blood thoroughly mixed with it ; as soon as the tint of the diluted blood equals that in the standard tube, no more water is added, and the degree attained will represent the percentage of haemoglobin in the specimen of blood examined. [Haemoglobin diminished in anaemia : in chlorosis, out of proportion to corpuscles.] Microscopical examination. 1. Red corpuscles . {a) Note whether rouleaux form speedily. [In anaemic and hydraemic states there may be no rouleaux.] (h) Size . — Average diameter is 7*5 /jl; but variations at different life-periods, and in disease. [Small spheroidal coloured corpuscles (micro- cytes), and unusually large forms (megalocytes), met with in anaemia.] 8 Notes on the Clinical Examination (c) Shape . — Considerable variations from the characteristic disc-shape, especially observed in progressive pernicious anaemia and in other chronic conditions. This change (poikilocytosis), depending apparently on undue plasticity of cor- puscles, as well as on their disintegration, results in appearance of tailed, pear-shaped, coloured bodies, and other irregular masses and granules. (d) Number . — Estimated by the haemacy- tometer, of which there are several forms. The simplest is that of Gowers. It consists of a micrometer scale engraved on a glass slide, and surrounded by a cell \ mm. in depth. The scale is ruled in squares, each measuring ^ mm. A drop of blood (5 cub. mm.) taken up in a capillary pipette is diluted to 200 times its bulk with saline solution (sulphate of soda, 104 grains, acetic acid, 1 drachm, distilled water, 4 ounces). Thus, 995 cub. mm. of this solution is placed in a small glass beaker, to which the 5 cub. mm. of blood is added, and the mixture thoroughly stirred. A drop of the diluted blood is placed in the cell, and the number of corpuscles which subside in each square can then be counted. of the Blood and Excreta. 9 Count the corpuscles in (at least) io squares, and strike the average. The number of corpuscles per cub. mm. of blood is arrived at by multiplying the average contents of a single square by 100,000. [For the contents of each square must be multiplied by (5 x 5) x (10 x 2), to be equi- valent to 1 cub. mm., and as the blood was diluted 200 times, this must be further multi- plied by 200.] The average number for normal blood is about 5,000,000 per cub. mm., which would give an average in each square of 50, or in every two squares of 100. Hence the contents of two squares will represent the percentage composition in corpuscles as com- pared with the healthy standard. [Red corpuscles diminished in all con- ditions of anaemia. Most markedly after profuse haemorrhage, and in pernicious anaemia. In the latter affection it is important to make repeated numerations.] 2. White corpuscles (leucocytes). Considerable variation in shape, size, and number in health. Relative increase in number in anaemia. io Notes on the Clinical Examination Absolute increase in leukhaemia. Numeration by haemacytometer may be made at the same time as that of red cor- puscles. But, owing to the much smaller number (except in leukhaemia) of the leuco- cytes, the contents of several squares must be observed. [A low power may be used, for these bodies are readily recognised by their bright refractile aspect.] 3. Fibrin, protoplasmic granules , etc. In febrile and inflammatory states the microscopic field is speedily covered by a network of fibrin. “ Blood platelets/’ “ granular masses/’ etc., occur in various states, not as yet fully defined. 4. Crystals. Crystals of haemoglobin have been found in haemoglobinuria and leukhaemia (Cope- man). Charcot-Leyden crystals (see p. 17) in leukhaemia. 5. Pigment. Free pigment granules (haematin) in haemo- globinuria. Small masses of pigment in melanaemia. of the Blood and Excreta . 1 1 6. Parasites. (a) Filaria sanguinis hominis. — Embryos filiform, about 0*35 mm. in length, enter lymphatic and blood stream periodically (during the hours of rest) from the parent- worm, which is usually lodged in the deeper lymphatic channels. Chyluria, lymph-scro- tum, elephantiasis, are the usual concomitant conditions, referable to lymphatic obstruc- tion. (b) Spirillum of relapsing fever (Obermeier). (c) Bacillus anthracis. — In malignant pustule and woolsorter’s disease. (d) Bacillus tuberculosis . — Rarely detected. (e) Streptococci and staphylococci. — Have been found in erysipelas, pyaemia, scarlet fever, ulcerative endocarditis. Amongst other organisms which have been met with in the blood are the plasmodium malariae, bacillus of typhoid, bacillus of glanders, and bacillus of tetanus 1 2 Notes on the Clinical Examination THE SPUTUM. General Characters and Composition. Mucoid, muco-purulent, purulent, watery’ serous, sero-sanguinolent. Aerated ; non-aerated. Thin, fluid. Thick, viscid, tenacious. Homogeneous ; nummulated. Colourless, yellowish, greenish, bile-stained, blood-stained, rusty, pigmented. Certain of the characters of the sputa best observed when they are suspended in water. “ Nummulation 99 is thus well shown. Also the presence of membranous shreds, bronchial casts, blood-clots, and other solid constituents. For they may contain : — Cheesy and calcareous masses. Particles of coal and other dust. Fibrinous casts in acute pneumonia and croupous bronchitis (v. p. 16). Membranous exudations in laryngo-tracheal diphtheria. Hydatid membrane. Foreign matter, as cotton fibre, hairs, food- particles, etc. In acute bronchitis , the sputum is at first aerated, mucoid, often pigmented, later muco-purulent. of the Blood and Excreta . 13 In chronic bronchitis , muco-purulent, pigmented ; or purulent and nummular, and perhaps non-aerated. In plastic bronchitis , mucoid, perhaps blood-streaked, containing bronchial fibrinous casts. In bronchiectasis , profuse, purulent, foetid. In phthisis ( a ) early, mucoid, streaked with blood or pus ; (b) advanced , purulent, nummular. In acute pneumonia, at first scanty, viscid, rusty, orange- coloured, blood-stained or of “ prune-juice ” character; afterwards greyish, muco-purulent. In pulmonary gangrene , very foetid, greenish or greenish-black, separating, on standing, into three layers — an upper, frothy and greenish ; middle, liquid, serous ; and lower, a thin brownish sediment. In pulmonary abscess , in empyema discharging through a bronchus, or other abscess opening into lung, the sputa may consist of pure pus, which may or may not be foetid. In pulmonary oedema , copious, thin, serous or sero- sanguinolent, often non-aSrated. In acute pulmonary congestion , aerated, intimately mixed with bright blood ; chronic congestion , markedly blood-stained. In pulmonary embolism , pure blood or of “prune- juice” character. In cancer of lung, sanguinolent. Hemoptysis. Blood may occur in the sputum from the rupture of vessels directly connected with lungs and bronchi ; or from other sources, as epistaxis, bleeding from gums, pharynx, 14 Notes on the Clinical Examination etc. In the latter class, distinguished as spurious haemoptysis, the sputa are very little else than blood- stained saliva, seldom of large amount, and forming a thin reddish or blackish-red fluid. True haemoptysis may occur in (i) ulceration of larynx ; (2) early phthisis, the blood being florid, of variable amount, sometimes only in streaks ; (3) advanced phthisis, from rupture of a pulmon- ary aneurism, when the blood is often in large amount and dark ; (4) plastic bronchitis ; (5) pulmonary congestion ; (6) pulmonary embolism, — both (5) and (6) occurring especially in association with mitral disease ; (7) hydatid of lung ; (8) cancer of lung ; and (9) aneurism (of aorta) rupturing into trachea or bronchus. Microscopical Examination. Take up by pointed glass rod or forceps a small portion and place it on a slide ; press down cover slip. Examine first without ad- dition of reagents ; then add drop of dilute acetic acid; and to another specimen some liquor potassae. Iodine or carmine may be added to stain cells. 1. Mucus corpuscles, leucocytes, pus corpuscles, often fattily degenerated. 2. Red blood corpuscles. 3. Epithelia. (a) Squamous — buccal. (b) Ciliated — from nose or trachea. of the Blood and Excreta . IS (i c ) Columnar — from trachea or bronchi. (d) Spheroidal or elliptical, finely granular, often containing granules of black pigment — from pulmonary alveoli ; generally contain oil globules and myeline masses. [In cases of malignant disease of larynx or lung some cancer cells may occur in the sputum, but they are seldom distinctive. The most characteristic are the cell-nests of squamous epithelioma from larynx.] [Nuclei brought into view by staining or by addition of acetic acid.] 4. Elastic tissue. May be detected by adding caustic soda or potash to specimen; or more effectually by collecting large quantity of sputum, and boil- ing it with equal amount of solution of caustic soda, until it has lost viscidity (avoid over- boiling) ; pour mixture into conical glass, and add 4 or 5 times quantity of cold distilled water. Set aside, and after 2 or 3 hours examine deposit. Recognise elastic tissue by its curling fibres with dark borders. (In phthisis the fibres may retain outlines of alveoli.) The detection of elastic tissue, especially if it retain 1 6 Notes on the Clinical Examination alveolar arrangement, is almost pathognomonic of pul- monary disorganisation. Fragments of such tissue are., however, also met with in chronic laryngitis, bronchitis, bronchiectasis, and chronic pneumonia. [N.B. — Cotton fibres, etc., not to be mistaken for elastic fibres.] 5. White fibrous tissue. (Seldom occurs, except in cases of abscess and pulmonary gangrene.) 6. Curschmann’s spirals. Consist mostly of whitish central thread covered by fine twisted fibrils, often entangling epithelial elements. These curious constituents of sputa are often sufficiently large to be visible to the unaided eye. They are of frequent occurrence, especially in capillary bronchitis and asthma ; and may be associated with Charcot- Leyden crystals (y.z/.). They are believed to be formed in the finest bronchioles. 7. Bronchial tube casts. Composed of fibrinous or croupous exuda tion ; distinguished by dichotomous division corresponding to bronchial ramifications. Small fibrinous casts may sometimes be detected in the rusty expectoration of acute pneuvionia. Larger forms, sometimes much branched, and either solid or tubular, are characteristic of plastic bronchitis. of the Blood and Excreta. 17 Shreds of membrane may be expectorated in diph- theria ; they are composed of fibrin entangling epithelia and leucocytes. 8. Corpora amylacea. Rare ; met with in pulmonary haemorrhage (Friedreich) and in gangrene. 9. Crystals. (a) Char cot-Ley den crystals . — Colourless, pointed octahedra, insoluble in cold water, ether, alcohol, chloroform ; soluble in alkalies, mineral acids, hot water, acetic acid. Met with in asthma (often with 6) and bronchitis, acute and chronic. Similar crystals were discovered in leukhcemic blood by Charcot they also occur in semen. ( b ) Hecmatoidin. — Long rhomboids or needles of ruby-red colour. May occur after haemoptysis, and in chronic congestion from heart disease. (c) Cholesterine . — Highly retractile, rhombic plates, often with one angle cut out, as it were ; soluble in chloroform; turning red with sul- phuric acid. In phthisis and abscess of lung. (d) Fat crystals (stearin, palmitin). — Very 2 1 8 Notes on the Clinical Examination pointed, acicular, in bundles ; soluble in ether and hot alcohol, insoluble in water and acids. In putrid bronchitis, bronchiectasis, pulmonary gan- grene. (e) Tyrosin , as masses of acicular crystals. (In same conditions as d.) {/) Ammonio-magnesium phosphate , and oxa- late of lime occasionally. io. Fungi. A. Non-Pathogenic. a. Moulds, as oi'dium albicans, aspergillus. b. Yeasts, as torula. c. Bacteria (including leptothrix buccalis) and micrococci (including sarcina pulmonis). B. Pathogenic. a. Bacillus tuberculosis, — Small, slightly curved rods (measuring i m $n to 3'5f), often containing spores (from 2 to 6), which give the bacilli a beaded appearance. For their detection special selective staining is required. The presence of these bacilli in the sputum is diag- nostic of a tubercular lesion in the air-passages or lungs. In acute miliary tuberculosis, however, they may be so scanty as not to be detected in the sputa after repeated examination. They are especially abund- of the Blood and Excreta. 19 ant in pneumonic phthisis, i.e ., where caseation and excavation are progressing rapidly. It is stated that abundance of bacilli with scanty expectoration indi- cates a limited lesion. In a given case the numbers of bacilli met with may vary from day to day ; and not much reliance can be placed upon their relative abund- ance in respect to prognosis. Other clinical facts have more significance in this matter. Method of Staining Tubercle Bacilli.* 1. Select opaque particles of sputum to size of a large pin’s head. 2. Spread out an even layer by pressing between two cover-glasses, and sliding them apart. 3. Dry between fingers over flame, smeared side downwards. 4. Pass three times quickly through flame to fi albumen, etc. 5. Place 3 drops of Neelsen’s solution on preparation, and warm till steam rises. [N.B. — Take care not to burn or warm un- evenly. Tilt about cover slips.] 6. Wash off excess of stain, and decolorise in acid (i.e., either H 2 S 0 4 — 25 p.c., or HN 0 3 Kindly furnished by Dr. Essex Wynter, 20 Notes on the Clinical Examination — 33 P- c -)> taking care to remove all stain. Test by frequent washing until it becomes a lavender tint. [Time, about 15 seconds.] 7. Wash off all acid thoroughly and put on one drop of methylene blue (concentrated watery solution). [Time, about 5 seconds.] 8. Wash off and dry in fingers over flame. 9. Mount in cedar oil (temporarily), or in xylol or balsam of Peru, or in Canada balsam. Neelsen's solution : — Fuchsine, 1 part, dis- solved in a 5 per cent, watery solution of car- bolic acid, 100 parts; alcohol, 10 parts. By this method the bacilli are stained of a red colour ; pus cells, etc., blue. Another Method. 1. Select opaque particles of sputum to size of a large pin’s head. 2. Spread out an even layer by pressing between two cover-glasses, and sliding them apart. 3. Dry between fingers over flame, smeared side downwards. 4. Pass three times quickly through flame to fix albumen, etc, of the Blood and Excreta. 2 1 5. Float cover-glass on surface of few drops of Weigert-Ehrlich solution in watch glass. 6. Warm over flame till vapour is seen to rise from surface. 7. Remove specimen from watch glass and allow it to cool. 8. Wash it in nitric acid (1 in 4). 9. Then in distilled water. 10. Then in weak alcohol. 11. Dry and mount in Canada balsam. Weigert-Ehrlich solution : — Saturated aqueous solution of aniline, 100 c.c. ; saturated alcoholic solution of fuchsine, 10 c.c. By this method also the bacilli are stained of a bright red ; and the specimen may, if desired, be counter-stained a blue colour by immersion in methylene blue solution. Or instead of fuchsine, methyl-violet or gentian- violet (saturated alcoholic solution) may be used in the primary stain ; in which case the bacilli have a blue colour; and the specimen may be counter-stained by vesuvin or Bis- marck-brown (filtered aqueous solution). b. Diplococcus pneumonia . Specimens pre- pared as above, but without decolorisation by nitric acid. Or the cover-glass preparation of 2 2 Notes on the Clinical Examination dried sputum allowed to float on surface of gentian-violet solution and aniline water for 5 minutes, then treated with solution of iodine (1 part) in iodide of potassium (2 parts) and water (300 parts). Wash in water and alcohol, dry, and mount in xylol. The diplococcus is characterised by a clear capsule. [Other micro-organisms in pneumonic sputa _ are the bacillus pneumoniae (Friedlander), streptococci and staphylococci.] c. Actinomyces or Ray-fungus. Of rare oc- currence in human subject, composed of clavate-shaped bodies radially arranged. Masses of the fungus are visible to the naked eye as bright yellow grains mingled with the expectorated pus. It may be stained in the same manner as b. 11. Infusoria. Monas and Cercomonas (met with in pulmon- ary gangrene). 12. Vermes. a. Echinococcus . Hydatid membrane (lami- nated) or hooklets. b. Bilharzia. Ova — spicule at one extremity. (This parasite has been found in the lung.) of the Blood and Excreta. 23 THE VOMIT.* Reaction . — Acidity may be due to normal gastric juice (HC 1 mainly) or to products of fermentation (acetic, lactic, butyric acids chiefly). Reaction may be neutral, or even alkaline ( e.g ., watery vomit, which is largely due to saliva). Characters . — May be watery, mucous, san- guinolent, biliary, purulent, faecal. May consist largely of : — 1. Water or saliva; thin, colourless, clear fluid (as in “ water-brash,” “ morning sickness,” “ hysterical ” vomiting). 2. Mucus, mingled with gastric juice (as in gastric catarrh). 3. Ingesta, in variable amount, and either quite undigested or semi-digested. (Note especially masses of casein from curdled milk.) 4. Fermentation-products (sarcinous vomit) often of frothy, “ yeasty” character and sour odour. (Best seen in cases of dilated stomach from pyloric stricture, where vomiting occurs at long intervals and in large amount.) Exclusive of cases of poisoning. 24 Notes on the Clinical Examination 5. Bile, frequently mingled in small amount with mucus and gastric juice. This “ bilious vomiting” has mostly a bright green colour (which may deepen on exposure), due to pro- duction of biliverdin by action of the acids of gastric juice. (In “ cerebral ” vomiting, in acute peritonitis, and other conditions where vomiting is repeated frequently and in small amount.) 6. Blood, in variable quantity. If copious haemorrhage may then have blackish clots and much fluid blood, but slightly altered ; or if it has remained long enough in the stomach to be acted on by gastric juice (or in the case of mineral acid poisons, when this change is at once effected), the vomit has the characteristic “ coffee-ground ” colour due to action of acid on the haematin of blood. ILematemesis. Blood in vomit may not be derived directly from the stomach, but may come from epistaxis, or from pharynx or oesophagus, and thence enter the stomach to be ejected subsequently. Or in larger amount may enter from rupture of an aneurism into oesophagus. A frequent source of gastric haemorrhage, sometimes very copious, is portal obstruction (cirrhosis of liver) ; but equally of the Blood and Excreta. 25 common sources are gastric ulcer and cancer. As a rule, the haemorrhage is more profuse, and the vomit therefore composed more of unaltered blood in ulcer than in cancer, where the “ coffee-ground ” character is more frequent. 7. Faecal matter gives a yellowish, greenish, or brownish colour to vomit, and a penetrating odour. (Significant of intestinal obstruction from any cause. Also in the rarer case of a gastro-colic fistula.) 8. Pus — a rare concomitant (implies rupture of an abscess into the stomach). The character of the vomit depends on the predominance of one or other of the above constituents. Examination. 1 . Note quantity ; character; reaction. 2 . Free HC1, if in large amount, causes decoloration of methyl-aniline violet (aqueous solution) ; and gives yellow or brown tint to “ emerald green.” Filtering paper soaked in solution of Congo, red may be used to detect the presence of free acid, which changes the colour to blue, the depth of tint obtained being proportionate to the amount of HC1 present. 26 Notes on the Clinical Examination There are several other tests for the detection of free HC 1 . The most delicate is said to be that with phloro- glucin-vanillin (phloroglucin 3, vanillin I, absolute alcohol 90 parts). One or two drops warmed in porcelain dish with filtered vomit. Deep-red tint if free HC 1 present ; brown or brownish-red deposit if absent. ( Vierordt. ) [There is excess of HC 1 in most cases of gastric ulcer, but a partial or total deficiency in cases of cancer.] 3. Lactic acid deepens the tint of dilute solution of ferric chloride. 4. Microscopical Examination. (i.) Blood corpuscles — white and red — al- tered and swollen. (ii.) Blood-pigment in granules. (iii.) Squamous and columnar epithelium. Food residues , as : — (iv.) Muscle-fibres — swollen, variously dis- integrated, often deep yellow colour, and striation well marked. (v.) Oil globules. (vi.) Fat crystals (needle-shaped). (vii.) Connective-tissue fibres, elastic and white. (viii.) Starch granules : — note markings, re- fractile appearance, and blue coloration on addition of iodine. of the Blood and Excreta. 27 (ix.) Vegetable cells (note chlorophyll) and jointed fibres (not to be mistaken for foreign matter). Fungi, as : — (x.) Moulds. (xi.) Yeasts, notably Tonda cerevisicz ; oval and spherical spores, with perhaps some my- celium. Also other kinds. (xii.) Bacteria, micrococci, especially the Sarcina ventriculi , recognised by large size, “ wool-pack ” appearance, and yellowish tint. THE FAECES. Consistence . — Solid (scybalous), semi-solid, pultaceous, loose, mucoid, slimy, fluid, watery. In constipation the motions are hard, dry, often in small rounded masses. In the various forms of diar- rhoea their consistence varies from semi-solid, loose motions, to watery stools, the latter being also pro- duced by hydragogue purgatives. In catarrhal enteritis, often slimy and mucoid ; also in cancer of rectum. In the diarrhoea of typhoid fever, the stools may have a characteristic appearance, compared to pea-soup, being thin and watery, with much drab-coloured sediment. In cholera they are very watery, and contain flakes of epithelium (rice-water stools). 28 Notes on the Clinical Examination Amount . — Scanty or copious; if solid, note the size of motion and its calibre. Flattening of solid motions may signify stricture of colon (e.g . , sigmoid) or rectum. Reaction , — Alkaline or acid. Normally slightly alkaline, but the reaction depends on quality of food as well as on fermentation changes in intestine. Pronounced alkalinity may be due- to albuminous disintegration; it is found in certain forms of dyspepsia, and in typhoid fever. In acute enteritis, and especially infantile diarrhoea, the reaction is acid. Colour . — Dark brown, bright yellow, pale yellow or drab, putty-like and white, greenish or black. Varies with degree of admixture with bile, with alterations in the bilirubin after its excretion, with presence of blood, with kind of food ingested, and of drugs that may be administered. Examples . — Stools may be drab-coloured or putty- white in obstructive jaundice or deficient bile formation. Greenish in infantile diarrhoea (due to acidity and con- version of bilirubin into biliverdin? or to fermentative changes?). Also often greenish after taking calomel. They are blackened in cases of haemorrhage high up in the intestine (meloena), from formation of sulphide of iron. Also from similar change — the stools are black when salts of iron, bismuth, or manganese are being of the Blood and Excreta. 29 taken. Blood — if unaltered (i.e., in copious haemorrhage from ulceration of ileum or colon, or from rectum) — and pus give their characteristic colour to the motions. The faeces may be of bright yellow tint, if rhubarb, senna, or santonin, be taken. Odour . A highly offensive odour developed under various conditions, mostly attributable to fermentation changes in albuminous materials ; when bile is deficient, this character usually obtains. Constituents . — Masses of undigested food, e.g ., casein from milk ; vegetable matter, grape- skins, orange-pulp, currants, seeds, fruit-stones, etc. Foreign bodies — accidentally swallowed. Excess of fat. Observed in cases of pancreatic disease and obstructive jaundice. Shreds or complete “ casts ” of false mem- brane, and of epithelium. As in membranous enteritis, and also in chronic ulcera- tion of bowel (eg., tubercular ulceration). Enteroliths. Gall stones and biliary concretions. The search for these should be carefully made by breaking up the motion in water and straining through muslin, 30 Notes on the Clinical Examination Intestinal worms. The presence of these parasites may be diagnosed by the detection of their ova in the faeces on microscopical examination {vide p. 33) ; but the worm itself, or in the case of tape-worms, its proglottides, are sufficiently large to be seen by the unaided eye. An ex- ception may perhaps be made in the case of the trichina, which is the smallest of these entozoa. The leading characters of the chief varieties are as follows : — Tania mediocanellata — fully 4 metres in length, often more. The head (1*5 to 2 mm.) with central groove or depression, and furnished with 4 suckers, generally sur- rounded by black pigment. No hooklets. The ripe segments or proglottides , which are passed in the motions, are opaque, white, oblong (measuring about 18 mm. by 5 mm.) ; the genital pore projects from one margin, and the uterus, filled with ova, is remarkably branched. Scolex stage passed in the ox. This is the commonest tapeworm in this country. Tania solium — attains less length than the T. medio- canellata. Its head (about I mm.) presents four lateral suckers, and bears anteriorly a rostellum around which is placed a double row of hooklets, about 26 in all. The ripe proglottis , narrower than preceding, contains a uterus, which in the much smaller number and greater width of its branches contrasts markedly with that of T. m. The genital pore is lateral. of the Blood and Excreta. 3i Scolex stage in the pig. Common in Germany. Bothriocephalus latus — from 5 to 8 metres in length. The head (2*5 mm. by 1 mm.) is elongated, with rounded end, and provided with a groove passing from before .backwards. The segments are much broader in proportion to length than in the Taenia, the width in- creasing until near the terminal extremity. The genital pore is placed on the surface of each segment, and the uterus has a rosetted appearance and does not fill the segment. Larval form in river fish, e.g., pike. This form of tapeworm chiefly met with in North Germany, Finland, and Switzerland. In the case of a Finn in the Middlesex Hospital (1891) the intestine contained no fewer than 14 of these worms. Ascaris lumbricoides — the largest intestinal nematode, the adult male measuring about 250 mm., and female 400 mm. The ordinary “ round-worm ” infesting small intestine (of children especially), seldom solitary ; some- times 5 or 6 present. Oxyuris vermicularis or threadworm ; males, 2*5 to 4 mm. in length ; females, 10 to 12 mm., white in colour, and posterior extremity spiculated. Its habitat is the rectum and descending colon. Tricocephalus dispar or whipworm, distinguished by the filamentous character of its anterior extremity, con- trasting with the rest of the body. Measures 40 to 50 mm. in length. Infests especially the caecum. 32 Notes 07i the Clinical Exa7nination This parasite has been found in great abundance in cases of beri-beri or “ tropical anaemia.” Trichina sph'alis — found in intestine in the adult sexually mature form, from I *5 to 3 mm. in length. Anchylostoma duodenale — males smaller (6-10 mm.) than females (12-18 mm.). Head bears a protruding mouth furnished with teeth, whereby it wounds the mucous membrane, and may cause intense, even fatal anaemia. Anguillula . — Two forms ( intestinalis and stercoralis ) have been met with ; they are smaller than Anchylo- stoma, which they somewhat resemble. Microscopical Examination. 1. Intestinal products. a. Epithelial cells, mostly columnar, bile stained. b . Red blood corpuscles and blood pig- ment. c . Leucocytes. Pus corpuscles. d. Flakes and shreds of fibrin (mem- branous enteritis). 2. Food residues. a. Muscle fibres, yellow stained. b . Elastic and white fibrous tissue. c. Fat globules and crystals. d. Vegetable cells and fibres. e . Starch granules. f. Detritus. of the Blood and Excreta . 33 3. Crystals of (a) haematoidin; ( b ) choles- terin ; (^r) fatty acids ; (d) lime salts, oxalates, carbonate, sulphate ; (e) triple phosphate ; (/) Charcot-Leyden crystals (vide “Sputum,” p. 17). 4. Ova of intestinal worms.* (a) Tcenia mediocanellata. — Nearly spherical, with thick shell, striated radially; in size — 0*035 mm. by 0*039 mm. ( b ) Tcenia solium. — Similar to (<2), but slightly smaller (0*033 mm. by 0*032 mm.). (c) Bothriocephalus latus . — Ovoidal (0*07 mm. by 0*045 mm -)> an d shell provided at one end with operculum. Coarse brown granules in interior. (d) Anchylostoma duodenale. — Oval (0*05 mm. by 0*023 mm.), clear shell, with granular con- tents often showing cell-division. [The importance of detection of these ova is sometimes great, the symptoms of anchylostomiasis being those of pernicious anaemia, which disappear on the expulsion of the parasite by anthelmintic remedies.] (e) Tricocephalus dispar. — Characterised by a nodular swelling at each pole of the well- marked shell. (f) Oxyuris vermicularis. — About 0*052 mm. long and half that in width ; granular contents in which nucleus and nucleolus are visible. * For characters of these parasites, see p. 30. 3 34 Notes on the Clinical Examination (g) Ascaris lumbricoides . — About 0*05 mm., surface covered with conical projections. 5. Certain forms of protozoic organisms, as monadinea, coccidia, cercomonas intestinalis , amoeba coli. 6. Moulds, yeasts, bacteria, micrococci, and the following pathogenic micro-organisms. a . Spirillum of cholera (comma bacillus pf Koch). b. Spirillum Finklerii (cholera nostras). c. Bacillus tuberculosis. d. Bacillus of typhoid. The examination for these micro-organisms is made by means of cover-glass preparations, as in the case of the sputum. THE URINE. General and Physical Characters. Quantity . — Normal daily average for adults, 40 to 50 ounces. Increased (polyuria) by excess of fluid in- gesta, renal degeneration (granular and waxy kidney), nervous conditions (diabetes insipidus, hysteria). Also in convalescence from acute of the Blood and Excreta. 35 disease ; in recovery from acute nephritis ; during absorption of fluid serous effusions; in cardiac disease after relief of dropsy. Action of diuretics, as digitalis, nitrous ether, scoparium, juniper, acetate and nitrate of potash, copaiba, etc. In diabetes mellitus. Diminished by restriction of fluid ingesta and increased activity of sweat glands ; in acute nephritis ; fevers ; certain nerve con- ditions, e.g.> hysteria. Suppressed in acute and chronic nephritis, obstruction of ureters, etc. Colour. May be (according to Vogel's scale) : — i. Pale yellow; 2. Bright yellow; 3. Yellow; 4. Reddish yellow; 5. Yellowish red; 6. Red; 7. Brownish - red ; 8. Reddish - brown ; 9. Brownish-black. Chief conditions are : — a. As regards amount of urinary pigment (urobilin). From pale, limpid, watery (as in diabetes insipidus, hysteria, granular kidney), to dark reddi§h-yellow '(as ip scanty loaded urine of acute febrile conditions, mitral disease, etc.). 1 b. From admixture with blood or blood- ^ A ill t 3 6 Notes ' on the Clinical Examination colouring matter. From brownish tint to bright red. c. From admixture with bile. A yellow- green tint, or dark olive-green and brown, depending on degree and duration of jaun- dice. d. From admixture with chyle (chyluria). Milky-white. e. Melanuria from pigment excreted in cases of melanotic sarcoma.* (For tests, see p. 48.) f From the action of drugs. Carbolic acid, urine darkens, becoming almost black, after standing. So also kairin, antipyrin. Santonin gives saffron-yellow tint, which changes to red on addition of alkali. Rhubarb, browmish (if acid), or red (if alka- line). Senna, ditto. * I am indebted to a former house physician, Mr. Panting, for observations on the urine in a case of secondary melanotic sarcoma of the liver under my care at the Middlesex Hospital (July — August, 1891). The urine was generally straw-coloured when first passed, becoming in a few hours of a dark brown (mahogany) tint, and later still, almost black. This change was apparently irrespective of exposure to light, and took place before putrefactive changes had set in. of the Blood and Excreta. 37 Transparency. Especially clear and bright if saccharine, or albuminous, — as in cases of granular kidney and lardaceous disease. Urine containing albumen retains for a long time the froth on surface that results from shaking the fluid. Turbidity. May be due to presence of excess of (i) lithates (in cooling); (2) phosphates; (3) pus, epithelium; (4) mucus; (5) blood (smoky urine) ; (6) chyle (chyluria). Odour. Ammoniacal, from putrefactive fermentation. Acetone odour, in diabetic urine. [Special odours from drugs, e.g., turpentine ; or articles of diet, e.g., asparagus.] Specific Gravity . Depends on relative proportion of solids to water, and especially urea. Normal — 1015 to 1025. [Rough estimate of percentage of solids obtained by multiplying the last two coeffi- cients of the specific gravity by 2*33, the re- sultant representing so many parts per 1000 — e.g., specific gravity, 1020, 20 x 2*33 = 46*6 38 Notes on the Clinical Examination per 1000 or 4*66 per cent, of solids; again, specific gravity, 1036, 36 X 2*33 = 83 88 per 1000 or 8 4 per cent. Urea equivalent to about three-fourths of total quantity of solids.]* Reaction . Acid, neutral, alkaline. Acidity due to acid salts (urates and phos- phates). Influenced by diet, drugs, and fer- mentation. Ordinary fermentation associated with conversion of urea into carbonate of ammonia by micrococcus ureae. Chief Sedimentary Deposits. Urates : — Generally pigmented (pinkish) be- cause they carry down pigment with them. Are deposited on urine cooling, and can be readily dissolved by warming it. Phosphates : — Generally in pale urine, forming white feathery deposit, insoluble by heat, soluble in nitric acid. The alkaline phosphates increase as urine ferments, when also ammonium urate is formed. Uric acid: — Scanty, but characteristic; as fine red dust or sand, it constitutes “gravel.” * See Percentage Table, p. 64. of the Blood and Excreta. 39 Oxalates : — Recognised by bright crystalline character. Pus : — White deposit. Blood : — Generally forms a dirty reddish- brown deposit. Qualitative Analysis. 1. Urates. — A deposit soluble on heating. 2 . Phosphates. — Precipitated by heat, solu- ble on addition of acid. 3 . Uric acid. — The murexide test : — Place a few grains on porcelain dish, add drop of HN0 3 , apply heat, and when nearly dry, expose to fumes of NH S ; a crimson colour developed where the NH 3 in contact. 4 . Sulphates. — Precipitated by baryta water. 5 . Chlorides. — Precipitated by nitrate of silver (previously add HNO3). 6 . Urea. — Concentrate the urine by boiling, add HN0 3 , crystals of urea nitrate formed. 7 . Indican. — Add carefully some HC1 so as to form stratum below urine. At line of junction a deep blue or almost black tint developed, according to amount of indican present. Or more delicately with further addition of calcic 40 Notes on the Clinical Examination hypochlorite ; and the separated indigo may be dissolved out in chloroform. Urine normally contains some indican, but such an excess of this substance as to give a marked reaction is usually only to be found in disease. It is especially abundant in intestinal obstruction, and more so in the acute than in the chronic forms ; but it also occurs in cancer of the stomach, peritonitis (acute and chronic)* and in wasting diseases ( e.g phthisis). Closely allied to the indican reaction is the deep red tint obtainable (also in intestinal derangements) on boil- ing with nitric acid, which changes to yellow on further addition of the acid. The red tint can be regained by carefully neutralising with ammonia or sodic carbonate. 8. Ehrlich’s Diazo reaction. — For this colour test the following solutions are re- quired : — A. Sulphanilic acid Nitric acid . . Distilled water . B. Nitrite of sodium Distilled water . 1 part. 2 parts, ioo „ i part. 200 parts. Shortly before use mix ioo c.c. of (A) with 2*5 c.c. of (B). About io cub. c.c. of this mixture is added to an equal amount of urine in a test-tube. The tube is now shaken, and a few drops of the Blood and Excreta . 4i of liq. ammoniae are added, when the fluid and the foam on its surface assume a bright red tint. This reaction is obtained in the urine of typhoid fever (according to Ehrlich, as soon as the middle of the first week), also in that of measles, and sometimes even in pneumonia and phthisis. Although of some value in the early diagnosis of typhoid, it is said to be present in acute tuberculosis also. 9. Albumen (serum). Is coagulated by : — a. Heat — i.e . 9 boiling in presence of excess of acid (acetic or a few drops of citric acid). b. Nitric acid, added in the cold. Form stratum of urine on surface of the acid in test tube. Not to be mistaken for crystalline deposits of urates or nitrate of urea ; or the cloudiness produced by the acid in urine or patients taking copaiba. c. Nitric acid (1 part) mixed with saturated solution of sulphate of magnesium (5 parts). d. Picric acid. Precipitate rendered more evident on boiling, and thus distinguished from peptones. e. Ferrocyanide of potassium in acid urine. (This secured by addition of citric acid.) 42 Notes on the Clinical Examination f Tungstate of soda. g. Trichlorac^ic acid very delicate for slight traces of albumen, io. Peptones. Not coagulated by heat. Peptones give with picric acid alone a white precipitate soluble on boiling, and reappearing as solution cools. To mixture of urine and liquor potassse add small quantity of solution of cupric sulphate, which gives a rosy-red colour, turning to deep red and yellow with picric acid. [This, the biuret test, is available for other albumens, but with them the colour is more of a violet tint.] Peptonuria has been shown (v. Jaksch) to occur es- pecially in cases of extensive purulent effusions, e.g suppurative peritonitis. It has also been met with in ulceration of the gastro-intestinal tract, in cancer of the stomach, and in the later stages of typhoid fever. n. Globulin and paraglobulin. Coagulated by heat ; may be precipitated by sulphate of magnesium (saturated solu- tion) ; and separated from serum-albumen by filtration, when the precipitate may be re- dissolved in water. Globulin may also be of the Blood and Excreta. 43 precipitated from urine made alkaline by am- monia, and filtered, by addition of sulphate of ammonia. (. Kander .) 12. Haemoglobin. Mix a few drops of (fresh) Tinct. Guaiaci with the urine and then pour in some ozonic ether. A deep blue tint at once develops at line of junction. Or pour a little urine on white bibulous paper and then add the guaiacum and ether. The chief fallacy in this test is the reaction yielded by the same agents in the urine of patients taking iodide of potassium. The colour in this case is, how- ever, more of a greenish-blue tint, and is seldom de- veloped with the rapidity that is seen when even a very small amount of blood colouring matter is present. Haemoglobinuria to such an extent as to give the urine a deep red or reddish-black tint, is seen in the affection “ paroxysmal haemoglobinuria.’’ Dr. Mahomed found haemoglobin before the appearance of blood in scarlatinal nephritis. 13. Blood. Same test as (12). Another test is the dirty reddish-brown flocculent precipitate obtained on boiling the urine with liq. potassae. The microscopical test ( q.v .) is of course 44 Notes on the Clinical Examination far more certain, and should never be omitted. Or the spectroscope may be employed. Hematuria. Haematuria may be of renal or extra-renal origin, the former including the action on kidney of cantharides, turpentine, etc., acute nephritis, renal embolism, granu- lar kidney, calculus, tuberculous pyelitis, and renal cancer ; the latter, especially villous growths in bladder, cystitis, the Bilharzia haematobia, prostatic and urethral haemorrhage. N.B . — In women the menstrual blood may become mixed with the urine that is passed. 14. Pus. The addition of equal parts of liq. potassae (or sodse) converts the deposit into a viscid glairy fluid. On boiling, the mixture gains in transparency, and its viscidity is evidenced by the entanglement of air-bubbles within it. For like reason purulent urine, if also ammoniacal, becomes “ropy.” Confirm by microscopical examination (< q.v .). Pus is present in the urine, in urethritis (gonorrhoea), cystitis, pyelitis of all forms, also in renal abscess, or from the rupture into the urinary tract of abscesses situated external to it. In women leucorrhoeal dis- charge may account for the deposit. of the Blood and Excreta . 45 15. Mucus. Flocculent; often as a filmy cloud floating in the urine. Is soluble in alkali, and can be re-precipitated on addition of acetic acid. 16. Sugar. a . Moore's Test. — Add equal portion of liq. potassae, and boil. Dark reddish-brown colour developed, with odour of caramel. b. Trommer's Test. — Add a few drops of cupric sulphate solution, and then liq. potassae until clear fluid obtained. Boil, get yellow- ish or orange-coloured precipitate (of cuprous oxide), the change of colour taking place before actual cooling occurs. c. Fehlinfs Test. — Similar to (b) 9 but the alkaline cupric solution previously prepared, consisting of cuprie sulphate, sodio-potassic tartrate, and caustic soda. Red precipitate. d. Bottiger's Test. — Take a few grains of carbonate of bismuth and boil with urine in presence of excess of alkali. The white powder becomes black (suboxide of bismuth). e. Johnson's Test . — Boil with picric acid and then add potash. A deep red colour produced, so intense as to appear almost black until it is diluted. 46 Notes on the Clinical Examination f Mulder's Test . — Solution of carbonate of soda added to urine ; then solution of indigo- carmine. On heating the colour changes to yellow, and again becomes blue on shaking with air. g. Phenyl- Hy dr azin Test .* — “Two parts of hydro- chlorate of phenyl-hydrazin and three of acetate of soda are placed together in a test-tube containing 6-8 c.c. of urine. If the salts do not dissolve when the fluid is warmed a little water is added, and the test-tube con- taining the mixture is placed for 20-30 minutes in boiling water. After this it is taken out and put into a vessel containing cold water. If sugar be present, even in very moderate quantity, there forms directly a yellow crystalline deposit which may appear amorphous to the naked eye ; but which when examined under the micro- scope is seen to contain yellow needles (of phenyl- glucosozon) detached and arranged in clusters.” h. Fermentation Test . — (See Quantitative Analysis.) 17. Acetone. Add few drops of concentrated solution of sodium nitro-prusside and caustic soda. An evanescent red colour produced, which, on addition of acetic acid, will be replaced by a purple tint. * Cited from von Jaksch {Clin. Diagnosis , p. 226), who considers it to be preferable to any other test. of the Blood and Excreta . 47 Or precipitate of iodoform crystals obtained by treating the urine (containing acetone) with few drops of iodine, potassium iodide, and caustic potash. [It may be well first to distil the urine, and to test the distillate as above.] In some cases of diabetes a red colour is produced by addition of ferric chloride to the urine. This may be due to the presence of diacetic acid, which occurs with acetone. 1 8. Bile pigment. Bilirubin converted into biliverdin by HNO3. Addition of this acid gives therefore a “ play of colours” (red to grass-green). Test best seen by noticing effect of action of drop of acid on drop of urine placed on porcelain plate ; or by soaking white bibulous paper in urine, and when dry placing drop of acid upon its surface. 19. Bile acids. PettenkofeS s Test . — To mixture of sulphuric acid and urine, add gently cprrcentrated solu; tion of cane-sugar. A purple colour produced. (Test open to fallacy ; frp^n charring of sugar by acid.) OIS- 48 Notes on the Clinical Examination 20. Melanin. Although there seems to be some difference of opinion as to the precise nature of the pigment found in melan- uria, the following tests are generally to be obtained. [They were invariably yielded by the urine of the case referred to in footnote on p. 36.] Nitric acid causes the urine to assume a deep port- wine colour, which disappears on the addition of ammonia or other alkali. , A few drops of solution of ferric chloride causes a dirty olive-green precipitate, which still further darkens (becoming almost black) on continued addition of -the reagent. Caustic potash dissolves the precipitate, and the mixture assumes a light brown colour. Sulphuric acid produces a black precipitate. 21. Drugs. Perchloride of iron gives purplish-coloured precipitate in urine containing : — (a) carbolic acid; ( b ) salicylic acid; (c) antipyrin; (d) kairin, etc. Copaiba gives cloudy precipitate on boiling, soluble in alcohol (not to be mistaken for albumen). Tannin, dark green with perchloride of iron. Santonin and rhubarb, red colour on addition of alkaline carbonate. of the Blood and Excreta . 49 Iodine, liberated by HNO3 or chlorine water. When shaken up with chloroform, the free iodine appears as red solution. QUANTITATIVE ANALYSIS. I. Urea. A. Estimation by Mercuric Nitrate (Liebig’s method). Reagents . a. Volumetric solution of mercuric nitrate (of which 10 c.c. = o*i gramme of urea ; or 1 c.c. = 'oi grm., i.e. = 1 per cent.). b. Baryta solution (2 vols. of baryta water and 1 of saturated solution of barium nitrate). c. Carbonate of soda solution (20 grs. to the ounce). Apparatus. 1. Centimetre measures. 2. Burette graduated in cubic centimetres. 3. Filters and filtering paper. 4. Beaker. 5. Porcelain plate. 6. Glass rod. 4 50 Notes on the Clinical Examination Process . 1. Take 40 c.c. of urine. [If albuminous, first boil and filter.] 2. Add 20 c.c. of (b) to precipitate sulphates and phosphates. 3. Filter. 4. Collect 15 c.c. of filtrate (i.e., 10 c.c. of urine) in beaker or dish. 5. Fill burette with (a) and drop it into the filtered urine. [Note when a definite precipitate forms, sub- tracting that amount, as indicating chlorides.] 6. After having used 10 c.c. of ( a ), place drops of (c) on porcelain plate, and after each addition of (a) to the urine, test for free mer- cury by mixing with (< c ). Cease as soon as yellow colour (i.e. yellow oxide) replaces white. 7. Then read off number of c.c. of (a) used before the yellow colour appears. Example . — For No. 5, suppose 3 c.c. of (a) used before a definite precipitate appears. For No. 6, when 33 c.c. used, get yellow colour with carbonate of soda. There- fore 33 — 3 = 30 c.c. of volumetric solution required to decompose whole of urea in 10 c.c. of urine. So that 30 x o*oi grm. = 0'3 grm. in 10 c.c. of urine, or 3 grm. in 100 c.c., i,e., 3 per cent. of the Blood and Excreta. 5i It is easy then to calculate total amount of urea from the total amount of urine passed in 24 hours, (v. p. 64.) B. Hypobromite method. In this process, urea estimated by amount of nitrogen given off in decomposition of urea by hypobromite of soda, thus : — CH 4 N 2 0 + 3BrNaO = 3BrNa + 2 H 2 0 + C 0 2 +.2N. The C 0 2 is absorbed by the excess of alkali, so that all gas evolved is nitrogen. Reagents . Solution of sodic hypobromite freshly pre- pared. [Take of bromine 1*3 c.c., and mix with caustic soda solution (1 in 25) 137 c.c., thus forming 15 c.c. of hypobromite solution.] Apparatus . Russell and West's . 1. A pipette graduated to 5 c.c. 2. A long tube with bulb and constriction into which glass rod protected by indiarubber may be inserted to act as stopper. 3. A trough to contain water, into floor of which the open mouth of (2) is fixed. 4. Gas receiver, a graduated tube closed £t one end. Portion of this tube, of capacity 52 Notes on the Clinical Examination of 55 c.c., is divided into 30 equal parts. Now '55 c.c. of N =0*15 grm. of urea, there- fore each single division on the tube = *005 grm. of urea. Since the total quantity of urine used in the analysis amounts to 5 c.c., each division of the tube will indicate o*i per cent, of urea, and the whole thirty divisions 3 per cent. Other more or less convenient forms of apparatus, all constructed on same principle, viz., to collect and measure the gas evolved by decomposing a given quantity of urine by hypobromite, are those of Gerrard, Doremus and Thursfield. The process. (a) Measure 5 c.c. of urine and place in bulb of tube (2), which can then be fitted into floor of trough. (b) Fill bulb with water up to constriction, and then insert stopper firmly, and fill rest of tube with hypobromite solution. (c) Fill trough with water and also the tube (4), which must now be inverted and moved over site of (2). ( d ) Remove glass stopper ; gas at once rises of the Blood and Excreta . S 3 and displaces water in (4). Note amount when all action ceased. C. Hypochlorite method. On similar principle as B, but solution of chlorinated soda employed instead of hypo- bromite. Squibb’s apparatus, usually employed for this, consists in two bottles of equal size, one of which (A) is filled with water, and com- municates by an indiarubber tube with the other bottle (. B ), and by another tube with a beaker (C). Four c.c. of urine in small test-tube placed in B , and then 40 c.c. of liq. sod. chloratae are poured into B , which is then tightly corked and connection made with A . The bottle B is agitated so that the urine and hypochlorite freely mix. Gas is given off actively, dis- placing water from A , which is received in C. At close of experiment measure the water in C, which indicates amount of N given off. Example . — Since 1 c.c. of N = o f oo27 grm. of urea, if 36 c.c. of water displaced by evolved gas, then 36 x 0*0027 — 0 0972 grm. of urea in 4 c.c. of urine, or 0*0243 grm. in 1 c.c., or 2*43 per cent. 54 Notes on the Clinical Examination II. Sugar. A. Estimation by Fehling's solution. Fehlings solution. Cupric sulphate, gr. 90^. Pot. tartrate, gr. 364. Sol. sodic hydrate (sp. gr. 1*12) fl. oz. 4. Water to fl. oz. 6. Since this solution is of such strength that two hundred parts is reduced by one part of sugar, the total reduction of 200 grains of the solution is equivalent to 1 grain of sugar ; or 10 cubic centimetres of solution to 0*05 grm. of sugar. Apparatus . 1. Porcelain dish. 2. Spirit lamp or Bunsen burner. 3. A glass measure (grains or cubic centi- metres). 4. Burette graduated in grain measures or cubic centimetres. 5. Glass rod. Process . Take some urine and dilute it with distilled water (1 in 10) and fill (3) with the mixture. of the Blood and Excreta . 55 Measure 200 grains of Fehling’s solution (or 10 c.c.), dilute it with water (equal parts or more), and boil. Whilst boiling, drop in dilute urine from burette, stir up freely, and cease to add urine directly all blue colour discharged from the solution. Then read off quantity of dilute urine used. Example . — Suppose 1000 grain- measures of diluted urine (— -t#-^ 100 gr.-meas. of urine) required, would mean that 100 grs. of urine contain 1 gr. of sugar — i.e., 1 per cent [or if 10 c.c. of Fehling decolorised by 10 c.c. of urine, since that means 0*05 grm. of sugar, this will amount to 0 5 per cent.]. N.B . — This test is less reliable when sugar is only present in small quantity, or if the urine contains excess of other solid constituents. B. By fermentation. Take two samples of urine, and place in bottles fitted with grooved corks. Into one add a small piece of German yeast. Keep both at warm temperature for 24 hours ; then decant, and compare the specific gravity of each. A loss of 1 degree of specific gravity is equivalent to 1 grain of sugar per fluid ounce of urine. 56 Notes on the Clinical Examination Suppose unfermented urine has specific gravity 1040, and fermented urine specific gravity 1008. Then the quantity of sugar = 40 — 8 = 32 grains per ounce of urine. [This result of course only approximate.] In all cases, calculate not only the per- centage, but the total quantity of sugar eliminated in 24 hours. The observations should be made on sample of the whole urine passed in this time. C. By Johnson’s Picro-saccharimeter. Apparatus . — One large boiling tube graduated up to 4 drachms from the bottom ; 2 smaller tubes, one containing standard orange-red solution,* the other graduated so that each degree represents o*i grain sugar to the ounce. Method . — To 1 drachm of urine add 30 minims of liquor potassse, and 80 minims of a saturated solution of picric acid (aqueous), and dilute with water up to 4 drachms. Boil for 60 seconds, cool, and make up again with water to exactly 4 drachms. Compare with standard .solution. If the tint corresponds * Composed of : Liq. ferri perchlor. fort., 3 i* Ac. acet. glac., 3 iv. Liq. ammonhe, in. 100. Aq. destill, ad, £iv. of the Blood and Excreta. 57 there is i grain of sugar to the ounce ; if lighter, less ; if darker, transfer to small graduated tube sufficient to occupy the first 10 divisions of the scale, and add water till tint corresponds ; the level on scale divided by io gives grains to ounce — e.g.y level on scale 35 =3*5 grains. This method gives consistent and reliable results, especially where sugar is present in small quantities : if exceeding 8 grains, first dilute with 9 of water and use 60 minims picric acid. Numbers on scale must not be divided at all, since they will now represent grains to the ounce. III. Albumen. The most accurate method, viz., precipitation, drying and weighing the precipitate, too difficult for clinical estimation. Esbactts method. A tube graduated to receive a certain quantity of urine, and so divided as to indicate, when all albumen is precipitated, the total quantity of grammes (of dried albumen) per litre, or in o'x per cent. The precipitant employed is : — Picric acid ... 1 part. Citric acid .... 2 parts. Water 100 58 Notes on the Clinical Examination This is added in definite proportion (marked on tube), and the mixture allowed to stand for 24 hours, when the height to which the deposit reaches may be read off. [If more albumen present than indicated by the marks on the tube, which do not exceed 07 per cent., the urine must first be diluted with an equal bulk of water.] Microscopical Examination of Urinary Deposits. Set aside urine in conical glass, protected from dust, and when sediment well deposited remove by pipette to slide. The deposits may be classified as (1) organic, and (2) inorganic. Organic. 1. Blood corpuscles . Appear mostly as clear discs or spheres i sometimes crenated ; may enter urine from : — a. Kidney, as in acute congestion, acute nephritis, granular kidney (sometimes) ; in haemorrhage, from calculus, tubercle, cancer, or embolism. Also in purpura, scurvy, and other blood states. of the Blood and Excreta . 59 b. Urinary tract, pelvis of kidney, ureter, bladder, urethra (including prostate). c. In women, menstruation and uterine haemorrhage may lead to admixture of blood with urine. 2. Pus corpuscles . As granular spheres, to which addition of acetic acid brings tri-partite nucleus into view. Source : — a . Acute nephritis. b. Tubercular and calculus pyelitis. c. Cystitis. d. Gonorrhoea, urethritis. e . Abscess bursting into urinary tract. /. Leucorrhoea. 3. Epithelium . a . Renal — small, rounded, granular, with large nucleus. b. Pelvic and urethral — tailed, pyriform. c. Vesical and urethral — flattened, various shapes. d. Vaginal — large, squamous. 4. Renal tube casts . a. Epithelial, in acute nephritis, later stages. b . Granular, in chronic renal disease mainly fine and coarse. 6 o Notes on the Clinical Examination c. Fatty, in chronic nephritis, especially large white kidney. d. Hyaline, large and small ; small hyaline casts in acute nephritis, and large in granular kidney. e. Blood in acute nephritis, renal embolisms. / Pus. 1 Most casts have a fibrinous basis ; their size depends on size of tubules whence they proceed, especially whether these are denuded or not of epithelial lining. [N.B. — Do not mistake for casts : — mucous coagula and filaments, hairs, cotton fibre, or scratches on the glass slide.] 5. Spermatozoa . 6 . Bacteria and Micrococci . Occasionally sarcince occur, sometimes (but not in- variably) in association with cystitis, or pyelitis (as in a case seen by writer in 1891), or after catheterisation. They are mostly somewhat smaller in size than sarcina ventriculi. 7. Echinococcus. Shreds of hydatid membrane or small cysts may be passed in cases of hydatid of the kidney. of the Blood and Excreta . 6 1 8. Bilharzia hoematobia , ova of — oval in shape, spiked. These ova after a time may be observed to rupture and give issue to ciliated embryos. Inorganic. A. In Acid Urine. 1. Urates of potash and soda — amorphous fine granules. 2. Uric acid — reddish-brown or yellowish crystals, of various forms — 4-sided tablets, 6-sided rhombs, lozenge-shaped, or ovoid, dumb-bell or barrel-shaped ; sometimes stellate aggregations. They are invariably coloured. 3. Oxalate of lime — as bright glistening small octahedra ; or (more rarely) dumb-bell or ovoid. 4. Leucin — yellowish-brown, striated, sphe- roids. 5. Tyrosin — silky, glistening, acicular crystals, in bundles. 6. Cholesterin — rectangular plates, often de- fective at one angle, soluble in ether. 7. Cystin — 6-sided plates, insoluble in water and acetic acid, soluble in hydrochloric acid and in ammonia. 62 Examination of Blood and Excreta . B. In Alkaline Urine . 1. Neutral phosphate of lime — fine amorphous granules. 2. Carbonate of lime, striated spheres. 3. Urate of ammonia — opaque, brownish coloured spheres, spiculated, sometimes dumb- bell crystals. 4. Phosphate of lime — crystals of “ stellar ” phosphate, i.e. y radiating bundles of oblong crystals (rare). 5. Phosphate of magnesia — flat elongated plates. 6. Phosphate of ammonia and magnesia, or “triple phosphate” — the usual form of phos- phatic crystals in urine — mostly as large prisms with bevelled ends. 63 WEIGHTS AND MEASURES. I kilogramme =1000 grm. = 15,432*3 grains. 1 gramme = i5'43 2 » 1 decigramme = o*i grm.= 1*5432 j> 1 centigramme = o*oi ,, = 0*15432 ,, 1 metre 1 decimetre 1 centimetre 1 millimetre = 100 centimetres=39*37 inches. = 10 „ = 3*9 = 0*39 ,, = o* 1 cm. = 0*039 ,, [1 micromillimetre(/*)= o*ooi mm. = 0*0003 ,,] 1 litre =1000 cub. centimetres^ 16,931 minims. 1 decilitre = 100 ,, ,, = 1,693 >> 1 centilitre= 10 ,, ,, = 169*3 >> I millilitre= 1 ,, ,, = 16*9 ,, (1 cub. centimetre of water at 40° C. weighs 1 grm.). 1 pint =567*9 cub. centimetres. 1 fl. oz. = 28*4 ,, 1 fl. dr. = 3*5 I minim = 0*059 ,, (437*5 gr.-meas.) PERCENTAGE TABLE. 48 o- „ .8 » ^ s I ^ sg o § s* ^ 00 .8 .co S £> .8 £ .60 S 5? -v ^ o .8 ^ co 8 I TO ■t^ ro O ,S3 £ •S 8 S S r . c^ * S v- O & ^ > 5 iw CO 01 <0 8 *r .8 S § ~ 0 >4 8 s*. g> « o' ■- - 8§ :&> 1 vis ^ I 111 ■s O.'S, <» s OI .10 to to to to O t' lO M tv lO 04 tv to ro tv h 1000 *04 b O ro tv. be -too ro tv w vo O to Ov ro h h S n nom’t ON to to to to to , n MON MON tv to u 5° r* , M .* 00 ° 04 vo ro tv be b>oo 00 "tvvb b to to V ro ro tv m to On ro tv m 10 Ov MHHNNtOOfO 00 COlOOtOOtoOlOOtOO - ro tv 0 tv h -vj-oo m to tC HHHNNflOrO tv .10 to to to to Tf\ 04 to tv N to tv N 10 £ '■O 04 00 lOH tv ro tp 04 be b H w 04 ro ro V to iob rovo On 04 1000 H Vi- tv 0 M M M 04 04 04 ro to . to to to to to 03 04 to tv 04 to tv 04 to i- 1 b 04 00 to "m *tv ro 0 b b bJO 04 to tv 0 ro toco *h rovo h M M M 04 04 04 to . to to to to to tf) tv lO 04 IV 10 04 tv 10 £ OO tvvp to ro 04 m 00 tv be m ro io tv on h ro tob 60 04 vj-vo 00 O ro to tv 0 M M M M H M 04 03 to to to to to Jh "tv to 04 0 "tv 10 *04 O "tv 10 be h ro to tv 00 0 04 vt to tv ro to to to to to rn 04 lO tv 04 to tv 04 to £ H 04 ro lO VO tv co H 04 be rob "001 iooo w 1000 *« H 04 to lO vO tv On O M to 04 tA to to to to to £ tv to 04 tv IO 04 tv to be 00 tv b to ro "04 h 0 do "tv H 04 rot tovo tv tv 00 H to to to to to ./ tv to 04 tv to 04 tv to u r . H r

Vo HHNcirotocot Ounces. C p g mif)N N 3 11 11 11 n g N O o - - - O VO OVO QJ to to C ti_( 0