RB 37 .A74 Copy 1 Medical Epitome Series CLINICAL DIAGNOSIS AN D URtNALYSIS ARNEILL I Class l Book ^ Copyright N°. COPYRIGHT DEPOSIT. ■BBSS Hi llliliilll^ H I M iP lffl HIBWkim^^ Bi^BBWB DJ £ X C Zbe flfcebical Epitome Series. CLINICAL DIAGNOSIS AND URINALYSIS. A MANUAL FOR STUDENTS AND PRACTITIONERS. BY JAMES RAE AKNEILL, A.B., M.D., Professor of Medicine and Clinical Medicine in the University of Colorado ; Physician to the Denver County Hospital and St. Joseph's Hospital, Denver; Consultant to the Jewish Consumptives Relief Society , Denver; Member of the Advisory Board of St. Joseph's Hospital for Con- sumptives, Silver City, New Mexico. SERIES EDITED BY VICTOR COX PEDERSEN, A. M., M. D., Instructor in Surgery and Anesthetist and Instructor in Anesthesia at the New York Poly- clinic Medical School and Hospital ; Genito- Urinary Surgeon to the Out-Patient Departments of the New York and the Hudson Street Hospitals ; Anesthetist to the Roosevelt Hospital. ILLUSTRATED WITH 79 ENGRAVINGS AND 1 COLORED PLATE. LEA BROTHERS & CO., PHILADELPHIA AND NEW YORK. LIBRARY of CONGRESS Two Copies decay**! MAV 11 J905 CoDyrigiu uiiry aw .to* Entered according to Act of Congress, in the year 1905, by LEA BROTHERS & CO., In the Office of the Librarian of Congress. All rights reserved. | v ELECTROTYPED BY WESTCOTT II THOMSON, PHILADA, PRESS OF WM. J. DORNAN. PHILADA. AUTHOR'S PREFACE. The great importance of laboratory examinations in all branches of medicine and surgery has come to be universally recognized ; but the ability to put the methods into practice, and to derive the information they can give, has not yet been as widely acquired by the profession. This brief volume, covering the essentials, is intended to serve the needs of physicians and students rather than those of experts. The practical side of laboratory work in its relation to the diagnosis of disease is emphasized. Many of the time-con- suming quantitative analyses are intentionally omitted or merely mentioned. To be of value they should be made by experienced chemists. An attempt is made to explain fully the most important tests and procedures, and to anticipate many of the difficulties and mistakes of the inexperienced worker. No claim is made for originality or completeness. Many of the standard works have been freely consulted — such as Simon, Von Jaksch, Nichols, Ewing, Cabot, Musser, DaCosta, Vierordt, Purdy, Peyer, Osier, and others. Numerous practical suggestions also have been obtained from the work in the clinical laboratory of the University of Michigan as instituted by Drs. Dock and Cowie. I am greatly indebted to Mr. Charles L. Bliss, late instructor in physiological chemistry in the University of Michigan, now government physiological chemist at Manila, for very valua- ble aid in the preparation of the section on Urinalysis. J. R. A. Denver, Colorado. 3 EDITOR'S PREFACE, In arranging for the editorship of The Medical Epitome Series the publishers established a few simple conditions, namely, that the Series as a whole should embrace the entire realm of medicine ; that the individual volumes should au- thoritatively cover their respective subjects in all essentials ; and that the maximum amount of information, in letter- press and engravings, should be given for a minimum price. It was the belief of publishers and editor alike that brief Avorks of high character would render valuable service not only to students, but also to practitioners who might wish to refresh or supplement their knowledge to date. To the authors the editor extends his heartiest thanks for their excellent work. They have fully justified his choice in inviting them to undertake a kind of literary task which is always difficult — namely, the combination of brevity, clear- ness, and comprehensiveness. They have shown a consistent interest in the work and an earnest endeavor to cooperate with the editor throughout the undertaking. Joint effort of this sort ought to yield useful books, brief manuals as con- tradistinguished from mere compends, 6 EDITOR'S PREFACE. In order to render the volumes suitable for quizzing, and yet preserve the continuity of the text unbroken by the interpolation of questions throughout the subject-matter, which has heretofore been the design in books of this type, all questions have been placed at the end of each chapter. This new arrangement, it is hoped, will be convenient alike to students and practitioners. V. €. P. New York, 1905, CONTENTS. CHAPTER I. Pages General Considerations 17-23 CHAPTER II. Blood ... 23-34 CHAPTER III. Clinical Examination of the Blood 34-48 CHAPTER IV. Study of the Stained Spread 48-60 CHAPTER V. Pathological Conditions of the Blood 60-63 CHAPTER VI. The Widal Reaction 64-67 CHAPTER VII. Less Frequently Applied Procedures 68-104 CHAPTER VIIL The Stomach 104-129 7 8 CONTENTS. CHAPTER IX. PAGES The Faeces 130-147 CHAPTER X. Sputum 147-16.' CHAPTER XI. Miscellaneous Examinations 163-170 CHAPTER XII. Urinalysis 170-191 CHAPTER XIII. Examination op the Urine 191-215 CHAPTER XIV. Urinary Sediments 215-238 CLINICAL DIAGNOSIS AND URINALYSIS. CHAPTER I. GENEKAL CONSIDERATIONS. EQUIPMENT AND SCOPE OF WORK. In purchasing laboratory supplies one should deal with an absolutely reliable firm. Because of the technical skill and experience required in the preparation of some of the solu- tions and stains, it is well for beginners to purchase them already prepared. This statement refers especially to the decinormal sodium hydrate solution and the like, and such stains as Wright's, Gram's, and Ehrlich's triacid stains. Griibler's stains (powders) have the reputation of being the best on the market. Laboratory tables should be painted black. Laboratory diagnosis includes examination of the blood, stomach-contents, sputum, feces, urine, transudates and exu- dates, and of the various secretions and excretions of the body. Special apparatus and reagents are required for some of this work, but the same apparatus may be employed in many of the foregoing subdivisions. Among the general utility articles are to be mentioned the following : Microscope (triple nose-piece, 2 eye-pieces, 3 objectives) — i. e. y oil-immersion and high and low dry lens. Thermostat. Glass rods, different sizes. Glass tubing, different sizes. Filter-paper, 4 inch, 6 inch, 8 inch, etc. 2— C. D. 17 18 GENERAL CONSIDERATIONS. Funnels, different sizes (2 inch, 4 inch, etc.). Graduates, different sizes (100 c.c, 500 c.c, 1000 c.c). Centrifuge. Two-gallon syphon bottle with distilled water* Teasing needles. Platinum loop. Cover-glass forceps. File. Canada balsam (for mounting permanent specimens ; keep in wide-mouthed bottle). Turpentine. Cedar oil. Xylol. Glass slides — w T hite, not green glass. Cover-slips are sold in four thicknesses, Nos. 0, 1, 2, 3. No. 1 is best for general work, since it is thin enough for use with the oil-immersion lens, and is not so easily broken as No. 0. The square f-inch cover-glass should be used. Cleaning Glassware. — In cleaning glassware that has never been used, Cabot, after a long experience with various chem- icals, has given them up, and uses nothing but soap and water, with thorough polishing. The glassware may be placed in acetic acid for twenty-four hours, more or less (if in a hurry, a minute will do), then thoroughly washed in water and transferred to a large- mouthed bottle containing alcohol. When wanted, it is dried and polished with a clean soft cloth. The following cleaning fluid for glassware is recommended by Nichols as especially useful for glassware that has been soiled : Potassium bichromate, 10 parts ; Sulphuric acid (commercial), 10 " Water, 100 " The glassware is left in this fluid for twenty-four hours, then thoroughly rinsed with water and transferred to alcohol, to be used as wanted. EQUIPMENT AND SCOPE OF WORK. 19 Carbol Fuchsin. — Fuchsin (S.), 1 part ; Absolute alcohol, 10 parts ; 5 Der cent, solution of carbolic acid, 100 " Lbffler's Methylene-blue. — Concentrated alcoholic solution of methylene-blue, 30 parts ; 1 : 10,000 aqueous solution of potassium hydrate, 100 " Gram's method requires the following solutions : 1. Aniline Water. — Prepare by adding aniline oil to 10 c.c. of distilled water, drop by drop, shaking thoroughly after the addition of each drop, until the solution becomes opaque. Filter through moistened filter-paper. 2. Aniline Water Gentian-violet. — Treat the foregoing solu- tion with 10 c.c. of absolute alcohol and 11 c.c. of a concen- trated alcoholic solution of gentian-violet. This combined solution keeps only a few days, and should, therefore, be made up fresh. 3. LugoVs Solution. — Iodine, 1 part ; Potassium iodide, 2 parts ; Water, 300 " Gram's method is employed for the differentiation of certain bacteria, especially the gonococcus, and for staining the cap- sule of diplococeus pneumonice and other germs. Application of Gram's Method. — 1. Cover spread with aniline water gentian-violet (made within two weeks) and heat to steaming-point. 2. Wash in water. 3. Cover with LugoPs solution for one-half to two minutes to decolorize. 4. Rinse in 95 per cent, alcohol until the violet color dis- appears to the naked eye. 5. Wash in water and mount. When thus treated, certain bacteria retain the stain, such as 20 GENERAL CONSIDERATIONS. diplococcus pneumoniae, diphtheria bacillus, tubercle bacillus, anthrax bacillus, streptococci and staphylococci. The bacteria which become decolorized are the following : gonococcus, typhoid bacillus, colon bacillus, influenza bacillus, and cholera spirillum. Fat-detection by Sudan III. — Test-solution. — Make a satu- rated alcoholic solution of Sudan III. Let stand for several days ; then mix 1 part of this solution with 1 part of alcohol and 1 part of water. The mixture is at once turbid, but clears on standing. Sudan III. stains fat red and leaves everything else unstained. Do not treat specimens with alcohol or ether before or after staining. Test — A drop or two of the solution is run under the cover- glass covering the specimen ; under the microscope the neutral fat is seen to take on a red color. Iodine Test for Starch. — Starch in granules or in solution strikes a deep-blue color in the presence of iodine. The stock test-solution is Lugol's. A drop or two of this solution is allowed to run under the cover-glass covering the specimen. In testing liquids for the presence of starch, dilute a few drops of this solution with water to a light-yellow color, and add a few drops of the suspected fluid. A deep blue indi- cates starch, a deep brown indicates erythrodextrin. Glycogen granules treated by the first method turn a deep mahogany brown under the microscope. Iodide Test for Starch. — Starch does not react to iodides in combination, but on setting free the iodine with nitric acid a deep-blue color develops. Technic. — A strip of starch-paper is moistened with the fluid to be tested and then touched with a drop of nitric acid. The characteristic blue color develops in the presence of iodides. Ethereal Extracts. — In certain tests the watery solution of the substance is shaken with ether or chloroform in order to extract the substance from the water. On standing the two fluids separate. Either the water or the ether may be re- moved by means of a pipette. Another method is to place the mixture in a filter which has been previously moistened EQUIPMENT AND SCOPE OF WORK. 21 with water. The watery portion will then filter through. If ether is used for moistening the filter, the ethereal portion will filter through. Guaiacum Test for Blood. — To 4 or 5 c.c. of tincture of guaiacum add from ^ to \ as much hydrogen peroxide, or an equal amount of " ozonized" turpentine (expose turpentine to light and air for a long time). The suspected fluid — in a long glass tube placed at the bottom of a test-tube — is allowed to run slowly out and underlie the reagent. At the junction of the two liquids a robin's egg blue layer forms, either imme- diately or in the course of a few minutes, if hsemoglobin is present. Iodides and iodine also give a blue color. Hsemin Test for Blood. — A drop of a 0.6 per cent, salt solu- tion is evaporated on a slide. A small bit of the suspected materia], well teased, is placed upon the layer of crystallized salt. Place a cover-slip over it, and allow glacial acetic acid to run in under the slip, filling the spaces. Heat carefully (three-quarters to one minute) till bubbles of gas begin to form Fig. 1. Hsemin crystals. beneath the cover. During evaporation glacial acetic acid is further added, drop by drop, from the edge of the slip, until a faint reddish-brown tint appears. Now hold specimen farther away from the flame, and slowly evaporate the last traces of acid. Add a drop of glycerin and examine under the microscope. If blood is present, heemin (or Teichmann) crys- tals form, in the shape of light- or dark-brown rhombic plates or columns. The size of the crystals varies with the manner in which they are produced. The more slowly the acetic acid is evaporated the larger the crystals. 22 G ENSEAL CONSIDERATIONS. H co § O & s ^ a ■s-S- .s • ^H • pH .5.5" *, 2 S"HS^ CM F— H 1 M O u P-. J^ £ o M- - & o~ - j3 u 2-§ Ph c3 £% o CO CO CO r TS'P P . fl P •rH v. ^ C3 ^* ** 2SS coo Si) *S PhPh CO C0r^ &£§ CO rh to COiOH CO CO (M ^HO a •i—i u & o CO 8 fee ©co oo O OO CO rH GO O Q iO © © CO CO © ri a 3 V. >» co 2 • 1—4 M O -»-a h ^ CD Ph O a~ ~ Ph CO • P >• 3 63 CP ■+-> o P rH P P O CO a cu o o O CO >* 2 3 3 '£ £;; - rP o P cp 'a p o a © CO CM t^ CO CO iO t>TH © 00 CO CO © rH CO © © CO iO t> CM CO i>ocoo GO CM ^* lO © co co © © CO CO CM" © © ©*©©"© CO rH t^CM CO 1 s • r-H X o >H Ph Ph C3 CM © © M 2 - ed - M W a B 5b o a a . bo be b9 qd sbS a o O T3 g be 2 50c.c.. • • { y 1Sf£r Thirty minutes. Sixty minutes. Ninety minutes. Total acidity 20 to 30 50 to 60 30 to 40 Combined acids ........ 20 to 30 40 to 50 25 to 35 FreeHCl 10 to 15 5 to 10 Digestive power of filtrate (Hammerschlag's test, about 90 per cent.). Filtrate in dilution of 1 : 3000 with normal HC1 solution digests disk of albumin after remaining in thermo- stat at 37° C. for twenty-four hours. Rennet ferment coagulates milk in dilution of 1 :40. Rennet zymogen coagulates milk in dilution of 1 : 160. Free HC1 appears in thirty minutes, reaches its height in about one hour, and, diminishing, continues to the end of digestion. Acetic acid and potassium ferrocyanide give a slight cloudi- 1 Pepsin, 3, TEST-MEALS. 109 ness after the first half-hour, up to early digestion. The biuret reaction (rose) runs the same course. Fehling's solu- tion is reduced during the first hour. LugoPs solution gives a brownish-purple color during the first one and a half hours. There should be no blood, a small amount of mucus, per- haps a little bile, and a small number of bacteria ; no organic acids ; no signs of fermentation, such as long bacilli, sarcines, or yeast. The stomach should be empty in two to two and a half hours after the beginning of the meal. Boas Test-breakfast. — A tablespoonful of rolled oats is added to 1000 c.c. of water ; this is boiled down to 500 c.c. A little salt may be added. Remove one hour later. Indications. — This meal is employed in suspected cases of cancer of the stomach, where it is important to determine the presence of lactic acid, since it contains none of this acid, while test-meals containing bread do. The stomach should be thoroughly washed out the night before. The chemical findings are about the same as those for the Ewald-Boas test-breakfast. Riegel Test-dinner. — Soup, 400 c.c; finely chopped or scraped beef, 200 grammes ; a slice or tw r o of wheat bread (50 grammes) ; and a glassful of water. Remove four hours later. Amount . 40 to 80 c.c. Two hours. Three hours. Four hours. Total acidity 40 to 50 45 to 70 60 to 80 Combined HC1 40 to 50 45 to 60 50 to 60 FreeHCl to 5 10 to 20 Free HC1 appears in about two and a half hours, continues about two hours, and disappears about twenty minutes before the stomach becomes empty. The cloudiness with acetic acid and potassium ferrocyanide and the biuret reaction (rose) begin near the end of the first hour, and disappear during the last fourth of the period of digestion. Very few striated muscle-fibres can be found. The stomach should be empty in five hours. Hammerschlag, about 90 per cent. 110 THE STOMACH Rennet ferment and zymogen are the same as in the test- breakfast. Lugol's solution produces a brownish-violet coloration. Ordinary Meal. — It is a good custom to examine occasion- ally the stomach contents removed four hours after the patient's average dinner, and make the analysis as after the regular test-meals. Contraindications to the Use of the Stomach-tube.— Chief among these are aneurysm of the aorta and inflamma- tory conditions of the oesophagus. Advanced arteriosclerosis, especially with involvement of the coronary arteries, with a history of attacks of angina pectoris, forbid the passage of the stomach-tube except in those accustomed to its use. Con- trary to common opinion, it is frequently used as a thera- peutical measure in cases of valvular heart lesions, even dur- ing the stage of incompensation. Cancer and ulcer of the stomach, instead of always contraindicating its use, are at times strong indications for its use unless there is a history of recent hemorrhage. Good judgment should govern one in the selection of cases. Stomach-tube. — The tube most commonly employed is manufactured by the Goodrich Rubber Company. The most satisfactory tube is made of soft rubber and has a bulb attachment ; sizes 21 E, 22 A, 33 F. Its outside diameter is ^g- inch, lumen ^ inch. A smaller tube is used for children. The entire length of the tube, including the bulb, is about 65 inches ; length to bulb is about 43 inches. A white ring indicates the distance to which the tube should be introduced in the average case. One soon learns the correct distance by experience. The tube most often em- ployed has an opening at the end and one on the side, a short distance above. Some prefer a tube with a blind end and lateral openings, because there is less danger of damaging the stomach mucous membrane by suction into the terminal opening. The tube should not be too flexible. It is well to cut it in two about 12 inches from the funnel end and insert a piece of glass tubing, in order the better to inspect the character of the washings as they pass through. REMOVAL OF THE STOMACH CONTENTS. Ill A rubber or glass funnel can be used. A special glass funnel for this purpose is manufactured by the Kny-Scheerer Co. Patients with syphilis, tuberculosis, and cancer should have tubes for their exclusive use. Passing the Tube. — The patient should be told that it is not a serious operation, and that it will not interfere with his breathing. There is usually no need of introducing the fingers of the left hand into the mouth to guide the tube. Moisten the tube in water or glycerine, hold it in the fingers of the right hand, as one would a pen, four to five inches from the end, aim directly at the middle of the posterior pharyngeal wall, cautioning the patient not to bend his head backward too far, tell him to swallow, and push the tube forward without hesi- tancy. In most cases it will enter the canal readily. With the left arm thrown around the patient's head from behind, the tube is held in place between the index and middle fin- gers, and rapidly pushed into the stomach with the right hand. Occasionally a spasmodic contraction of the oesopha- geal muscles at the isthmus of the fauces or lower down will obstruct the passage. Steady pressure will overcome this resistance in a few seconds. If the tube is quite flexible, it may not enter the isthmus at all, but bend to the side and pass around the patient's mouth. An extremely irritable pharynx may be sprayed w 7 ith cocaine, or a pledget of cotton may be soaked in a 5 per cent, solution of cocaine and sucked for five minutes, care being taken not to swallow the saliva. Such procedures are almost never necessary. The tube may meet an organic stricture, due to cancer, ulcer, or tumor pressing from the outside. REMOVAL OF THE STOMACH CONTENTS. The contents may be obtained in three ways : (1) Self-expression. — By bearing down, as at stool, or by coughing, the abdominal muscles and stomach are made to contract and thus force out the contents. Slight vomiting movements may be produced by moving the tube back and forth, thus facilitating the expulsion. 112 THE STOMACK Fig. 34. Showing on upper shelf drop reagent bottle, suction flask, and platinum wire and loop ; on lower shelf, Politzer bag and atomizer bulb ; on table, beginning at the left, funnel for syphon stomach-tube, Cowie burette stand, reagent bottle, rack for 6UCtion flask, etc., bulbed stomach-tube, irrigator with spout cap. (2) Suction. — The modified Politzer bag of the aspirator of Boas can be used. (See Fig. 34.) Ewald or Tubes are REMOVAL OF THE STOMACH CONTENTS, 113 now manufactured with the Boas aspirator attached. With the fingers of the left hand the tube is compressed between the bulb and the stomach. The bulb is now compressed, the first pressure relaxed, and the tube beyond the bulb then compressed, and the pressure on the bulb relaxed. The bulb sucks the stomach contents into itself. They are now ex- pelled by again compressing the tube toward the stomach, and then compressing the bulb. The Politzer bag when used is first compressed and then attached to the stomach-tube, and on expanding draws the contents into itself. The aspirator used in cleansing the blood pipettes will be found very conve- nient for this purpose. (3) Position and Gravity. — With the patient in the hori- zontal or knee-elbow position, the contents can sometimes be more easily removed. The tube should be just through the cardia and held in the mouth to prevent it dragging on the larynx. Failure to obtain contents may be due to several causes : (1) The stomach may be empty. Cases are met with in which the test-breakfast is forced into the bowel in less than half an hour. (2) The tube may be plugged with food or mucus. Com- pression of the Boas bulb or the Politzer bag may free the tube. An extra effort on the part of the patient may dislodge the obstruction. The tube may be introduced too far or not far enough. It may be necessary to remove the tube, cleanse it, and introduce it again. The introduction of water for syphon purposes renders the analysis unsatisfactory, and is not to be recommended. If unsuccessful in obtaining the stomach contents by the above methods, very often enough can be obtained for analysis by firmly comjjressing the tube with the fingers and withdrawing, the tube being in many instances partially filled with stomach contents. 8— c. d. 114 THE STOMACH, EXAMINATION OF THE STOMACH CONTENTS. Macroscopical Examination. — (a) Quantity. — The quan- tity varies much with the size of the stomach, condition of the motor power, presence of obstruction, size of meal, and period at which it is removed. (6) Odor. — The contents in health have a characteristic stomach odor. In fermentative conditions there is a disa- greeable, rancid odor. In health, following a test-meal, the contents should be moderately fluid, not thick and tenacious ; the food is fairly well digested and broken into small pieces, yellowish in color, and on standing separates into two layers — lower solid, upper liquid. A small amount of mucus is present ; there should be no macroscopical blood unless it comes from irritation of the oesophagus by the tube. A small amount of bile is often found when the tube is passed on those unaccustomed to its use. Pus should not be present. In disease the quantity may be diminished or very much increased. There may be great excess of mucus, which is easily recognized by its appearance. Food eaten many hours, even days, before may be present. Fresh red blood, or dark altered blood, excess of bile, a brownish scum in which sar- cines are often found, pieces of gastric mucous membrane, or bits of tissue from new growths or ulcers, all should be looked for. The naked eye usually detects the presence of bile. This examination is most satisfactorily made by pouring the residue after filtration upon a plate and examining with the aid of teasing-needles. Microscopical Examination of Normal Contents. — The findings vary with the meals. Vegetable cells, starch-gran- ules, altered meat-fibres, a few bacteria, a few red and white cells (result of tube irritating throat and oesophagus), fat- globules, possibly leptothrix, may be found. Microscopical Examination of Abnormal Contents. — This shows in different cases undigested meat-fibres, vegeta- ble cells, numerous red cells, pus-cells, sarcines, yeast-cells, EXAMINATION OF THE STOMACH CONTENTS. 115 numerous bacteria, most important of which are the lactic acid bacilli. (Plate X.) These are better recognized by a study of the figures than by description. Sarcines, yeast- cells, and lactic acid bacilli are all signs of fermentation. Whenever a bit of the stomach mucous membrane is obtained, it should be sectioned and examined by a pathologist. It is recognized under the microscope by the special arrangements of cells. In cases of suspected carcinoma or atrophic gastritis such examination is extremely valuable. It has been claimed that the presence of lactic acid bacilli (Oppler-Boas) is quite positive evidence of cancer of the stomach, but too much stress must not be placed on them as evidence, as observers of late years have found them rather frequently in non-malignant conditions. Pus and blood are recognized by their appearance under the microscope, as described in other chapters. If necessary, the hsemin crystal test or the guaiacum test may be applied for the demonstration of blood. Sarcinae occur in characteristic squares, resembling cotton bales. Yeast-cells appear as oval bodies 3 to 10 /i long, showing the budding formation. There may be chains of three or four, or more commonly one larger body with a small one springing from it. Oppler-Boas Bacillus. — This is a long, large, non-motile bacillus, usually growing in chains which take a zigzag course. Frequently pairs of bacilli are seen joined together at an angle. Ralston Williams has succeeded in growing these bacilli on glucose-agar. They may be stained with methylene-blue. Under the oil immersion they appear made up of short rods. Filtration of Stomach Contents. — For rapid work a suc- tion flask is attached to the aspirator and the contents filtered. An ordinary funnel and filter-paper can be used, but the process is slow if much mucus is present. 116 THE STOMACH. CHEMICAL ANALYSIS OF GASTRIC JUICE. Qualitative Tests. — Free acid of any kind turns Congo- red solution or paper a bright blue. Free organic acids can not be distinguished from free mineral acids bv this test. Acid salts do not give the reaction. Test.— A strip of Congo-red paper is dipped into the stomach juice, or to a few cubic centimetres of Congo-red solution (made by dissolving a bit of the powder in water) a few drops of stomach filtrate are added. Free Hydrochloric Acid. — This acid is recognized very well by Gitnzberg's test. Two or three drops of phloroglucin vanillin solution and an equal amount of filtrate are placed in an evaporating-dish and slowly heated over a flame, care being taken not to burn the contents. If free hydrochloric acid is present a beautiful rose-red color appears, especially at the periphery of the drop. This is due to the formation of minute red crystals. Dimethyl-amido-azo-benzol paper is a yellow bibulous paper which strikesa red color in the presence of free hydrochloricacid. Free Organic Acids. — Uffelmann's test is most commonly employed. Application. — To a small amount of carbolic acid solution of any strength a drop of ferric chloride solution is added ; a very dark-blue results ; distilled water is added till this solution becomes an amethyst-blue color. A few drops of the filtrate are added. If lactic acid is present in moderate amount, it becomes a canary yellow ; if in small amount, a greenish yellow. The reaction is unsatisfactory. Free HO clears up the blue solution, acetic and combined HC1 give it a yellowish- brown color ; and butyric acid a grayish opalescent appearance. Kelling's Test. — Kelling's is a more reliable test for lactic acid. It is applied as follows : 5 c.c. of gastric juice are diluted with 10 volumes of water and treated with 1 or 2 drops of a 5 per cent, aqueous solution of ferric chloride. In the presence of lactic acid a distinct greenish-yellow color is seen if the tube is held to the light. A positive reaction is obtained only in the presence of lactic acid. CHEMICAL ANALYSIS OF GASTRIC JIUCE. 117 Strauss' Test — Strauss' apparatus is filled with gastric juice to the mark 5 c.c., then ether is added to the 25 c.c. line. After shaking thoroughly the separated liquids are allowed to escape by opening the stopcock until the 5 c.c. mark is reached. Distilled water is then added to the 25 mark, and the mixture treated with 2 drops of the official tincture of the sesquichloride of iron, diluted in the proportion of 1 : 10. On shaking, an intensely green color appears if more than 1 pro mille of lactic acid is present, while a pale green is ob- tained in the presence of 0.5 to 1 pro mille. Small amounts of lactic acid do not show with this test. The exact quantitative estimation of lactic acid is not of clinical value. If so desired, Boas' method may be used, for a description of which the reader is referred to Simon or ( v. Jaksch. The recognition of butyric, acetic, and fatty acids is not important. The first two are usually recognized by their odor, especially if they are heated. Quantitative Determination of the Acidity of the Gastric Juice. — The best results are obtained by selecting one good method for constant use. Such a one is Topfer's Method. — This requires a burette, graduated pipettes, 3 small beakers, decinormal sodium hydrate solu- tion, and 3 color reagents, solutions of phenolphthalein, sodium alizarin sulphonate, and dimethyl-amido-azo-benzol. Solutions containing phenolphthalein turn pink in the pres- ence of an alkali, becoming permanently pink when the mixt- ure becomes even faintly alkaline. Sodium alizarin sulphonate is stated to be unaffected by hydrochloric acid in combination with proteid. Dimethyl-amido-azo-benzol in alcoholic solution becomes red in the presence of free hydrochloric acid. The following determinations are made by means of color reactions : 1. Total acidity. 2. Combined hydrochloric acid. 3. Free hydrochloric acid. 4. Organic acids and acid salts. 118 THE STOMACH. Procedure. — The stomach contents are filtered : 1. Total acidity : a. By means of a graduated volume pipette place 10 c.c. of filtrate in a beaker or whiskey glass. b. Add 2 drops of phenolphthalein (indicator). c. Titrate with decinormal sodium hydrate solution, adding it drop by drop, stirring after the addition of each drop, until the first permanent pink is detected. (This color reaction indicates that the acid filtrate has been made slightly alkaline by the addition of sodium hydrate, since phenolphthalein solutions turn pink in the presence of an alkali.) Read off the number of cubic centimetres of sodium hydrate required to bring about this end-reaction ; for example, 10 c.c. 2. Combined hydrochloric acid: a. Place 10 c.c. of filtrate in a beaker. b. Add 2 drops of sodium alizarin (indicator). c. Titrate with sodium hydrate solution as in (1) until a permanent pure violet color is obtained. Read off the number of cubic centimetres of sodium hydrate required to bring about this end-reaction ; for example, 6 c.c. This figure does not indicate the combined hydrochloric acid, but instead the entire acidity minus the combined hydro- chloric, since alizarin does not react to hydrochloric acid com- bined with proteids. Hence the combined hydrochloric is calculated by subtracting 6 c.c. from 10 c.c. = 4 c.c. 3. Free hydrochlonc acid : a. Place 10 c.c. of filtrate in a beaker. 6. Add 2 drops of dimethyl-amido-azo-benzol (indicator). (The mixture will turn red in the presence of free HC1.) c. Titrate with sodium hydrate until the mixture turns a lemon yellow. Read off the number of cubic centimetres required ; for example, 2 c.c. The indicator (dimethyl) reacts to free mineral acids, but is not affected by organic acids unless present in more than 0.5 per cent. 4. Organic Acids and Acid Salts. — Subtract the acidity due to combined HC1 and free HC1 from the total acidity SCHEME ILLUSTRATING THE ABOVE PROCEDURES. 119 and the result is the organic acids and acid salts ; for exam- ple, 10 c.c. — (4 c.c. + 2 c.c.) = 4 c.c. To illustrate the estimation of per cent, of acid in the above calculations. One cubic centimetre of the decinormal sodium hydrate solution represents 0.00365 gramme of hydrochloric acid. Total acidity =10 c.c. X 0. 00365, or 0.0365 gramme for every 10 c.c. of filtrate used ; or for 100 c.c. of filtrate 0.3650 gramme or per cent. Combined HCl= 4 c.c. X 0.00365, or 0.01460 gramme for every 10 c.c. of filtrate used ; or for 100 c.c. of filtrate 0.1460 gramme or per cent. Free HCl = 2 c.c. X 0.00365, or 0.00730 gramme for every 10 c.c. of filtrate used; or for 100 c.c. of filtrate 0.0730 gramme or per cent. Organic acids and acid salts = 0.3650 — (0.1460 + 0.0730) or 0.1460 gramme or per cent. Combined HCl = 0.1 460 per cent. Free HCl = 0.0730 Organic acid and 1 ~ -m^a acid salts / ' a Total acidity = 0.3650 " SCHEME ILLUSTRATING THE ABOVE PROCEDURES. 1. Phenolphthalein indicates 2. i \ Total acidity ) The entire I acidity ex- f cept com- J bined HCl 3. Dimethyl-amido-azo- 1 ^ nni benzol indicates j * ree MU 4. Organic acids and 1 1 /o i \ acid salts j 1 <^+°> Sodium alizarin sulphonate in- dicates f Free HCl, com- I bined HCl, j organic acids |^ and acid salts. f Free HCl, or- l ganic acids and acid salts. | Free HCl. 120 THE STOMACH, a. Total acidity, 10 c.c. b. Combined HC1, 4 c.c. c. FreeHCl, 2 c.c. c/. Organic acids and acid salts, 4 c.c. Substitute for Percentage Calculation. — The number of cubic centimetres of decinormal sodium hydrate solution required to bring about the end color reactions in 100 c.c. of stomach filtrate in each of these calculations is used to indicate the degree of acidity. For example : If in estimating the total acidity 10 c.c. of filtrate were used, and it required 10 c.c. of sodium hydrate solution to bring about the end-reaction, it would require 100 c.c. of sodium hydrate to bring about this reaction if 100 c.c. of filtrate were used. Consequently, total acidity is repre- sented by 100. If only 1 c.c. of filtrate is used, the number of cubic centimetres of sodium hydrate is multiplied by 100. Example : 10 c.c. of filtrate. Sodium hydrate. Figure. Per cent. Total acidity 10 c.c. 100 0.3650 Combined HC1 4 c.c. 40 0.1460 Free HC1 ........ 2 c.c. 20 0.0730 Organic acids and acid salts. 4 c.c. 40 0.1460 It is helpful to notice that each 25 of acidity corresponds approximately to jo per cent, by weight. SHORT METHOD. In many stomach analyses it is necessary to determine only the total acidity and free hydrochloric acid. A unique method for determining these figures is the fol- lowing : a. Place 10 c.c. of filtrate in a beaker. 6. Add 2 drops of dimethyl (indicator) and determine the amount of free HC1 present by titration with sodium hydrate. c. Add to this same filtrate 2 drops of phenolphthalein, and continue the titration with sodium hydrate till the first permanent pink results. The total acidity is represented Jby~ the entire number of cubic centimetres of sodium hydrate used. It frequently happens that not sufficient stomach contents are obtained to furnish 10 c.c. of filtrate for each of the three SHORT METHOD. 121 titrations, and the few cubic centimetres required for the digestion test. Under these circumstances 2 c.c. or 5 c.c. may be used and calculations made accordingly. If the normal pipette is used for measuring the filtrate, the last drop should not be blown out. It is recognized by the presence of a white ring near its tip. Digestion Test. — Following the determination of the acidity of the gastric juice, the next test is for the presence of pepsin. Common Method. — If free hydrochloric acid has been de- monstrated to be present, a small test-tube is partially filled with the filtrate and a small disk of coagulated egg-albumin added to it. This is placed in the thermostat for twenty- four hours and examined from time to time. If free HC1 has been proved absent or in very small quantity, another test- tube should be prepared in the same way and a couple of cubic centimetres of a 0.4 per cent, solution of HC1 added. Two or three drops of official dilute HCL may be used instead. This second test-tube will furnish evidence of pep- sinogen, since free HC1 changes it into pepsin. Digestion is shown by the periphery of the disk becoming translucent ; and a rough idea of the amount of pepsin can be gained by noting the depth to which this translucent area extends. The egg-albumin disks are prepared as follows : An egg is boiled hard, shell removed, and the white carefully separated from the yolk. With a cork-borer numerous cylinders of the white are removed and cut into disks of the same size and preserved in glycerine. Before use the glycerine should be washed off with water. Mett Method of Determining Peptic Digestion. — Eal- ston Williams describes this method as follows : " Briefly described, glass tubes filled with coagulated egg- albumin are placed in 2 to 4 c.c. of gastric juice and kept in the incubator for ten hours. At the end of this time the tubes are removed and the number of millimetres of albumin digested is estimated. This is ascertained by measuring the portions of the ends of the tubes that are clear, including also the clouded 122 THE STOMACH. or opalescent zone, if one be present. For this purpose a scale graduated to 0.5 mm., a small lens magnifying 2 to 3 diameters, and a small black glass plate are employed. With very little practice one can correctly read fifths of a millimetre. The digestion which goes on within the first ten hours, according to Ssamojloff, corresponds to the normal period of stomach digestion. Franz Jung states that from 5.5 to 5.9 mm. should be digested in ten hours ; however, the results obtained in the clinical laboratory of the University Hospital at Ann Arbor would indicate that these figures are too high, and the 3.5 to 4.5 mm. would be more nearly correct. It has been established by Borrissow and Schutz that the amount of pepsin in one juice, as compared with another, is as the squares of the number of millimetres digested are to each other. The foregoing fundamental statements are gath- ered from Jung's abstracted translation of Pawlow's book, "The Work of the Digestive Glands" (Jour. A. M. A., May 10, 1902), and is the basis of the experiments that follow. There are several ways of preparing and preserving the Mett tubes, the one employed by the writer is as follows : Thin-walled glass tubing having a calibre of 1.5 mm. is cleansed in distilled water and dried. It is then cut into lengths of about 10 cm., convenient for storage for use. These then are filled by suction with the white of a fresh egg. The egg-albumin must be free from air bubbles, one of the chief sources of annoyance and error being the presence of these air bubbles. In filling the tubes the endeavor is made to secure only the more fluid portion of the egg. This can be done readily by care and manipulation. As each tube is filled its ends are passed slowly through a white gas flame, thus forming small coagulated plugs, which serve temporarily to prevent the escape of albumin. When a sufficient number of these tubes are thus prepared they are placed in a basin of distilled water, supported on glass rods. The water is then heated to a temperature between 90° and 95° C, which is maintained for five minutes. Care is taken to keep an equable temperature throughout the basin. From here the tubes are transferred to a 66 per cent, watery solution of glyc- SHORT METHOD. 123 erine, in which they are preserved. When it is wished to make a test a tube is selected, the glycerine washed therefrom, and about 10 mm. of one is snipped off, a sharp Stubb's file being employed for this purpose. This piece is thrown away and another about 18 mm. long is taken. In this way a por- tion is secured free from the action of glycerine, which has an inhibiting effect on the digestion of the egg. This small tube, placed in 3 or 4 c.c. of gastric juice is put into the incubator, and left for either ten or twenty-four hours. The digestion in twenty -four hours is proportionately more. For the rea- sons before stated ten hours is preferred, but usually the twenty-four-hour period is much more convenient and is therefore used. Frequently in the digested tubes two zones will be seen, one perfectly clear, from which the albumin has entirely disappeared, the other hazy or cloudy. In other tubes cone-shaped translucent plugs are formed. The expla- nation of this is not quite clear, since in the more perfect tubes the digestion is sharply defined, there being only the clear digested and solid or undigested zones. The results may be recorded as the number of millimetres, but for pur- poses of comparison these figures should be squared, this being the true index to the amount of pepsin in the sample. Nirenstein and Schiff have shown that the strength of one gastric juice, as compared to another, is as the squares of the number of millimetres digested, only in juices up to a cer- tain strength. Beyond a certain point the rule does not hold good. Furthermore, they have shown that the soluble chlorides and carbohydrates interfere. They have obviated these difficulties by diluting the gastric juice fifteen times, 16:1, under which conditions the laws are correct. For practical purposes, however, the old way is sufficiently accu- rate. Jung 1 draws the following conclusions from his work with this method : (1) The normal values for pepsin digestion are, according to Mett\s method, 5.5 to 5.9 mm. (2) Subacidity and anacidity have lower values than normal or superacidity — i. e., 1.9 mm. average. 1 Jour. Am. Med, Assoc, May 10, 1902. 124 THE STOMACH. (3) Superacid ity, generally speaking, has high and highest values of pepsin, yet there are cases of unusually high HC1 figures with disproportionately low pepsin values. (4) The diminution of pepsinogen does not run proportional with that of HC1. Even with a deficiency of HC1 the value of pepsin can be higher than that of mild subacidity. Com- parison average of Hammerschlag and Mett methods : Mett 5.5 mm. superacidity ; 1.9 mm. subacidity. Hammerschlag . . 6.0 " " 4.5 " " Hammerschlag's Method of Quantitative Estimation of Pepsin. — Three Esbach's tubes are employed (albuminime- ters). Tube A is filled to the mark U with a mixture of 10 c.c. of a 1 per cent, solution of serum-albumin in 0.4 per cent, hydrochloric acid, and 5 c.c. of filtered gastric juice. The second tube (B), which is the standard, is also filled to the mark U, but 0.5 gramme of pepsin is added to the serum solution instead of the gastric juice. The third tube (C) simply contains a mixture of the serum solution and 5 c.c. of water. Place in thermostat for one hour at temperature of 37° C. Esbach's reagent is added to each tube to the mark R. After standing for twenty-four hours the amount of pre- cipitated albumin is read off, and the difference between that in A and C compared with that in B. Rennet and its Zymogen. — A few drops of the stomach fil- trate are added to 10 or 15 c.c. of milk in a test-tube, and placed in a thermostat at a temperature of 37° C. If the rennet is normal, the milk will be coagulated solid or with the separation of a small amount of whey in ten to fifteen minutes. If the curdling takes place more slowly, rennet is deficient. If the filtrate does not show hydrochloric acid, add a small amount of calcium chloride solution to the mixture. Rennet zymogen, if present, is then converted into active rennet and coagulates the milk. Tests for Proteids. — Examine for acid albumin or syn- tonin, albumin, albumose, and peptone. The customary tests for proteids are used. EXAMINATION OF STOMACH DURING FASTING. 125 Acid albumin, if present, is precipitated by carefully neu- tralizing the filtrate with the deeinormal solution. An excess of either alkali or acid redissolves the precipitate. Albumin. — After removing syntonin by neutralizing and filtering, the filtrate may be tested for albumin by the various well-known tests, such as Heller's ring test, acetic acid and potassium ferrocyanide, etc. Albumose. — Precipitate the syntonin and albumin by boil- ing the unneutralized filtrate. Filter, and test filtrate for albu- mose as follows : Mix equal quantities of the cooled filtrate and a satu- rated solution of sodium chloride ; add a drop or two of acetic acid. A turbidity or precipitate in the cold, disappearing on heating and reappearing on cooling, indicates presence of albumose. The filtrate should also give the biuret reaction. Peptone. — Remove albumin, syntonin, and albumose as above indicated. The filtrate should be negative to the albu- min tests. If peptone be present, it should give the biuret reaction — a violet-red or purplish color on the addition of a drop or two of dilute copper sulphate solution. Tannin and some other substances also give this reaction. Carbohydrates. — Starch, erythrodextrin, sugar, and achroo- dextrin, may be present in the filtrate. Starch.— Dilute a small amount of Lugol's solution to a light-yellow color ; add a few drops of gastric filtrate. If unchanged starch is present, a blue color results ; if ertyhro- dextrin a deep brown or mahogany. For detecting sugar the customary tests are used, such as Fehling's, etc. EXAMINATION OF STOMACH CONTENTS DURING FASTING. This procedure is of value in demonstrating dilatation and diminished motor power of the stomach, or the presence of an obstruction at the pylorus. If food is found in the stomach which has fasted overnight (eight to twelve hours), it gives evidence of one or all of the above conditions. 126 THE STOMACH. The fasting stomach is also examined to learn whether there is an excessive secretion of gastric juice. It should be washed out the night before. Normally the fasting stomach contains from a few cubic centimetres up to 50 or 60 c.c. of juice. Above this amount indicates hypersecretion, so-called Reich- man's disease. This juice should be subjected to the same tests as the juice obtained after a test-meal. Fig. 35. Collective view of vomited matter. (Eye-piece III., objective 8 A, Reichert.) or, muscle-fibres ; 5, white blood-corpuscles ; c, c/, squamous epithelium ; c", columnar epithelium; d, starch-grains, mostly changed by the action of the digestive juices: e, fat-globules ; /, sarcinse ventriculi ; g, yeast-fungi ; h, forms resembling the comma bacillus found by v. Jaksch once in the vomit of intestinal obstruction ; i, various micro-organisms, such as bacilli and micrococci ; k, fat -needles, between them con- nective tissue derived from the food ; I, vegetable cells, (v. Jaksch.) Ordinary Meal. — In patients complaining of indigestion much can be learned by removing the ordinary meal and sub- jecting it to all of the above routine examinations. In fact, the writer believes that in many instances such a meal may prove much more valuable than the test-meals. The vomitus should also be subjected to the above examina- tions — macroscopical, microscopical, and chemical. In suspected cancer of the oesophagus with regurgitation EXAMINATION OF MOTOR rOWER OF STOMACH. 127 chemical examination often throws much light on the case. If the various acids (free HC1 and combined HC1) and ferments are present, it indicates that the material vomited is from the stomach. If absent, it indicates that the material had not reached the stomach (stricture of oesophagus with dilatation) or that a condition of achylia gastrica is present. The reaction of the vomitus to litmus-paper is of no value. EXAMINATION OF MOTOR POWER OF THE STOMACH. This is one of the most important of stomach examinations, and the one most often neglected. The best method is by the use of the stomach- tube. The average meal should be passed on into the intestine in six or seven hours. At the expiration of this time after an ordinary meal the tube should be passed and the stomach washed out. Presence of food indicates deficiency in motor power. The usual method is to wash out the stomach in the morning, before breakfast, nothing having been eaten since 6 o'clock the even- ing before. In mild cases of diminished motor power food may be retained in the stomach from meal to meal during the day, being finally passed into the intestine during the long fast of the night, Another but much less satisfactory method consists in administering a gramme of salol in three or four capsules immediately after a meal. Salol is unchanged in the acid contents of the stomach, but as soon as it mixes with the alkaline contents of the intestine it is decomposed into phenol and salicylic acid. The latter is absorbed and excreted in the urine, where it may be recognized. The addition of a few drops of ferric chloride solution, in the presence of salicylic acid or its derivatives, gives a brown or violet color. The urine should be tested every half to one hour for this reaction, and again after twenty-four hours. Normally it appears in sixty to seventy-five minutes. The salol should be entirely excreted in twenty-four hours. A delayed appear- ance of the reaction indicates diminished motor power. Nega- 128 THE STOMACH. tive examinations during the first twenty-four hours indicate pyloric stenosis. Too many factors are involved to make this a satisfactory test. Stomach contents must be acid, in- testinal contents alkaline, and the kidneys should be normal. Diminished motor power is present in many gastric condi- tions, such as cancer of the stomach, with stricture of the pylorus, benign stricture of the pylorus, dilatation, gastric atony, gastroptosis, chronic gastritis, etc. ABSORPTIVE POWER OF THE STOMACH. Test. — A capsule containing 0.2 gramme of potassium iodide (all traces being carefully removed from outside of the capsule) is given shortly before a meal. The saliva is now examined every two or three minutes with starch-paper for a trace of potassium iodide. Normally a violet color is obtained in six and a half to eleven minutes, a bluish tinge in from seven and a half to fifteen minutes. A delayed appearance of the reaction is observed in most diseases of the stomach, especially in dilatation and carci- noma, less so in chronic gastritis, variable in ulcer ; but abso- lute dependence can not be placed on this reaction, since it has been obtained in dilatation and chronic gastritis within the normal time limit. SIZE, SHAPE, AND POSITION OF THE STOMACH. A fairly accurate idea of these three points may be gained by distending the stomach with air by means of the stomach- tube and atomizer bulb. This is a satisfactory method in those who take the tube well. In others it is well to distend the stomach with carbonic acid gas generated in the following way : 6 grammes of tartaric acid dissolved in half a glassful of water are swallowed, and immediately followed by a solution of 7 grammes of sodium bicarbonate in half a glassful of water. The stomach is immediately distended, revealing its position, shape, and in a general way its size. It should never be dis- tended in those giving a history of ulcer or recent hemorrhage. The capacity of the stomach is determined by measuring the quantity of water which can be poured into it through ORGANIC ACID FERMENTATION. 129 the tube without causing special distress. That of the normal stomach varies with the individual, measuring on an average from 1000 to 1500 c.c. Ewald considered 1700 c.c. abnor- mally large. The extremes may be placed at 800 c.c. and 2000 c.c. for the adult. Classification of Digestive Conditions. Normal HC1 acidity =Euchlorhydria. Increased HC1 acidity =Hyperchlorhydria. Diminished HC1 acidity = Hypochlorhydria. Absent HC1 acidity = Achlorhydria. Normal pepsin = Eupepsia. Increased pepsin = Hyperpepsia. Diminished pepsin = Hypopepsia. Absent pepsin = Apepsia. Organic Acid Fermentation. Duration of Digestion. 1. Normal length of time. 2. Increased length of time. 3. Diminished length of time. QUESTIONS. What are the objects of stomach examinations? Mention the reagents required in this work. Describe the test-meals commonly employed. What are the contraindications to the use of the stomach-tube? Describe the correct method of passing the tube. What means are employed in the removal of the stomach contents ? What points are considered in the macroscopical examination of the stomach contents ? What are the microscopical findings in normal and abnormal stomach con- tents ? What is Giinzberg's test for free hydrochloric acid f Describe Kelling's test for lactic acid. Describe in detail Topfer's method for the quantitative determination of the acidity of the gastric juice. Describe Mett's method of determining peptic digestion. What facts are learned by the examination of the stomach contents during fasting? What methods are used in determining the motor power of the stomach ? Describe the test for determining the absorptive power of the stomach. How are the size, shape, and position of the stomach determined ? Classify the digestive conditions. 9— C. D. 130 . THE FuECES. CHAPTER IX. THE F^CES. The faeces consist of undigested particles of food, intestinal mucus, unabsorbed intestinal secretions, epithelial cells, and bacteria. The number of stools per day varies with the individual. The average person has one formed stool a day, usually at a regular time. There are numerous exceptions to this rule, as many healthy persons have normally only one stool in two or three days, while others have two or three daily. So in deciding whether there is constipation or diarrhoea, it is necessary to learn the " stool habit " of the individual The amount of faeces varies with the diet. It is much larger with a carbohydrate than with a proteid diet, 60 to 250 grammes being the extremes in health. The consistence of the faeces depends on the character of the food in health. With a vegetable diet (containing 80 to 85 per cent, of water) it is much softer than with a proteid diet (containing 60 to 65 per cent, of water). Normal stools are usually cylindrical and firm. A mushy stool, however, may be normal for some persons. When faeces remain long in the intestine the moisture is absorbed, and they are passed as round, hard, scybalous masses. Odor of Faeces. — The presence of skatol and indol, products of albuminous decomposition, is largely responsible for the obnoxious odor of faeces. Sulphuretted hydrogen, methane, and traces of phosphin add to the odor. Color of Faeces. — The color varies according to the food, pathological products present, and medicine ingested. The ordinary color varies from light to a blackish brown. Exclu- sive milk diet produces a light-yellow stool. Under normal conditions the color is never due to native biliary coloring- matter, but chiefly to the presence of hydrobilirubin. THE F^JCES. 131 Starches tend to produce a yellow, chlorophyll a greenish color. In obstructive jaundice the stool is of an ash or light- gray color. Blood in the stool (unless fresh) always gives it a dark appearance, the so-called tarry stool ; this is due to the forma- tion of hsematin. Iron, manganese, and bismuth produce a dark-brown or black color, owing to the formation of the sulphides of those metals. The green color of calomel stools is probably due to the presence of biliverdin. Santonin, rhubarb, and senna produce a yellow color ; hsematoxylin a red color resembling that of blood. The chemical reaction of the faeces varies much, depending on the kind of fermentation present. In intestinal catarrh with acid fermentation it is acid ; with alkaline fermentation it is alkaline. Macroscopical Examination of Normal Faeces. — Un- digested particles of food, skins of various animal and vege- table foods, berries, seeds and stones, woody vegetable fibres, large pieces of connective tissue, undigested pieces of fruits, grains of corn, flakes of casein, etc., are all frequently seen. Foreign bodies of various sorts are sometimes swallowed, and passed in the stools. It is necessary to keep this in mind when dealing with children, the hysterical, and the insane. Small quantities of mucus may be found in health, and particles resembling sago grains may be present as a result of overindulgence in starchy food. Stools of Vegetarians. — The color of the stools of veg- etarians is light brown, rarely becoming black as in the case of meat eaters. If eggs are largely used, however, and taken without proper mastication, the stools may become dark from the decomposition of the albumin. The consistence depends on the quantity of fluids or fruit that is eaten. When fruit, fruit juices or sugars are eaten in large quantity the stools are soft, When, on the other hand, the diet consists largely of grains the stools are apt to be hard ; and if the diet consists chiefly of bread with a small quantity of fruit, and when the food is masticated with very great thoroughness, the stools are likely 132 THE FJZCES. to be small and very dry. When fats are taken freely the stools are light in color (Kellogg). Macroscopical Examination of Pathological Faeces. — Mucus, when present in large quantities, indicates a catarrh of the mucous membrane of the intestine. In mucous colitis large strips of mucus (sometimes in the form of molds of the intestine, resembling sausage skins) are passed in the stools. Usually, when the mucus is mixed with the faeces and appears in small bits, it comes from the small intestine ; but in dysentery it may be mixed with the thin stool and come Fig. 36. V s *mmm Cholesterin crystals. (Simon.) from the large intestine. When the hard faeces are covered with mucus, or when it appears in shreds, it is derived from the large intestine. The " rice-water " stool of cholera is so named because of the presence of bits of mucus resembling grains of rice. Gall-stones should be sought for in all suspected cases of cholelithiasis. The Boas sieve will be found very useful for this purpose. These stones vary from the size of a pea to that of a hen's egg. They may be soft and crumbling masses (intrahepatic calculi, made up chiefly of cholesterin, Fig. 36), or hard and many-faceted. THE FMCES. 133 They are usually light in weight, and vary in color from pale yellow to brown and green, or have a mottled appear- ance, and change color on exposure to air. Following the administration of olive oil, lumps of soap may form in the intestine and be mistaken for gall-stones. Blood. — When bright red in color, it usually comes from the rectum (haemorrhoids, fissures, etc.) or some part of the large intestine. However, if a large haemorrhage takes place in the small intestine (as in typhoid fever), the blood may pass quickly through the bowel and appear unaltered in the stool. Blood coming from the stomach and small intestine is usually altered by the juices of these organs and has a black color, the so-called " tarry " stool. Pus may appear in the stool in an unmixed state when abscess cavities rupture into and discharge through the bowels. It is often mixed with mucus or blood when derived from ulcerative conditions, as in dysentery, tuberculosis, etc. It may coat the stool or be mixed with it. Fat. — A small amount of fat is present in the normal stool. In diseases of the pancreas, jaundice, and diarrhoea it is present in unusually large amounts, giving the stool a greasy or clay-like appearance. Microscopical Examination of Normal Faeces. — Vegeta- ble cells, starch-granules, muscle-fibres, elastic tissue, con- nective tissue of w T hite fibrous variety, fat-globules, and flakes of casein are to be found. Under normal conditions muscle-fibres are not numerous unless unusually large quantities of meat have been eaten. Starch-granules if in excess — except in young children — in- dicate a pathological condition of the gastro-intestinal tract. They are easily recognized by the blue color they assume after running a few drops of LugoPs solution under the cover- glass preparation. Fat may occur in droplets or in the form of needle-like crystals or highly refractive polygonal masses of a yellowish or reddish-yellow color. Numerous bacteria are present in normal faeces (Fig. 37). Method of Obtaining Specimen. — Probably the most im- 134 THE FJECES. portant practical point connected with the microscopical examination of the faeces is the proper method of obtaining the stool. It should be passed into a warm receptacle, and the examination made as soon afterward as possible. This is essential when examining for Amoeba coli or trichomonades, since the diagnosis is rendered certain only by the detection of the characteristic movements of these organisms, which cease as soon as the faeces become cold. The amoeba may be kept active by the use of a warm stage. A good method of obtaining a specimen for examination at one's own conve- Fig. 37. Collective view of the faeces. (Eye-piece III., objective 8 A, Reichert) : a, muscle- fibres ; b, connective tissue ; c, epithelium ; d, white blood-corpuscles ; e, spiral cells ; /, i, various vegetable cells ; A% triple phosphate crystals in a mass of various micro- organisms ; I, diatoms, (v. Jaksch.) nience is by the introduction of a rectal tube. In the various diarrhoeas a small amount of faeces will be brought away by the tube. In using the rectal speculum a quantity of the desired material can usually be obtained. As a routine measure, in order to secure a satisfactory stool for examina- tion, an ounce of Carlsbad salt should be given before break- fast. Several liquid stools usually result. If the material is tenacious, such as the bloody mucus in cases of amoebic dysentery or the muco-pus of tuberculosis, it can be transferred to a glass slide with the teasing-needle ; if watery, it can be THE F^CES. 135 drawn up into a small glass pipette by capillary attraction and a drop or two transferred to the slide and a cover-glass placed over it. This is examined with a high, dry objective. For staining, spreads should be made and fixed as with sputum preparations. Morphological Elements derived from the Alimentary Canal. 1. Epithelial Cells. — The cylindrical and goblet cells are almost always so altered in the normal faeces that it is difficult to recognize them. Pavement epithelial cells, when present, come from the anal orifice. 2. Leukocytes are almost never found in normal stools. 3. Red blood-corpuscles may occasionally be present in very small numbers. 4. Structureless granules in large numbers may be seen in every stool. 5. Necrotic tissue and pieces of new growth may be present in the faeces. 6. Crystals. — A large number of crystals — of almost no diag- nostic importance — are found ; these are needle-like crystals of free fatty acids (Fig. 38). Calcium and magnesium salts, neutral calcium phosphate and ammonio-magnesium phos- phate. Calcium oxalate crystals occur in abundance follow- ing ingestion of certain vegetables, as sorrel and spinach. Calcium carbonate and sulphate, and (in children) lactate of calcium are rare. Hsematoidin crystals are never found in normal stools. Charcot-Leyden crystals are found under cer- tain pathological conditions, and are supposed to indicate the presence of intestinal parasites. Vegetable and Animal Parasites. — Vegetable parasites are always present in enormous numbers. It is not yet known what relation they bear to the process of digestion. It has been proved that they are not entirely essential. Fungi are rarely found. Schizomycetes belong to the normal constituents. About 97 per cent, of bacteria are derived from the ingested food and 3 per cent, from the saliva. Most of these are non-pathogenic, but unJer suitable conditions a small per- 136 THE FAECES. centage develop pathogenic properties. There are two large classes found in normal stools : Class I. are stained a yellow or yellowish-brown with iodo- potassic iodide. Class II. are colored blue or violet. Routine bacteriological examinations of the faeces are of little practical value because of the enormous number of bacteria of all kinds that occur in the feces and the almost Fig. 38. Fatty crystals obtained from the feces. (Simon.) insurmountable difficulty of isolating them, and because, as a rule, there are easier methods of recognizing disease. In acute infectious tropical dysentery a specific bacillus, that of Shiga and Flexner, or that of Strong, is found in the intestinal discharges. In typhoid fever the Eberth bacillus is present in the stools, but it is difficult to isolate because of its close resem- blance to numerous members of the colon group. The spe- cific organism of Asiatic cholera is present in the feces in that disease. Tubercle Bacillus. — The examination of the stools for THE FJSCES. 137 tubercle bacilli, or of discharges for pus obtained during rectal examination, is a very important procedure in establishing or excluding the diagnosis of intestinal tuberculosis. It must be remembered that the stools may be contaminated by swallowed sputum. Method of Search for the Tubercle Bacilli. — If pus is found, cover-glass preparations should be made, fixed, and stained, as in the sputum examination. To find tubercle bacilli in feces, dilute the stool with 10 volumes of water in a wide- mouthed bottle of 200 c.c. capacity. Mix thoroughly and let stand for twenty-four hours. The tubercle bacilli will be found in the narrow layer between the thin liquid and the more solid sediment. With a pipette, some of this material is drawn off and spreads made from it. The feces may be carefully inspected in the receptacle, and suspected bits of mucus or muco-pus removed with teasing- needles, and spread upon cover-slips and examined in the routine way. For method of differentiating from smegma bacilli, see chapter on Urine. Animal Parasites. — The adult form and the ova are found in the human intestine and feces. They belong to the classes of : I. Protozoa. II. Vermes or worms. III. Insects. Only a few are common to man in the United States. Spe- cial mention is made of these alone. The possibility of con- tamination of the stools must always be kept in mind. I. Protozoa. — Amoeba coli is the only protozoon of patho- logical importance. Its etiological relation to amoebic dysen- tery has been proved by many observers. It is, of course, rarely found in the temperate zone, and is of more interest to tropical medicine. However, it has been found in the north- ern part of the United States, and every case of dysentery should be examined for this parasite. It is found in abscesses of the liver complicating tropical dysentery. The Amoeba coli is found especially in the mucopurulent or 138 THE FMCES. gelatinous masses of the faeces. These organisms may be so numerous as to fill completely the field under the microscope. They vary in size from 12 to 35 jut in diameter. They consist of a clear outer zone (the ectosarc) and a granular inner zone (endosarc), a nucleus, and one or two vacuoles. They are easily recognized during their active stage by their peculiar amoeboid movements, which greatly alter their shape. Pseu- dopodia are thrust out from the periphery and the remainder of the cell flows into it. When cold, it is difficult to recognize them, and they are likely to be mistaken for swollen, altered, Fig. 39. Amoeba coli. (Hallopeau.) granular epithelial cells (Fig. 39). They are well stained by Wright's method. Trichomonas and Cejxomonas intestinalis are frequently found in diarrhoeal stools, but seem to have no causal rela- tion. They are pear- or oval-shaped bodies possessing fla- gella. The trichomonas is the larger, and, in addition to the flagella, shows an undulating membrane (Fig. 40). Other protozoa found in the intestine are coccidia, cerco- monas, Megastoma entericum, and Balantidium coli. II. [Vermes Worms). — Cestodes (Tapeworms). — These are recognized in the macroscopical examination of the feces by THE F^CES. 139 discovering the segments (proglottides), either singly or a number of them joined together. The important part, and that most difficult of recognition, is the head. It is joined to the slender neck — and its variety can be learned by micro- scopical examination under a low power. Tcenia saginata is the most common tapeworm in Europe Fig. 40. Trichomonas intestinalis : a, a f , e, trichomonas of the urine, after Marchand ; b. Trichomonas vaginalis, after Donne ; b f , same, after Scanzoni and Kolliker ; d, Trichomonas intestinalis, after Piccardi ; e, ef ', e", same, amoeboid forms ; /, /', trichomonas of the urine, after Dock. and North America. It is the beef tapeworm, and is recog- nized by the fact that its head is unarmed. The head is surrounded by four pigmented suckers, each of which is encircled by a dark ring* Each segment contains male and female generative organs. The uterus occupies the centre, and has numerous clichotomoug branches, about twenty 140 THE FJECES. Fig. 41. Taenia saginata : a, natural size ; 6, head much enlarged ; c, ova much enlarged. (Simon.) THE FJSCES. 141 on a side (Fig. 41). The ova are elliptical, brown, and usually enclosed in a vitelline membrane. Tcenia Solium.-*-A pork tapeworm, rarely found in the United States, but common in Asia and Africa. It is usually Fig. 42. Head of Taenia solium ; X 45. (Leuckart.) much shorter than the saginata, and its distinguishing charac- teristic is its armed head. In addition to the four pigmented suckers there is a rostellum at the tip, furnished with twenty- four to twenty-six hooklets arranged in a double row. The mature segments differ from those of the saginata in having a uterus with only five to seven branches (Fig. 42). The ova are round, of a brownish color, and surrounded Fig. 43. Bothriocephalus latus. with a thick, radially striated membrane. The hooklets of the embryos can usually be found in their interiors. Bothriocephalus Latus, — This worm is found much more rarely than the other two in this country. It is very large, 142 THE FMCES. being 5 to 9 m. in length. Its head is shaped like a bean, and on its flat surface are two distinct grooves which probably act as suckers. The segments are almost square. The genital apparatus opens in the median line. The uterus presents four to six Fig. 44. Ascaris lumbricoides. (Eye-piece I., ob- jective 8 A, Reichert) : a, worm, half natu- ral size ; b, head slightly magnified ; c, eggs, (v. Jaksch.) Fig. 45. Oxyuris vermicularis : a, head ; 6, male ; c, female ; d, eggs. (v. Jaksch.) convolutions on each side. In water they have a rosette-like appearance (Fig. 43). The ova are oval, enclosed in brown envelopes, at the anterior ends of which a lid can be recognized. It is found in Europe and Japan, and is of marked pathological interest because it produces a severe form of ancemia. Nematodes (filiform, resembling a thread) differ from ces- THE FMCES. 143 todes in having the sex distinct. The female is always larger than the male. The most important of these are : Ascaris lumbricoides, Oxyuris vermicularis, Uncinaria duo- denalis (very important variety) (Anchylostoma duodenale), and Trichinella spiralis. Ascaris lumbricoides is the most common human parasite, and is found chiefly in children. The female is 7 to 12 inches long, the male from 4 to 8 inches. It is cylindrical, pointed at both ends ; four longitudinal bands can be seen, Fig. 46. 1? a Anchylostomum duodenale : a, male, natural size ; b, female, natural size ; c, male, magnified; d, female, magnified; e, head (eye-piece II., objective C, Zeiss) ; /, eggs. (v. Jaksch.) and it is striated transversely. It may be reddish in color or yellowish brown. Its head is trilobed (Fig. 44). The ova may be found in large numbers in the feces. They are small, oval, 60 to 75 mm. in size, brownish red, with a thick covering. Oxyuris Vermicularis.- — This is a small round worm ; the female measures 10 mm., the male 4 mm. in length. They may be present in the lower bowel and faeces, and look like bits of thread (Fig. 45). 144 THE FJECES. The ova are about 50 by 24 // in size, coarsely granular, and surrounded by a double-contoured envelope. Uncinaria Duodenalis : (syn., Anchylostoma duodenale (Fig. 46). The great importance of this parasite as a cause of certain forms of anaemia has been properly emphasized dur- ing the past few years. It is a blood-sucking parasite, and is one of the most dangerous met with in the human being. It has a wide distribution, being found in Italy, Germany, Fig. 47. Eggs of Uncinaria amerieana in different stages of development. (Personal obser- vation.) Magnified about 300. (Simon.) Switzerland, Belgium, and Egypt. C. N. Stiles has recently shown that the hook-worm, found in the United States and West Indies, is a distinct species. He has denominated it the Uncinaria amerieana. This investigator has demon- strated that it is a very common parasite in the sandy regions of the South. Infection with it is very common among the poorer classes of this region, probably as a result of the habit of dirt-eating. The stools of all cases of severe aiuemia THE FMCES. 145 should be carefully examined for the eggs of this parasite. The adult worm is almost never found in the faeces (Fig. 46). The parasite is fairly common in dogs, cattle, and sheep. Fig. 48. Trichina spiralis in muscle. (Simon.) The female is 10 to 18 mm. long ; male 6 to 12 mm., with an expanded copulatory pouch and slender penile organ at its posterior extremity. The head is turned dorsally and has a 10— C, D, 146 THE FJECES. hollowed mouth armed with six booklets. The ova are abundant in the feces, are elliptical (30 by 50 //), and have a thin, colorless, vitelline envelope, enclosing varying numbers of rapidly dividing cells. These segmenting bodies rapidly develop outside of the human body, so that after twenty-four to forty-eight hours embryos may be found in the same feces in which the eggs were observed, or fully developed ova may be found after allowing the feces to stand for only a few hours. (Fig. 47.) Examination of the Faeces in Uncinariasis. — There are two methods, the microscopical and the gross. Microscopical Examination. — Take a small amount of the feces, preferably from near the surface, spread this out in a drop of water on a microscopic slide and cover the prepara- tion with a cover-slip. Examine under the low dry objective, with not too strong illumination, or for closer study with the high dry objective. Do not mistake the egg of the unci- naria for that of the Ascaris lumbricoides, which has a thick, gelatinous, often mammillated, covering, and an unsegmented protoplasm, or the egg of the Oxyuris vermicularis, which has a thin, asymmetrical shell (one side being almost straight) and containing an embryo, or for the egg of the whip-worm (Trichuris trichiura, more commonly known as Trichocephalus dispar), which possesses a smooth, thick shell, apparently per- forated at each pole, and an unsegmented protoplasm (Stiles). Gross Examination. — Give a small dose of thymol, 10 to 15 grains, followed in two hours by oil, and collect all of the stools passed. Wash the stools thoroughly several times in a bucket, and examine the sediment for worms about half an inch long, about as thick as a hair-pin, and with one end curved back to form a hook (Stiles). Trichinella Spiralis. — The adult forms of the trichina occur in the intestine. They are 1.5 to 4 mm. long, and may be found in the stools in trichiniasis. The larval forms can be demonstrated by pressing a small piece of favorable muscle- fibre between slides, and examining under the microscope with a low power (Fig. 48). Chemistry of the Faeces. — The clinician seldom finds the SPUTUM. 147 chemical analysis of the faeces of any practical value ; hence the reader is referred to the larger text-books for its con- sideration. QUESTIONS. What factors are responsible for the consistence, odor, and color of faeces ? What are the macroscopical findings in normal and abnormal faeces ? What are the microscopical findings in normal faeces ? Name the varieties of parasites found in faeces. Mention the important vegetable parasites found in faeces. Classify the animal parasites found in faeces. Describe the Amoeba coli. What is the difference between a cestode and a nematode ? Mention the important cestodes and nematodes. Describe the Uncinaria duodenalis and its ova. Describe the methods of examining the faeces in uncinariasis. How are the larval forms of Trichinella spiralis demonstrated ? CHAPTER X. SPUTUM. GENERAL CONSIDERATIONS. Apparatus for examination of sputum includes — Glass teasing-needles made from glass rods. Platinum loop. Glass plate, 5 inches square. Kronig's sputum plate or a soup plate with bowl painted black. Slides. Cover-slips. Stains and reagents for examination of sputum — Carbol-fuchsin. Loffler's methylene-blue. Gabbets stain. Reagents for Gram's stain. Eosin, same as in blood w 7 ork. Nitric acid, about 30 per cent. The term sputum means that material which is brought up from the pharynx and respiratory tract by the acts of cough- 148 SPUTUM. ing, hawking, and at times vomiting. It is usually asso- ciated with diseases of the pharyngo-respiratory mucous mem- branes, and its examination is often of great value in throw- ing light upon diseases of the respiratory and neighboring organs. General Remarks. — Sputum examination has become one of the most important and useful of laboratory diagnostic measures. To be of the largest value, it must be combined with a proper physical examination. In most instances the examination of the sputum furnishes only an etiological, not a pathological, diagnosis. At times it is possible to make a diagnosis of beginning tuberculosis from the physical signs when tubercle bacilli can not be found in the sputum. On the other hand, it frequently happens that the physical signs are very indefinite, possibly indicating a slight bronchitis ; in such cases tubercle bacilli are often demonstrated and the diagnosis clinched. Failure to find the bacilli may be due to the fact that the sputum is chiefly from the throat and contains none of the suspected bacteria. In a great many cases, especially when the bacilli are scarce, it is due to faulty technique. One frequently sees sputum examined in the following imperfect manner : A platinum loop is dipped at random into the sputum cup and a small amount of sputum withdrawn, placed upon a cover- slip, spread, fixed, and stained, with negative results. Such a method is very faulty, and can not be depended on except in advanced cases of tuberculosis, when the entire sputum is filled with bacilli. Correct Method of Obtaining Sputum. — The patient should be told to clean the mouth thoroughly and expecto- rate into a clean sputum cup or wide-mouthed glass bottle, in order to avoid contamination with food, since food particles roughly resemble the opaque bits which are rich in tubercle bacilli. Throat sputum, except in cases of laryngeal tuber- culosis, seldom shows anything of importance. To secure sputum from those with suspicious signs but scant expectora- tion, it is sometimes useful to administer potassium iodide in doses of 3 grains every three or four hours. GENERAL CONSIDERATIONS. 149 Correct Method of Examining Sputum. — The sputum should be poured upon a glass plate. This may be an ordinary window pane or a cleaned photograph plate. By means of two sharp-pointed glass teasing-needles the sputum is torn apart and carefully inspected. A second method consists in the use of a glass slide (Fig. 49). The sputum is pressed out between plate and slide ; about an inch of the slide extends beyond the plate and is used as a handle. If present, the suspicious opaque bits can be readily seen. The slide is moved about so that fresh portions of sputum are examined successively. When suspicious particles are found by these macroscopical Author's sputum slide. methods, they are either transferred immediately to cover- slips and spreads made or, better, the plate is transferred to the microscope, and the particles examined in situ with a low- power dry lens. By this means it can be immediately de- termined whether it is a bit of food, elastic tissue, or a col- lection of pus. The slide can now be slipped off and the bit transferred to a cover-slip if staining procedures are indicated. Methods of Spreading Sputum. — 1. Transfer the sus- pected bit of sputum to a cover-glass, place upon it another cover-glass, press down with forceps until the material i§ spread out in a thin layer, and slide them apart, 150 SPUTUM. 2. The material may be spread in a thin layer with the teasing-needle or the platinum loop. The cover-slips are dried in the air or held in the fingers above a flame, then fixed by passing them several times slowly through the flame of a Bunsen burner or alcohol lamp. Sputum Examination. — The examinations of the sputum which are of value to the clinician are macroscopical and microscopical. Macroscopically the following points should be noted : (1) Quantity in twenty-four hours or during a certain stated period ( (a) consistence. 1 (h\ (2) Character-^ (b) color. ( (c) odor. The amount of sputum varies much with the disease. In some conditions only a few cubic centimetres are raised in twenty-four hours, in others 1000 c.c. and more. In incipient tuberculosis, early stages of acute bronchitis, and dry pleurisy, and some cases of croupous pneumonia the cough may be fre- quent, with little or no expectoration. On the other hand, in some cases of chronic bronchitis, advanced tuberculosis with cavities, hemorrhage from the lungs, pulmonary oedema, bron- chiectasis, and perforations into the lungs of pus from the thorax or abdomen, there is a large amount of sputum. In bronchiectasis large quantities of mucopurulent sputum may be raised in a short time, with change of position, espe- cially op rising in the morning. Consistence of Sputum. — The consistence corresponds in a general way to the amount ; it may vary from a watery to an extremely tenacious sputum. Whether mucin or nuclein derivatives are the cause of the tenacity is not thoroughly understood. In oedema of the lungs the sputum is liquid and resembles blood-serum, and is covered by a frothy surface layer. When the sputum is mostly pus, as in pulmonary gangrene, pulmo- nary abscess, putrid bronchitis, and following the perforation of an empyema or subdiaphragmatic abscess into the lungs, it GENERAL CONSIDERATIONS. 151 is quite liquid. In croupous pneumonia the sputum is so tenacious that the cup containing it may be inverted with- out losing a drop, provided there is not an associated bron- chitis. This is also the case following an attack of bronchial asthma and in the beginning stages of acute bronchitis. Color of Sputum. — The color may vary from colorless mucoid to the dark-brown sputum containing altered blood. It may be gray, yellow, green, red, or brown. Admixture with fresh blood gives the red color, while admixture with pus (depending on the number of leukocytes) gives a color varying from gray to green. Green sputum may be due to admixture with bile, as in the perforation of a liver abscess into the lung, jaundice, and pneumonia accompanied by jaundice. The sputum in amoebic abscess of the liver which has per- forated the lung has a color resembling anchovy sauce — red- dish-brown, of a brick-dust color — due to blood-pigments and corpuscles. Red sputum, varying in intensity with the amount of blood present, is found in pneumonia, tuberculosis, heart disease, gangrene and abscess of the lungs. In pneumonia the spu- tum gradually changes from a bright-red color, due to un- changed blood, to a rusty or orange shade. In low types of the disease it resembles prune juice. Prune-juice sputum (dark mucoid) is present in a large per- centage of cases of cancer of the lungs. Greenish-yellow sputum in coin-like lumps is found in influenza (PfeifFer). In anthracosis the sputum may be very dark in color, so-called " black spit." Odor of Sputum. — Sputum is usually odorless, but at times, as in foetid bronchitis and pulmonary gangrene, the stench is most obnoxious. In bronchiectasis, perforating empyema, and ulcerative proc- esses the odor is sweetish. In perforating empyema an odor resembling old cheese is sometimes present, 152 SPUTUM. Varieties of Sputum. — f Mucoid. Homogeneous \ P^ulent. oerous. (^Sanguineous, f Mucopurulent. JV1 u o o se t*ou s Heterogeneous -l a j berosanguineous. (^ Sanguinomucopurulent. Sputum crudum is an example of pure mucoid sputum, and is seen in the first stages of bronchitis. Nummular sputum is made up of roundish, coin-like disks, which sink in water. It is found in the second and third stages of phthisis. Sputum globosum consists of fairly dense, round, grayish- white masses, secreted in old cavities. Cheesy particles, varying in size from that of a millet-seed to that of a pea, are seen in cases of tuberculosis. They are usually rich in tubercle bacilli and elastic tissue. It is im- portant to search for such particles in the macroscopical ex- amination of sputum. Caseous masses which form in the crypts of tonsillar tissue are very common and frequently cause much unnecessary worry. They are coughed up or brought up by clearing the throat. Their microscopical examination is negative. They have a very foul stench, due to fatty acids. Macroscopical examination of sputum by means of teas- ing-needles, glass plate and slide is of great value in facilitat- ing the microscopical examination. Opaque particles may contain elastic tissue or tubercle bacilli. Fibrinous casts may appear as masses of a white color ; they are often yellowish brown or reddish yellow, owing to the presence of blood coloring-matter. They are found in fibrinous bronchitis, pneumonia (either before or after resolu- tion has taken place), and in cases of diphtheria where the dis- ease has extended into the finer ramifications of the bronchi. The suspected bits should be transferred from the glass plate or Kronig's sputum plate, and shaken out in water in order to GENERAL CONSIDERATIONS. 153 unravel them. These casts may vary from 12 cm. in length by several millimetres in thickness, to very small fragments 0.5 to 3 cm. in length. Those found in pneumonia are small ; those in fibrinous bronchitis come from the smaller and medium-sized bronchi. These casts branch dichotomously and contain a cavity in Fig. 50. Fibrinous coagulum from a case of croupous pneumonia. (Bizzozero.) their larger portion, while the finer branches appear to be solid (Fig. 50). Curschmann's spirals occur in bronchial asthma, also in chronic bronchitis and even in pneumonia. Macroscopically they appear as thick, yellowish-white masses, which show a spirally twisted appearance, 154 SPUTUM. Microscopically with the low power they are seen to consist of a spirally twisted network of extremely delicate fibrils, which is wound around a clear, colorless central thread. In this mass are found epithelial cells and leukocytes which are mainly of the eosinophile type. Not all spirals are perfect ; the central thread may be absent or the spiral arrangement may be imperfect. They vary in length from 1 to 1.5 cm. Their presence usually indicates a desquamative catarrh of the bronchi and alveoli (Fig. 51). Echinococcus membranes, concretions, and foreign bodies are rarely found. Ftg. 51. A Curschmann spiral from a case of true bronchial asthma. (Simon.) Microscopical examination of sputum consists in the use of a low dry lens with the glass plate and slide, and of a high dry lens with cover-glass and slide, and of an oil immer- sion with stained preparations. The objects of chief interest and diagnostic value are : (1) Elastic tissue. (2) Parasites. (3) Red blood-cells. Of less value are : (1) Leukocytes. (2) Epithelial cells. (3) Crystals. (4) Food particles, GENERAL CONSIDERATIONS. 155 The examination should begin with the employment of the glass plate under a low-power lens. Attention is directed especially to the small opaque bits. Examination for Elastic Tissue. — A portion of sputum is placed upon a glass plate about 5 inches square, a size con- venient for handling on the stage of the microscope. With a slide for a spatula the sputum is pressed out into thin layers, and all suspicious bits examined. Elastic tissue-fibres have the following appearance under the low power of the micro- scope ; they are very slender threads of varying lengths, curl- Fig. 52. Elastic fibres in the sputum. (Eye-piece III., objective 8 A, Keichert.) (v. Jaksch.) ing and branching somewhat at their ends. They refract light in such a way as to give them the appearance of having a double wavy contour with a colorless centre. Occasionally they show an alveolar arrangement, making plain their origin (Fig. 52). Macroscopically, particles of food, masses of epithelium, and debris are most often mistaken for these suspicious bits which contain elastic fibres. Microscopically, the beginner frequently mistakes vegeta- ble fibres, such as lint from a towel, etc., and masses of lepto- thrix for elastic tissue, 156 SPUTUM. The more slender fibre with its double contour and curl- ing, branching ends distinguishes the elastic fibre (Fig. 52). Whenever elastic tissue is found, it is certain that a destructive process is going on in the respiratory tract. It is especially important when associated with tubercle bacilli. It is most frequently found in tuberculosis, but may also be present in abscess of the lung, bronchiectasis, and occasionally in pneu- monia. In gangrene of the lung, elastic tissue usually is not found (perhaps it is destroyed by a ferment). Vegetable parasites found in sputum are : tubercle bacilli ; Diplococcus pneumoniae ; bacillus of influenza ; streptococci and staphylococci; Leptothrix buccalis; Oidium albicans; Aspergillus fumigatus ; Mucor corymbifer, etc. Tubercle Bacillus. — By far the most important sputum ex- amination is that for tubercle bacilli. After selecting the suspicious bits by macroscopical examination they are trans- ferred to cover-slips or slides, and spreads made as directed. These are fixed by passing through a flame several times, specimen side up, and are then ready to be stained. If the specimen is spread upon a slide, forceps are unnecessary, and cover-slips may be dispensed with, unless permanent speci- mens are desired. Methods of Staining. — The following solutions are re- quired : (1) Carbol-fuchsin. (2) 25 per cent, nitric acid. (3) L5ffler ? s methylene-blue. The cover-glass, held with forceps, is covered with a few drops of carbol-fuchsin, placed over a flame till it steams, then moved aside, and returned to the flame several times. The stain is washed off in water, and the specimen dipped into the nitric acid solution for a few seconds till pretty thoroughly decolorized, only a faint pink tint remaining. The specimen is again washed in water till it is certain that all traces of nitric acid are removed. It is then covered with a few drops of the methylene-blue solution for one-half to one minute. This is washed off with water and the speci- men dried between filter-paper and mounted in Canada GENERAL CONSIDERATIONS. 157 balsam, and examined with the oil immersion ; or it may be examined in water instead of Canada balsam. The bacilli appear as red rods on a blue background, measuring from 3 to 4 p. in length by 0.3 to 0.5 ju in breadth. They may appear homogeneous, or as made up of small red beads with unstained spaces between ; they may be straight or curved, and occasionally branched. The beginner often mistakes the edges of cells or particles of dirt, which retain the red color, for these bacilli. Very little dependence can be placed upon the relation between the number of bacilli and the severity of the disease. In some incipient cases many bacilli are found in the mucoid sputum ; while, on the other hand, in some advanced cases and in acute miliary tuberculosis the bacilli are scarce. As a rule, however, the severity of the disease corresponds in a general way with the number of bacilli. * Gabbet's Method. — The fixed spreads are stained with carbol-fuchsin as in the above ; washed in water, and covered with Gabbet's solution, which consists of 75 parts of water, 25 of sulphuric acid, and 2 of methylene-blue. This is allowed to remain for from fifteen to sixty seconds, until by washing in water the red color is seen to have disappeared and been replaced by the blue. The preparation is dried be- tween filter-paper and mounted in Canada balsam. If the physical signs are suspicious and the tubercle bacilli have not been found, it is wise to resort to the following de- vices to increase the chance of finding them : (1) Nuttal has demonstrated that these bacilli will multiply in the sputum itself at a certain temperature. It is w T ell then to place the specimen of sputum in the incubator for twenty- four to forty-eight hours and then examine it. (2) The use of the centrifugal machine also increases the chance of finding the bacilli. The following procedure may be employed : About 100 c.c. of sputum are boiled with double the amount of water, to which from 6 to 8 drops of a 10 per cent, solution of sodium hydrate have been added, until a homogeneous solution has been attained, water being added from time to time to allow for evaporation. This is 158 SPUTUM. then centrif ugated or set aside for twenty-four to forty-eight hours and the bottom portions examined for tubercle bacilli and elastic tissue. The only organisms likely to be mistaken for the tubercle bacillus are the bacillus of leprosy and the smegma bacillus. All three organisms are characterized by the great tenacity with which they retain acid stains and the great difficulty with which they take up basic dyes. The latter two organ- isms are, however, almost never found in the sputum. In the examination of urine and faeces, however, it is nec- essary to exclude smegma bacilli by the use of Pappenheim's stain or decolorization in alcohol. Diplococcus Pneumoniae. — In the great majority of cases of lobar pneumonia this organism is the etiological agent, and can be found in the sputum. It is a rod-shaped diplococcus surrounded by a characteristic capsule, which serves to dis- tinguish it from other cocci. Welsh's Method of Demonstrating the Capsule. — Spread and dried cover-glass preparations are treated first with glacial acetic acid, which is allowed to drain oif, and is replaced (without washing in water) with anilin gentian-violet solu- tion. The stain is repeatedly added until all the acid is dis- placed. The specimen is now washed in a weak salt solution (about 2 per cent.) and examined in this — not in balsam. Gram's method stains the diplococcus and its capsule blue- black. Loffler's methylene-blue stains the diplococcus well, but does not stain the capsule. Specific stains for the capsule are often unsatisfactory, and have little advantage over Loffler's methylene-blue. Bacillus Pneumoniae of Friedlander. — This is a larger organ- ism than the pneumococcus, and appears in the form of plump, short rods surrounded by a capsule. It occurs occa- sionally in pneumonia, but is probably not a cause of the genuine lobar variety. Bacillus of Influenza (PfeifFer). — This germ is found in the sputum of this disease, and its recognition is of diagnostic importance. Cover-glass preparations are made in the usual GENERAL CONSIDERATIONS. 159 way, and stained with Loffler's methylene-blue for from five to ten minutes, washed in water, and mounted in balsam or water. The organisms appear as extremely small blue rods. The end stains more deeply than the middle portion. Streptococci and Staphylococci. — These organisms are extremely common in sputum, but are not specific in any pulmonary disease. They are found especially in tubercu- losis, bronchitis (acute and chronic), pneumonia, pulmonary gangrene and abscess, etc. Actinomycosis. — Actinomycosis has been positively shown to be a variety of infections due to different species of strep- tothrix, instead of being, as was formerly believed, a single disease entity, caused by a single micro-organism (Actino- myces bovis). Because of this fact it seems advisable to sub- stitute the name streptothricosis for actinomycosis. A number of cases of pulmonary streptothricosis have been reported in which the physical findings could not be distin- guished from those of tuberculosis. The sputum and pus from cavities in the lungs contained branched threads which were " as acid-fast as tubercle bacilli." Various investigators have described several varieties of streptothrix as the cause of pulmonary infections. At the present time it is impossible to classify them definitely. In the pus derived from ulcerating actinomycotic tumors, in the sputum of cases of pulmonary actinomycosis, and in the faeces of intestinal cases, characteristic yellow granules, measuring from 0.5 to 2 mm. in diameter, may be found. These granules, when pressed out under a cover-slip and examined with the microscope, will be seen to consist of numerous threads, which radiate from a centre in a fan-like manner and show club-shaped extremities. Leptothrix buccalis is a common non-pathogenic mouth micro-organism of the fission fungi type. It is frequently present in the sputum, and in the unstained specimen has been mistaken by beginners for elastic tissue. In pulmonary gangrene it is known as Leptothrix pulmonalis. It takes on a violet or bluish color when treated with Lugol's solution. 160 SPUTUM. Oidium albicans, or Saccharomyces albicans, produces a stomatitis called thrush, and is seen most often in children and tuberculous adults. It belongs to the order of yeast-fungi, and consists of branching filaments, from the ends of which ovoid torula cells develop (Fig. 53). Aspergillus fumigatus, Mucor corymbifer, and Sarcina pulmo- nalis may occasionally be found in sputum, but are of little importance. An important practical point is the fact that a number of pathogenic micro-organisms can be found in the sputum or mouth in health. Such are Diplococcus pneumoniae, strepto- Fig. 53. Oiclium albicans, the vegetable parasite of muguet or thrush. (Reduced from Ch. Robin.) cocci and staphylococci, Bacillus pneumonia} of Friedliinder, Bacillus coli communis, and even the bacillus of diphtheria. Animal Parasites. — Portions of echinococcus cysts — /. e., pieces of membrane and hooklets — are occasionally found in the sputum when the parasite has entered the lungs or neigh- boring organs. Trichomonades, similar to Trichomonas vaginalis, have rarely been observed in cases of gangrene of the lungs and in the pus removed from lung cavities post mortem. Amoeba coli, when found in sputum, make it certain that an hepatic abscess has perforated into the lungs. GENERAL CONSIDERATIONS. 161 Distoma pulmonale, a lung parasite, is the cause of a dis- ease resembling phthisis, and occurs frequently in Japan. The worm and ova are found in the sputum. Bed blood-cells (Fig. 54) in small numbers are found in almost every sputum, being derived from inflamed mucous membranes. When present in large numbers, they are of im- portance, especially in phthisis. They occur in almost all pulmonary diseases. The appearance of the red cell depends upon the length of time it has been in the lung, and will vary from a typical cell to its shadow or a mere fragment. The Fig. 54. Epithelium, leukocytes, and crystals of sputum. (Eye-piece III., objective 8 A, Reichert): a, a', a", alveolar epithelium; b, myelin forms; c, ciliated epithelium; d, crystals of calcium carbonate; e, hsematoidin crystals and masses; /,/,/, white blood-corpuscles ; g, red blood-corpuscles ; h, squamous epithelium, (v. Jaksch.) presence of blood-pigment is not always indicated by a red color. It may show a golden-yellow or greenish tinge, having undergone certain chemical changes. Leukocytes, usually polynuclear, are seen in every sputum. In bronchial asthma a large number of eosinophile and even basophilic leukocytes are found. The sputum of pulmonary abscess, perforating empyema, and putrid bronchitis is made up chiefly of degenerating leukocytes. Epithelial cells are present in the sputum, but are of little importance in determining the location of the pulmonary disease. 11— C D. 162 SPUTUM. The cylindrical epithelial cells are usually so much altered that they resemble leukocytes. It has been proved that alve- olar epithelial cells occur in almost every known pulmonary disease, and also in normal expectoration after a very forcible expiration. Heart-disease cells are alveolar epithelial cells, containing numerous hsematoidin granules. They are found in the sputa of bronchitis associated with chronic heart disease (see Fig. 4). Crystals. — The following crystals have been found in spu- tum : Charcot-Leyden, hsematoidin, chloesterin, margarin, tyrosin, calcium oxalate, uric acid, and triple phosphates. © ^°e / ® ©/© Charcot-Leyden crystals. (Scheube.) None of these is of diagnostic importance, although at one time Charcot-Leyden crystals were supposed to have an etio- logical relation to asthma. They are more often present in this disease than in any other pulmonary affection, but they have also been found in acute and chronic bronchitis and in phthisis (Fig. 55). QUESTIONS. Describe the correct methods of obtaining and examining sputum. Mention the different varieties of sputum. Upon what factors do the varying colors of sputum depend ? What points are to be considered in the macroscopical examination of sputum ? What are the chief objects of interest and diagnostic value in the micro- scopical examination ? MISCELLANEOUS EXAMINATIONS. 163 Describe elastic tissue and the best method for its examination. What is a Curschmann spiral ? Name the vegetable parasites found in the sputum. Describe Gabbet's method of staining tubercle bacilli. What bacilli are most likely to be mistaken for tubercle bacilli ? Describe Welsh's method of capsule staining. Of what importance is the streptothrix in pulmonary infections ? Of what significance are Charcot-Leyden crystals and eosinophile leuko- cytes ? CHAPTER XL MISCELLANEOUS EXAMINATIONS. 1. CLINICAL BACTERIOLOGICAL EXAMINATIONS. Most of this work consumes very little time when carried out by microscopical examination of stained cover-slip prepa- rations, as described in preceding chapters. In case of a mixed infection or difficulty in recognizing bacteria by the fresh cover-glass method, it is occasionally necessary to resort to more time-consuming examinations, such as cultural methods and animal inoculation. For this purpose a sterilizing oven, Petri plates, and cult- ure-media are needed in addition to apparatus before men- tioned. Reliable culture-media may be purchased from the lead- ing manufacturing pharmacists. The following will serve ordinary purposes : (1) Bouillon, 2 per cent, glucose-bouillon if desired. (2) Agar, 2 per cent, glucose-agar if desired. (3) Loffler's blood-serum. Bacteria are isolated by means of (1) plate cultures or (2) the streak method. Plate Cultures. — For this method three sterilized Petri plates and three tubes of agar are employed. The culture-medium is melted in the tubes by heating over a Bunsen flame, and then placed in a hot water-bath. Cool melted material below 50° C. and inoculate before solidifica- 164 MISCELLANEOUS EXAMINATION. tion commences. With a sterilized platinum loop the first tube is inoculated with two or three loopfuls of the material and stirred thoroughly. The platinum loop is sterilized again, and the second tube inoculated with two or three loop- fuls of material from tube No. 1, and well mixed. The loop is sterilized once more, and then tube No. 3 is in- oculated with several loopfuls of material from tube No. 2. The cotton plugs are again removed and the upper portions of the tube heated in the flame and the contents poured into Petri dishes. They are now placed in the thermostat or set aside at room temperature. In the growth which follows the colonies of bacteria are separated. They may now be transplanted to different tubes, thus rendering it possible to isolate and study them. The Streak method is much more simple. The platinum loop is charged with the material and drawn several times over the surface of the culture-medium. In this way the bacteria may be separated and grown in isolated colonies. The different bacteria may be recognized by their cultural characteristics, or may be transferred to cover-slips and studied microscopically. Animal inoculation is especially practical clinically for the diagnosis of tuberculosis and rabies. Suspected sediments are injected into the peritoneal cavities of guinea-pigs or rabbits. Solid material is introduced through a small ab- dominal incision under aseptic precautions. The symptoms are carefully observed, and later a postmortem is performed and the necessary bacteriological and histological examina- tions made. Bacteriological examination of the following bacteria is practical, and may be of great value : Diphtheria Bacillus. — Spreads may be made directly from the throat, stained, and examined microscopically. A better method is to inoculate a tube of Loffler's blood- serum with the material from the diseased throat. Two tubes are required : (1) Loffler's blood-serum ; (2) a tube con- taining a swab, made by winding absorbent cotton around a wire. Both tubes are plugged with cotton and sterilized. CLINICAL BACTERIOLOGICAL EXAMINATIONS. 165 The sterilized swab is rubbed against the membrane and then smeared over the surface of the blood-serum. The swab is burned or returned to its tube. The culture-tube is placed in the thermostat at 37° C. If diphtheria bacilli are present, characteristic colonies should grow in from eighteen to twenty- four hours. They are large, elevated, rounded, grayish or creamy- white, moist, discrete or confluent, with a centre denser than the periphery. Spreads are made from these colonies and stained with Loffler's methylene-blue or by Gram's method. The bacillus is nonmotile, 2.5 to 3 /jl in length, 0.5 to 0.8 fi in thickness. It is a straight or slightly bent rod, with rounded ends. Irregular forms are common, such as rods with one or both ends swollen. They stain unevenly — some areas deeply, others slightly — giving a beaded or segmented appearance. The most characteristic thing about this bacillus, and one which greatly facilitates its recognition, is the presence of small granules near the poles of the bacillus, which stain blue with Neisser's method, while the body of the organism is colored brown. Streptococci and staphylococci frequently pro- duce exudates in the throat which resemble the diphtheritic membrane. Tubercle Bacillus. — Because of their small numbers, it is often impossible to demonstrate tubercle bacilli in urine, exu- dates, transudates, etc., by staining methods. Animal inocu- lation should then be resorted to. The fluid is centrifugated and the sediment injected. In examining urine, faeces, and genito-urinary discharges for the tubercle bacilli, the spread should always be decolor- ized in alcohol, in addition to nitric acid, in order to exclude the smegma bacilli. Pappenheim's stain may be used for this purpose. Diplococcus Intracellulars Meningitidis. — This resembles the gonococcus in its morphology and staining properties. It is associated with infectious cerebrospinal meningitis, and is obtained from the cerebrospinal fluid and meningeal exudates. Micrococcus lanceolatus of pneumonia is recognized by staining methods. (See Sputum.) 166 MISCELLANEOUS EXAMINATION. Cerebrospinal Fluid.— Examination of this fluid may be of great diagnostic aid in diseases of the cerebrospinal tissues, especially in meningitis. There may be inflammatory, suppurative, hemorrhagic, and dropsical processes ; one looks for alterations in the amount, appearance, specific gravity, quantity of albumin, and the presence of pus, blood, and bacteria. The presence of a turbid fluid is important. The chief examinations are macro- scopical, microscopical, and bacteriological. The fluid should be centrifugated, spreads made from the sediment, stained, and examined for the various bacteria with the oil immersion. The tubercle bacillus, Diplococcus intracellularis meningi- tidis, Micrococcus lanceolatus, staphylococcus, streptococcus, and typhoid bacillus are the chief causes of meningitis. The spreads should be stained by appropriate methods. If the microscopical examination is unsatisfactory, cultural methods or animal inoculation should be resorted to. Lumbar Puncture. — Cerebrospinal Fluid as Obtained by Lumbar Puncture. — This simple operation should be performed in all obscure conditions suggesting cerebrospinal involve- ment. The patient should lie on the side, with the back bent forward as far as possible, in order to separate the vertebrae and make the lumbar region prominent. The sitting posture may also be assumed with the back bent forward. A local anaesthetic is usually all that is neces- sary. Very often the patient is comatose and requires none. A long, strong, aspirating-needle is introduced midway between the second and third or third and fourth lumbar vertebrae, about an inch to the side, and directed a trifle inward. It should be inserted from 2 to 3 cm. in a child and from 7 to 8 cm. in the adult. As soon as the subarachnoid space is entered, the fluid makes its appearance, usually drop by drop ; but when large in amount and under great pressure, in a stream. Normal cerebrospinal fluid is a clear, limpid, noncoagulating liquid, with a specific gravity of 1005 to 1007. Microscopi- cally a few endothelial cells, leukocytes, and fibrin-filaments CLINICAL BACTERIOLOGICAL EXAMINATIONS. 167 may be seen. A few cubic centimetres of fluid can nearly always be obtained. It is increased in hydrocephalus and meningitis; in some cases 100 c.c. have been withdrawn. In fibrinous and purulent conditions it is decreased, or can not be obtained. The same is true in adhesions or when tumors press upon the canal. Articular Fluid. — Examination of synovial fluid — obtained by aspiration or incision — may throw considerable light upon the nature of the disease. The same methods of examination should be followed as in the above. Transudates and exudates of the various cavities of the body, pleura, pericardium, and peritoneum, should be exam- ined in the same way. Frequently by microscopical and cult- ural means, or animal inoculation, the etiological factor can be discovered. The examination of the sediment of the various exudates by staining with hematoxylin may be of value in the diag- nosis of malignant growths of the serous membranes. Dock has found that in cancerous effusions there are more cells showing mitoses than in simple or tuberculous inflammations. Transudates are found in noninflammatory conditions, and are usually clear and light yellow in color, while exudates are found in inflammatory conditions and are darker in color and turbid. The specific gravity of transudates is usually below 1018 ; while in exudates it is usually above this figure, and may reach 1030. Exudates contain much more albumin. Microscopically the transudates are free from microorgan- isms, and show only a few isolated leukocytes and endothelial cells. Exudates contain many more formed elements, and may be serous, serofibrinous, seropurulent, purulent, putrid, hemor- rhagic, chylous or chyloid. They may be free from micro- organisms, but more often they are not. In empyemas, various streptococci and staphylococci, the pneumococcus, and FrankePs diplococcus may be found. If entirely free from microorganisms, tuberculosis should be 168 MISCELLANEOUS EXAMINATION. suspected. Pus made up of a large percentage of mono- nuclear leukocytes instead of perinuclear strongly suggests a tuberculous origin. Discharges from the various mucous membranes of the body, such as the urethral, vaginal, nasal, conjunctival, etc., should be examined microscopically by means of spreads and appro- priate stains. Average Human Milk. — Analysis taken from Rotch's Pedi- atrics : Reaction, amphoteric or slightly alkaline. Specific gravity, 1028 to 1034. Water 87 to 88 per cent. Total solids 12 to 13 " Fats 3 to 4 " Milk-sugar 6 to 7 " Proteids 1 to 2 " Total mineral matter 0.1 to 0.2 " Average Cows' Milk. — Reaction, slightly acid. Specific gravity, 1029 to 1033. Water 86 to 87 per cent. Total solids 13 to 14 Fats 4 Sugar 4.5 Proteids 4 Total mineral matter 0.1 Laboratory examination of milk may be of value from the standpoint of infant feeding. The specific gravity and the determination of the per cent, of fat are the two chief practical tests, since the other solid ingredients vary proportionately with the fat. From these a fairly accurate idea of the nutritive strength of the milk can be gained. The total solids can be approximately calculated (for cows' milk) by adding 1.2 times the per cent, of fat to one-fourth of the specific gravity at 15° C. Fat Estimation. — This is most easily made by means of the lactoscope of Feser. Draw milk into the pipette up to the mark M; empty into cylinder C. Einse pipette with CLINICAL BACTERIOLOGICAL EXAMINATIONS. 169 water and add washings to the milk. Shake and add water until the black lines upon the milk-colored glass plug A can just be discerned. The height to which the mixture reaches is noted on the scales. The figure on the right indicates the percentage amount of fat, while that on the left indicates the number of cubic centimetres of water w r hich have been added. The simplest method of determination of fat is by the cream gauge (Holt) (Fig. 50). Although its results are only approx- imate, they are in most cases sufficiently accurate for clinical purposes. The tube is filled to the zero mark with freshly drawn milk, which stands at a room temperature for twenty-four hours, when the percentage of cream is read off. The ratio of this to the fat is approximately 5:3; thus 5 per cent, cream indicates 3 per cent, fat, etc. For a more accurate determination the best ready method is probably the modifi- cation by Lewi of the Leffmann and Beam test for cows' milk. This is a centrifugal test requiring special tubes (made by Richard & Co., New York) used in the ordinary centrifuge for urine. Only 6 c.c. of milk are necessary ; and if care- fully made the results are almost as accurate as by a chemical analysis. The Babcooh fat-tester is frequently employed. Equal volumes of milk and commercial sulphuric acid are mixed in a test- bottle which has a long, graduated neck. This is cen- trifugated at once — while still hot. After whirling, the bottle is filled to the neck with hot water, returned to the machine, and whirled again for one or two minutes, after which it is filled with hot water to about the 7 per cent. mark. It is again whirled for a short time. The fat separates and its percentage is noted on the scale. Specific Gravity. — This is best determined with the lacto- densimeter of Quevenne. The instrument is graduated for a temperature of 60° F., so it is necessary to correct the spe- cific gravity for different temperatures. The error, however, is very small, and if taken at room temperature need not be considered. 170 URINALYSIS. QUESTIONS. Mention several important culture-media. Describe the plate culture method of isolating bacteria. Describe the streak method. What is meant by animal inoculation, and when is it indicated ? Describe in detail the correct method of making a bacteriological exami- nation in a case of diphtheria. Of what importance is examination of cerebrospinal fluid ? Describe the method of making lumbar puncture. What is the difference between a transudate and an exudate ? What are the two chief practical tests in the examination of milk ? Mention several methods for determining fat per cent. CHAPTER XII. UKINALYSIS. APPARATUS AND REAGENTS USED IN URINALYSIS. 1. Test-tube, 4 and 6 inches. 2. Test-tube stand and brush. 3. Urinometer (preferably Squibb's). 4. Doremus ureometer. 5. Esbach's albuminirneter. 6. Burette graduated in 0.2 or 0.1 c.c. 7. Graduated cylinders, 100 c.c. and 500 c.c. or 1000 c.c. 8. Flasks of several sizes. 9. Conical glasses. 10. Nest of beakers. 11. Set of porcelain evaporating dishes. 12. Glass funnels, 2-inch and 5-inch. 13. Nipple pipettes, 1 c.c. 14. Glass tubing of different sizes. 15. Glass rods of different sizes. 16. Bunsen burner or alcohol lamp. 17. Centrifuge, centrifuge tubes. 18. Litmus-paper, blue and red. 19. Filter-paper, to fit funnels. APPARATUS AND REAGENTS USED IN URINALYSIS. 171 20. Small file. 21. Slides and cover-slips. 22. Stains — carbol-fuchsin, methylene-blue, Gram's stain. 23. Microscope. Several test-tubes should be file-marked in order that the same quantities of reagents and urine may always be used in making such tests as the diazo, indican, etc. Esbach's Reagent. — 10 grammes of picric and 20 grammes of citric acid, dissolved in 1000 c.c. of distilled water. Fehling's Solutions. — Two solutions, kept in separate rubber- stoppered bottles. Solution I. : 34.64 grammes of pure crystallized copper sulphate, dissolved in distilled water and diluted to 500 c.c. Solution II. : 173 grammes of tartrate of potassium and and sodium, and 60 grammes of sodium hydrate dissolved in distilled water, and diluted to 500 c.c. Purdy's Solution for Sugar Determination. — Pure cupric sulphate, 4.752 grammes ; Potassium hydroxide, 23.50 grammes ; Strong ammonia (U. S. P., specific gravity 0.90), 350 c.c. ; Glycerin, 38 c.c. ; Distilled water, to 1000 c.c. Prepare by dissolving the cupric sulphate and glycerin in 200 c.c. of distilled water with the aid of gentle heat. In another 200 c.c. of distilled water dissolve the potassium hydroxide. Mix the two solutions, and when cooled add the ammonia. Finally with distilled water bring the volume of the whole up to exactly 1000 c.c. Diazo Solutions. — ( Sulphanilic acid, 1 gramme ; Solution I. < Hydrochloric acid (concentrated), 50 c.c. ; ( Distilled water, ad., 1000 c.c. q i , . tt f Sodium nitrite, 0.5 gramme ; * \ Distilled water, ad., 100 c.c. The nitrite solution readily oxidizes to nitrate ; it is there- fore necessary to keep it in a well-stoppered bottle. It should be fairly fresh. 172 URINALYSIS. Hypobromite solution, for Doremus ureometer. Solution 1. / Rustic soda 100 grammes ; ( Distilled water, 250 c.c. Solution 2. Bromine. Sudan III. Test Solution. — Saturate a certain amount of alcohol with Sudan III. After standing several days, 1 part of this solution is mixed with 1 part of alcohol and 1 part of water. It is turbid at first, but clears on standing. Lugol's Solution. — Iodine, 1 gramme; Potassii iod., 2 grammes ; Water, 300 c.c. Silver Nitrate Solution. — Dissolve 5 grammes of silver nitrate in distilled water and dilute to 100 c.c. Keep in dark-colored bottles. Ferrocyanide of Potassium Solution. — Dissolve 10 grammes of potassium ferrocyanide in water enough to make 100 c.c. Ferric Chloride Solution. — Dissolve 10 grammes of ferric chloride in enough water to make 100 c.c. Potassium or Sodium Hydrate Solution. — Dissolve 10 grammes in 100 c.c. of water. Barium Chloride Solution. — Dissolve 10 grammes of barium chloride in enough water to make 100 c.c. Nitric acid (HNO s ), sp. gr. 1.42. Hydrochloric acid (HC1), sp. gr. 1.20. Sulphuric acid (H 2 S0 4 ), sp. gr. 1.84. Ammonium hydrate (NH 4 OH), sp. gr. 0.96. Glacial acetic acid (HC 2 H 3 2 ). Ether. Chloroform. Distilled water. Sodium nitroprusside powder. Phenylhydrazin hydrochloride. Sodium acetate. Sodium chloride. APPARATUS AND REAGENTS USED IN URINALYSIS 173 Value of Urinalysis. — A properly made analysis of urine may furnish much valuable information concerning body metabolism, the diagnosis and prognosis of both renal and other diseases. On the other hand, an enormous amount of valuable time and labor may be wasted by ill-judged resort to quantitative analyses, such as estimations of urea, uric acid, phosphates, sulphates, etc. These estimations are on occasions of value, but as ordinarily made by anyone except an expert are worse than useless. For instance, urea is often estimated for a single day or in a separate portion of urine ; the nitrogen intake through the food is not regarded, and the nitrogen passed in the faeces is not taken into consideration in the calculation. No diagnostic, prognostic, or therapeutical deductions can be drawn from such examinations ; in fact, they may be very misleading. To be of value, quantitative estimations must be made for a number of days in succession, under known conditions of diet, rest, etc. In most cases in- formation of much greater value can be obtained by the more simple and easily applied qualitative tests and the micro- scopical examination of the sediment. Characteristics of Normal Urine. — Recently passed nor- mal urine is clear, with no visible cloud or sediment ; turbidity in freshly passed urine in the majority of cases indicates an abnormal condition. However, at certain times during the day, especially two to three hours after a heavy meal, the freshly passed urine in health may be distinctly turbid from the presence of amorphous phosphates. After standing for some time a normal urine develops a light cloud which settles to the bottom. This cloud consists of mucus, containing a few round granular cells, somewhat larger than normal leuko- cytes, so-called mucous corpuscles, and a few pavement epi- thelial cells derived from the genito-urinary organs. In normal urine which is allowed to stand for some time at ordinary temperature, and more quickly at a somewhat ele- vated temperature, certain important changes take place as the result of the development of ammoniacal fermentation. The reaction gradually changes from acid to alkaline ; a bulky sediment forms, made up of triple phosphates, earthy phos- 174 URINALYSIS. phates, and ammonium urate, in addition to enormous num- bers of bacteria. The supernatant liquid is permanently cloudy even after filtration, owing to the presence of numer- ous bacteria. Freshly voided urine exhibiting such a sedi- ment indicates the presence of germs in the genito-urinary tract. If urine be kept in a cool place, this decomposition may be delayed for days, and instead a deposit of amorphous urates or uric acid may appear. A recognition of the fact that such marked changes in urine can take place on standing is of great practical importance. It emphasizes the necessity of examining fresh samples of urine, especially in warm weather. The tests for albumin and sugar, and the microscopical examination of the sedi- ment in particular, are very unsatisfactory in decomposing urines; not only this, but they may also lead to a wrong diagnosis. The amount of urine varies much in health, depending on many factors, such as the quantity of liquid taken, variety of food ingested, amount of water lost through the skin, bowels, and lungs ; age, sex, and season also cause variation in the amount. The limit may be placed at 600 to 1800 c.c.; and yet even these limits may be exceeded in some instances. The average for the adult in the United States, according to Simon, is 1000 to 1200 c.c. for twenty-four hours for men and a trifle less for women. Children pass relatively more than adults. The amount of solid matter in the urine is also higher for men than for women. In disease the amount may vary from none at all, as in complete suppression (anuria), or a few ounces as in acute Bright's disease (oliguria), to several litres (polyuria), as in diabetes mellitus or insipidus and chronic interstitial nephritis. The quantity is measured with graduated cylinders. The specific gravity of urine is as variable as the quantity, ranging ordinarily from 1015 to 1025 ; these limits, however, can be extended considerably in health. It depends upon the quantity of solids in solution. In disease the specific gravity may be high with a large volume, as in diabetes mellitus, or low with a small volume, as in many chronic w r asting diseases APPARATUS AND REAGENTS USED IN URINALYSIS. 175 and in the later stages of acute disease, indicating defective elimination of solids. In estimating the specific gravity, the Squibb urinometer is used for routine work. For very accurate estimations the Lohnstein urinometer is best, especially in making the fer- mentation test for sugar. The following precautions should be observed : the urinometer should not adhere to the side of the cylinder ; all foam should be removed from the surface of the urine with filter-paper ; the reading should be taken at the lower meniscus. If great accuracy is essential, the tempera- ture of the urine must be taken into consideration, since the specific gravity increases or decreases 1 degree for every 3 degrees Centigrade above or below 15° C, the temperature at which the instrument is standardized. For most clinical work the temperature is disregarded provided the urine be at the room temperature. Reaction of Urine. — Normally the reaction of the twenty- four hours' urine, and also of separate portions, is acid ; but in many healthy people, at different periods of the day, it is faintly acid, neutral, or even faintly alkaline, especially after hearty meals. The urine of those living on strictly vegetable diet will usually be very faintly acid or alkaline. The acidity is due to diacid phosphate, chiefly of sodium, while alkalinity is due to the monoacid or primary phosphates and to carbon- ates of sodium and potassium. Litmus-paper is used to test the reaction ; acid urine turns blue litmus red, alkaline urine turns red litmus blue. Neu- tral urine does not change the color of either. Color. — This varies from a very light yellow or even watery, to a very dark brownish yellow. The depth of color is pro- portional to the amount of water present, and thus to the dilu- tion of urinary pigments. Pathologically the color of urine varies a great deal. It may be the color of water in the polyuria of nervous condi- tions and chronic interstitial nephritis. In febrile conditions it is usually very highly colored. The red tints of urine are usually due "to the presence of blood ; the dark-brown tints may be due to methsemoglobin. The urine may be almost 176 URINALYSIS. black in the presence of melanotic cancer, especially after standing for some time. Bile gives a brownish or greenish- brown color. Blue urine may be present in cholera and typhus, owing to the presence of indigo. Certain drugs alter the color of urine. Turbidity in urine may be due to pus, urates, phosphates, bacteria, and epithelium. Acid urines, as a rule, are darker in color than alkaline. The odor of normal urine is characteristic ; after eating cer- tain substances or administration of certain drugs more or less peculiar odors are imparted. If ammoniacal fermentation has taken place, the urine smells of ammonia; if the urine is decomposed, a strong, putrid, ammoniacal odor is noticed. Acetone is easily recognized if present in any quantity by a fruity odor. Rarely, however, is the odor of clinical value, though it may give a clue. Constituents of Normal Urine. — Normal urine is a watery solution of the waste products of metabolism and the decomposition products of excess of ingested food. It is evi- dent that the composition will vary from hour to hour during the day, being a very dilute solution after eating or drinking, and very concentrated in the early morning hours. The total amount of urine passed by an individual in one day will, however, be very nearly the same in composition as that of another day, other things being equal. The constituents of urine may be divided into two groups, organic and inorganic, or mineral. Of these, the most important are : Organic. — Urea, uric acid, and alloxuric or xanthin bases ; creatinin ; hippuric acid ; indoxyl, phenol, and cresol as con- jugate sulphates; other sulphur compounds (neutral, orunox- idized sulphur) ; pigments and chromogens. Inorganic. — Chlorides, sulphates, phosphates of sodium, potassium, calcium, magnesium, and ammonium. Oxalates and carbonates may be present also. IMPORTANT NORMAL CONSTITUENTS OF URINE. 177 CONSIDERATION OF THE IMPORTANT NORMAL CON- STITUENTS OF THE URINE, VARIATIONS IN THE QUANTITY OF WHICH MAY INDICATE DISEASE. Water. — Upon this constituent depend the concentration and dilution, and consequently the quantity of urine excreted. It varies much in amount, depending upon many factors such as are mentioned under Amount Solids. — The total daily amount of solids excreted in the urine is more constant than that of the water. If estimated for a number days in succession under known conditions, it may be of clinical value. One estimation is a waste of time. Composition of Normal Urine (Bliss) : Organic matter, about 35 grammes. Urea, about 30 grammes. The remaining organic matter consists principally of uric acid, hippuric acid, creatinin, extractives, and coloring-matter. Mineral matter, about 25 grammes. Half to two-thirds of this consists of sodium chloride; the remainder is made up of sulphates, chlorides, and phosphates of the alkalies and alkaline earths. Urea, CO^ t\xtt 2? is the most important nitrogenous con- stituent of the urine. It is of clinical significance, since it to a large extent represents the nitrogenous katabolism of the body. Under normal conditions it represents about 85 per cent, of the total nitrogen eliminated by the kidneys. The normal daily amount of urea excreted in the urine varies from 25 to 35 grammes. The liver is held to be the seat of the formation of urea. Simon says : " It might be supposed that an accurate idea of tissue destruction could be formed from a quantita- tive estimation of the urea. This is not the case, since, in pathological conditions especially, the quantitative relations existing between the excretion of urea and the remaining nitrogenous constituents is subject to wide variations. The urea may disappear entirely from the urine, the nitrogen being eliminated in the form of other compounds. So it is 12— c. D. 178 URINALYSIS. necessary to determine the total nitrogen excreted by the kid- neys when one wishes to gain an accurate insight into the nitrogenous metabolism. The elimination of urea, and of nitrogen in general, is sub- ject to great variations, depending on the amount of nitrogen ingested, and that resulting from tissue destruction, which in turn is largely influenced by the body weight. The elimina- tion of nitrogen should always be compared with the amount of food ingested. A variable amount (in disease it may be considerable) of nitrogen is eliminated in the faeces; conse- quently this factor must be reckoned with if accurate conclu- sions are to be drawn. The tediousness and the difficulty of such estimations render them entirely impractical. Approximate results can be obtained by parallel estimation of chlorides. In health the amount of the chlorides is equal to about one-half that of the urea. Whenever the amount of urea is greatly in excess of the normal amount of chlorides, an increased tissue destruc- tion may be inferred, and vice versa. Urea is increased in amount in fevers, diabetes, excessive bodily exercise; and with a meat diet. An important clinical point is the fact that its total excretion is diminished in uraemia, kidney diseases with impaired excretory power, in liver diseases such as cirrhosis, in which the urea-form- ing function of the organ is impaired. Little is definitely known about the relation of urea, uric acid, etc., to gout and lithsemia. In certain diseases of the kidney the amount of urea formed may be decreased, but the kidneys are unable to excrete all ; and in certain liver diseases, while the amount of urea formed is diminished, the nitrogenous substances which go to urea formation are eliminated and the total nitro- gen excreted remains the same. Characteristics of Urea. — Owing to its ready solubility, it appears in the urine in solution. In concentrated solution it is precipitated in the form of crystals of nitrate of urea on the addition of nitric acid. This is shown in the applica- tion of Heller's test, urea nitrate crystals forming just above the junction of the two liquids. IMPORTANT NORMAL CONSTITUENTS OF URINE. 179 Urea is converted into ammonium carbonate by certain bacteria (CON 2 H 4 + 2H 2 = (NH 4 ) 2 C0 3 ). This is the com- monly observed ammoniacal decomposition which is seen whenever urine stands for a length of time at ordinary tem- perature, and in pathological conditions inside the bladder, as in cystitis, etc. Xanthin bases enter into the formation of the nucleins, the essential chemical constituents of the nuclei of body-cells. Those in the urine are derived from food and nuclear katab- olism. They have practically the same origin, significance and fluctuations as uric acid. The quantity is ordinarily about one-tenth that of uric acid. Clinically they have the same significance. Uric acid is an oxidation product of the xanthin bases, and the chief form in which they are excreted. It represents the katabolic breaking down of the cell-nuclei. The amount of uric acid excreted daily in the urine varies from 0.4 to 0.8 gramme, having a proportion to the amount of urea excreted of 1 : 40 to 1 : 60. Physiologically it is increased by the ingestion of food rich in cells, such as liver, kidney, etc. ; pathologically, by increased breaking down of tissues. Uric acid is increased in conditions attended with leukocy- tosis, such as leukaemia (may be 5 grammes in twenty-four hours), pneumonia, etc. ; and in febrile conditions, acute rheu- matism, and in so-called uric acid diathesis. It is dimin- ished in leukopenic and anaemic conditions, and especially in kidney diseases associated with uraemia. Characteristics. — Uric acid has a strong tendency to crys- tallize upon contact with any solid substance. This fact ex- plains the large percentage of uric acid calculi. The deposit of uric acid is pathological if it occurs in urine passed within four to six hours. Normal urine deposits uric acid after standing ten hours or more. If uric acid is deposited soon after being voided, it suggests the possibility of its being deposited in the urinary tract, with the formation of gravel and uric acid calculi. The chief form in which uric acid occurs in the urine is 180 URINALYSIS. as the urates of sodium, potassium, calcium, and magnesium. High acidity forces the uric acid from these combinations. They are more soluble than uric acid, and more so in warm than in cold liquid. The mixed urate deposit is a reddish, granular-looking sediment, the so-called "brick-dust deposit." It may vary from a pink to a brick-red. This deposit dis- solves on heating the urine. It gives the murexid reaction, similar to uric acid. It dissolves in solutions of the caustic alkalies, and is decomposed by mineral acids with precipita- tion of uric acid crystals. Hippuric acid, benzoic acid, and creatinin are found in very small amounts in normal urine. Time spent in their examination is wasted from the clinical standpoint. Ammonium compounds, similar to the corresponding sodium and potassium salts, are normally excreted in small amounts. Total nitrogen in the urine is represented by the above sub- stances. It gives a more exact idea of nitrogenous metabo- lism than urea alone. Sulphates. — The sulphur of the urine is excreted chiefly in the form of mineral sulphates and the conjugate or ethereal sulphates. They resemble urea in being produced chiefly by the decomposition of albuminous material, either taken in with the food or that broken down in katabolic processes. The quantity varies from 1 .5 to 3 grammes daily, calculated as S0 3 , fluctuating parallel to urea. Mineral sulphates make up the bulk (nine-tenths) of the urinary sulphates. Sodium sulphate is most abundant, with a small proportion of potassium, ammonium, and perhaps cal- cium and magnesium sulphates. These salts all appear in solution. Calcium sulphate very rarely appears in the sedi- ments. Conjugate Sulphates. — Indol, phenol, and similar sub- stances generated in the course of albuminous decomposition become oxidized and combine with potassium or sodium sulphate to form the conjugate or ethereal sulphates. They make up about one-tenth of the excreted sulphates. They are formed in the intestine, absorbed, and then excreted by IMPORTANT NORMAL CONSTITUENTS OF URINE. 181 the kidneys, chiefly as indoxyl potassium sulphate — i. e. (in- dican), phenol potassium sulphate, potassium sulphates of cresol and traces of catechol, and skatoxyl. Indican is the most conspicuous, and may be taken as rep- resentative of this class. Increase of indican indicates an increase of the total ethereal sulphates, and thus an increase in bacterial putrefaction in the intestine. Unoxidized Sulphur Compounds. — Only small amounts of sulphur other than sulphates occur in the urine normally. Pathologically cystin and other substances are found ; hydro- gen sulphide may be absorbed from the intestine in putrefac- tive processes or from foul abscesses, and be excreted by the kidneys. It is usually associated with indican. Sulphates are increased by meat diet, excessive exercise, acute fevers, especially acute rheumatism and meningitis, leukaemia, etc. Conjugate sulphates are small or large, depending on the extent of intestinal decomposition. They are increased in the various gastric and intestinal diseases (in practice this fact is chiefly noted by the test for indican). Phosphates. — The quantity excreted varies between 2.5 and 3 grammes, depending largely on the amount ingested, in- creasing with animal, decreasing with vegetable diet. A cer- tain amount is derived from the katabolism of body-tissue, muscle-cell, bone, nerve-cell, blood-corpuscles. Some tissues (nerve) contain more phosphorus than others. The normal proportion between the excretion of phosphoric acid and nitrogen is 1 : 7. In urine phosphates occur as sodium, potassium, calcium, and magnesium salts of the tribasic acid, H 3 P0 4 . Most im- portant of these is diacid sodium phosphate, NaH 2 P0 4 , to which the acidity of the urine is principally due. The phos- phates vary with the reaction of the urine. In acid urine there are diacid sodium phosphate and diacid calcium phos- phate ; in amphoteric urine, besides these are found disodium phosphate, monocalcium phosphate, and monomagnesium phosphate ; in alkaline urines, trisodic phosphate, neutral cal- cium phosphate, and neutral magnesium phosphate may be 182 URINALYSIS. present. The alkaline phosphates exceed the earthy phos- phates by about one-third. Sodium is combined with more of the phosphoric acid than potassium. Alkaline phosphates of sodium and a small amount of potassium are freely soluble in fluids of any reaction, and only appear in the urine in solution. The normal excretion amounts to 1.5 to 3 grammes daily, calculated as P 2 5 . Earthy Phosphates are those of calcium and magnesium. They are practically insoluble in pure water, very readily soluble in acid, insoluble in alkaline fluids. In alkaline urine they occur as a white precipitate. Earthy phosphates may be precipitated by heating urine, but the urine clears up on adding a drop or so of acid. Phosphates are decreased in most acute fevers, the degree corresponding to the severity of the disease. This is due to failure of excretion. They are also decreased in acute and chronic nephritis, anaemia, hysteria, chronic lead-poisoning, acute yellow atrophy of the liver, cirrhosis of the liver, etc. An increase occurs in the so-called " phosphatic diabetes," some nervous diseases, some bone diseases, starvation, and convalescence. Triple phosphate, ammoniomagnesium phosphate, indicates ammoniacal fermentation, occurring either within the bladder (fresh urine) or outside the bladder. Chlorides. — These are excreted almost entirely as sodium chloride, with a small amount of potassium, ammonium, cal- cium, and magnesium chlorides. From 10 to 16 grammes are excreted in twenty-four hours. They are derived from the food (surplus over body need), not from body metabo- lism, and thus vary in health with the habits of the indi- vidual. Their estimation is at times of clinical importance. They are diminished in most acute fevers (the degree depend- ing on the severity of the disease), excessive secretion of gas- tric juice, exudations and transudations, these withdrawing the chlorides that would otherwise appear in the urine. They are increased during the absorption of exudates and transu- dates, in convalescence, and in polyuria. Oxalic acid is present in normal urine in very small IMPORTANT NORMAL CONSTITUENTS OF URINE. 183 amounts. It is derived chiefly from vegetable foods. It may be derived in part from uric acid through a process of oxidation, or from carbohydrates from incomplete oxidation. The quantity is small, varying from a faint trace to 20 milli- grammes in twenty-four hours. The recognition of calcium oxalate crystals in the sediment is ordinarily taken as an index of the excretion, but is misleading, since with a quantitative diminution in the excretion there may be numerous crystals of calcium oxalate, and vice versa. Oxalic acid is increased in gastro-intestinal disturbances, diabetes, and in some cases of albuminuria, and in the so-called oxalic acid diathesis. This fact is determined in practice chiefly by recognition of calcium oxalate crystals in the sedi- ment, but the method is untrustworthy. The frequent pres- ence of calcium oxalate crystals in the urine of an individual should lead to suspicion that it may be deposited within the bladder and thus cause the formation of calculus. Pathological Substances. — As a result of disease of the genito-urinary system, or of local or general disease in other parts of the body, or of altered metabolism, any of the above- mentioned constituents of normal urine may be either increased or diminished. More important than this, however, is the occurrence of additional substances. These are as follows : 1. Proteids: serum-albumin, serum-globulin, and albu- mose. Of very rare occurrence are nucleo-albumin, fibrin, and mucin. 2. Carbohydrates: glucose; less frequently lsevulose, lac- tose, sucrose, maltose. Very rarely are pentoses, glycogen, dextrin, animal gum, and inosite found. Normal urine con- tains a trace of glucose, barely enough to respond to the most delicate tests, and not enough to interfere with any clinical tests. 3. Acetone, aceto-acetic or diacetic acid, /?-oxybutyric acid. 4. Diazo substances. 5. Ammonia. 6. Bile, bilirubin, bile salts. 7. Blood and its constituents : albumin, blood-corpuscles (red and white), haemoglobin and its derivatives. 184 * URINALYSIS. 8. Pus-cells — when few in number called leukocytes. 9. Casts ; cylindroids. 10. Spermatozoa. 11. Epithelium. 12. Tissue debris, floating particles, etc. 13. Clap-threads, mucous threads. 14. Crystals of various normal and abnormal substances, amorphous debris, and calculi. 15. Parasites, vegetable and animal. Less important constituents are fat, volatile and nonvolatile fatty acids, lactic acid, alcohol ; glycuronates, glycerin-phos- phoric acid, alkapton ; cystin, xanthin, cholesterin, leucin, tyrosin, ferments, and toxins. Albumins. — Of the several albumins mentioned on another page, serum-albumin is of the greatest clinical importance. When speaking of urinary albumin this variety is always in- dicated. The presence of albumin in the urine must always be con- sidered abnormal, though the clinician must keep in mind that it may be transient and unimportant, as in the so-called " physiological albuminuria." Even in this variety there is probably disturbance in the nutrition of the epithelium of the capillaries of the tufts, or of the cells surrounding the glome- rulus. Albumin is present in the urine in the following conditions, varying greatly in amount : (a) Functional albuminuria ; (b) febrile albuminuria ; (c) hsemic changes — i. e. } purpura, scurvy, chronic poisoning by lead or mercury, syphilis, leukaemia, severe anaemia, bile and sugar in the blood ; (d) certain nervous diseases (neurotic albuminuria), after epileptic attacks, apoplexy, tetanus, blow on the head, etc. ; (e) congestion of the kidney, active or passive ; (/) organic diseases of the kidney — acute and chronic, Bright's disease, amyloid and fatty degeneration, suppurative nephritis, and tumors ; (g) all affections of the pelvis, ureter, bladder, and urethra associated with the forma- tion of pus ; (/*) haemorrhage along the urinary tract. Serum-globulin is always found together with serum-albu- IMPORTANT NORMAL CONSTITUENTS OF URINE. 185 rain; in amyloid degeneration the proportion is unusually high. It responds to the same tests and has the same signifi- cance. Albumose (Peptone). — Traces of albumose are found in many acute diseases, and in chronic suppuration. Albumose often accompanies serum-albumin. Urine containing albumin may after decomposition fail to respond to the tests ; in such cases positive tests for albumose may be obtained. Haemoglobin occurs in the urine (haemoglobin uria) whenever there is such a destruction of red blood-corpuscles that the liver can not transform into bilirubin all the blood-containing matter set free, as in poisoning by potassium chlorate, in extensive burns, certain infectious diseases, malaria, haemo- globinuria of the newborn, etc. Whenever blood occurs in urine, haemoglobin is present within the corpuscles. After these disintegrate it will be in solution in the urine, although likely in modified form. Nueleo-albumin is inconstant in disease of the kidneys, but has been found frequently in cases of acute nephritis, and sometimes in febrile and functional albuminuria. It may be still present when serum-albumin and serum-globulin can no longer be demonstrated. Mixed albuminuria, in which several of the above sub- stances are present at the same time, is not very infrequent. Carbohydrates. — Glucose (dextrose, grape-sugar), C 6 H 12 6 , is the only important member of the group, from the clinical standpoint. Its presence, when persistent, indicates diabetes mellitus. It is frequently present in small amounts for short periods, as in febrile affections, alimentary disturbances, and dietetic errors, and is then not of serious import. The specific gravity of the urine is increased even higher, np to 1040, or in proportion to the amount of sugar present in spite of the large amount of water. But it is sometimes present even with low specific gravity if the amount of water is very large or the other constituents small. Other carbohydrates may appear along with glucose. Sugar may be present up to 500 grammes or even more in twenty-four hours. 186 URINALYSIS. During the late stages of pregnancy and during lacta- tion, lactose in very small amount is frequently present in urine, but is not likely to respond to the ordinary sugar- tests. Clinically the remaining carbohydrates are of very minor importance; the reader interested in their chemistry is referred to larger text-books. Acetone; Diacetie Acid ; ft-oxybutyrie Acid. — These three substances are closely related, and are of great pathological importance, as their presence in diabetic urine indicates the possible approach of diabetic coma. Acetone appears in very small quantities in normal urine, the amount being so small, however, that special procedure is necessary to dem- onstrate it ; diacetie and oxybutyric acids never occur nor- mally. Acetone is most abundant when little albuminous food and no carbohydrates are eaten. It is derived from proteid material. Diacetie acid has practically the same sig- nificance as acetone, and is met with in diabetes, digestive disturbances, and fevers. It is now generally believed that /3-oxybutyric acid is the cause of diabetic coma. The amount of this substance excreted in twenty-four hours may be enormous. Siilz found in 3 cases, 65, 100, and 226 grammes respectively. Acetone and diacetie acid are derivative prod- ucts of /2-oxybutyric acid. Diazo Substances. — Of great practical importance is the detection in the urine of substances which give the Ehrlich diazo reaction. This test is of great clinical value in the diagnosis and prognosis of typhoid fever ; likewise in prog- nosis in pulmonary tuberculosis, since a persistent reaction indicates a severe case. It occurs sometimes in acute tuber- culosis, measles, smallpox, and scarlet fever, but seldom in other diseases. It occurs in a large per cent, of all typhoid cases, but almost never in the other diseases for which typhoid may be mistaken (with the exception of acute mil- iary tuberculosis). It may appear as early as the fifth day, and its disappearance usually indicates subsidence of the disease. A reappearance suggests a relapse. Bile appears in the urine in jaundice, both of the haema- IMPORTANT NORMAL CONSTITUENTS OF URINE. 187 togenous and hepatogenous varieties. Bilirubin and bile salts are present, the former alone being of importance. Blood in the urine (hematuria) results from hemorrhage at some point along the genito-urinary tract. Examination of the urine during the menstrual period is very likely to show blood and its various constituents unless the patient is catheterized. Whenever blood-corpuscles are found in urine, the other constituents may be assumed to be present. A faint albumin reaction should therefore be ascribed to this cause rather fhan to a kidney lesion. Hsematin, hsematoidin, and hsematoporphyrin are rarely present in the urine. Pus is found in the urine in many conditions involving the genito-urinary tract, such as pyelitis, pyelonephritis, renal and vesical stone, genito-urinary tuberculosis, cystitis, urethritis, rupture of an abscess into the urinary passages, leucorrhoea, etc. A small amount of albumin accompanies pus, fat, and lymph. Leukocytes are often present in small numbers in normal urine. In catarrhal and inflammatory conditions they are more numerous. They may be derived from the vaginal dis- charges. They are mostly polynuclear, and become altered and disintegrated by ammoniacal urine. Casts of the uriniferous tubules are of remarkable diag- nostic importance, nearly always indicating disease of the kidneys, though a few hyaline casts in middle life are of no great significance. They are cylindrical bodies, 20 to 50 ju in diameter, having the shape and size of small sections of the uriniferous tubules ; they are unbranched, usually with one or both ends rounded, though one end may be broken off sharply. Various substances enter into their composi- tion, giving the following classification : (a) hyaline, (6) epithelial, (c) granular, (d) fatty, (e) waxy, (/) leukocyte, (f/) blood, (ft) pseudocasts made up of bacteria or urates. They may be of considerable aid in the prognosis and the diagnosis of the variety of Bright's disease. Hyaline and granular casts are common to all varieties. Blood and epi- thelial, and especially leukocyte casts are most commonly seen in acute Bright's disease. Dock believes that the 188 URINALYSIS. presence of enormous numbers of dark, coarsely granular casts is a bad prognostic sign. Cylindroids are hyaline bodies, longer and more slen- der than casts, and tapering toward a wavy point, giving them a w T hip-like appearance, and at times showing a coat- ing of granules. They are of very common occurrence, and at most indicate only a slight degree of renal irrita- tion. It is believed that they are formed in the uriniferous tubules. Spermatozoa are found in the urine after sexual inter- course, masturbation, or emissions, in spermatorrhoea, and sometimes following epileptic convulsions. They may be found in the urine of women after intercourse. Epithelium. — Very little concerning their site of origin can be learned from the epithelium, since the same kind lines the renal pelvis, ureters, and bladder. In normal urine vary- ing numbers of epithelial cells appear, shed from the mucous membrane of the urinary tract. The urine from the female nearly always contains numerous cells, many of them coming from the vagina. The cells may appear singly or in patches. The urine is often distinctly cloudy. Squamous cells — i. e. 9 pavement cells — are shed from the most superficial layers of the renal pelvis, ureters, bladder, and vagina. Spherical cells are much smaller than the above. They resemble a leukocyte somewhat, but are larger and have a single round nucleus. Some of them may originate from the renal tubules, but most of them are derived from the deeper layers of the renal sinus, ureters, and bladder. In large numbers they may indicate a catarrhal condition. Elongated caudate cells of varying shapes may appear in the urine. Their origin and significance are the same as those of the spherical cells. Tissue debris when formed in the urine may afford valu- able information in regard to new growths. Clap-threads are found floating in recently passed urine, even many years after a supposed cure of the gonorrhoea. Mucous threads are frequently found in the urine in catar- IMPORTANT NORMAL CONSTITUENTS OF URINE. 189 rhal conditions, especially of the prostate, and may be en- tirely independent of a gonorrhoea. Crystals are of extremely common occurrence in normal, and especially in abnormal, urine. They are not, however, of much pathological significance, except as they indicate ammoniacal decomposition and excess of uric acid, when they suggest the possible presence of calculi. They will be con- sidered in detail under microscopical examination of urine. Amorphous debris is usually present in all urine, especially after standing. It is derived from broken-down cellular material or insoluble salts. Calculi. — Uric acid and urates, oxalate of lime, and earthy phosphates are the most common constituents of urinary cal- culi. Very rarely cystin, xanthin, carbonate of lime, indigo, and urostealith form calculi. Renal sand, uric acid, or urates may be passed in the urine. Parasites. — Vegetable and animal parasites are at times found in the urine. Vegetable parasites are much the most common, and consist of bacteria and rarely of fungi. In normal urine, freshly passed, bacteria are very seldom found except in small numbers. After being voided, they develop, as a result of contamination from outside, in enor- mous numbers, causing ammoniacal fermentation. Pathogenic bacteria, are derived mostly from local infections in the course of the urinary tract. Of great importance are gonococci in gonorrhoea, tubercle bacilli in genito-urinary tuberculosis, streptococci, staphylococci, colon bacilli, and other germs associated with the causation of cystitis and pyelitis. In some of the acute infectious diseases, such as typhoid fever (in particular), scarlet fever, croupous pneumonia, ery- sipelas, the causative germ is excreted in the urine. Sometimes enormous numbers of bacteria are voided in the urine without demonstrable cause (idiopathic bacteriuria). Fungi. — If found in the urine, they are nearly always due to contamination after the urine is voided. Saccharomycetes, or yeast-fungi, may be found in old urine in diabetes mellitus. 190 URINALYSIS. In the United States animal parasites are almost never found in urine. Trichomonas, protozoa, and amoeba rarely appear. Trichomonas vaginalis is the most common. Worms are rarely found. Blood -moulds resembling earth worms are occasionally reported as examples of Eustrongylus gigas. In Egypt Schistosoma haematobium is common. Larval filaria and echinococcus may be found in the urine. Intestinal parasites are almost never found in the urine. Lymph occurs in the urine very rarely except in connec- tion with filariasis, when there is rupture of lymph-vessels into the urinary tract (lymphuria, chyluria). Fat does not occur in the normal urine. When it occurs in large amounts, recognizable with the naked eye, it is termed lipuria. Small amounts, recognized with the micro- scope, occur whenever there is fatty degeneration of the renal epithelium, pus-corpuscles, or tumor particles in the urinary tract. In chyluria, a tropical affection usually asso- ciated with filariasis, there is a large amount of fat in the urine, due to leakage of chyle into some part of the urinary tract. Toxins are excreted in the urine in health and disease, but very little is known about them. Foreign Matter. — Vegetable fibres, such as threads from towels, starch-granules from toilet powders used on the geni- tals, oily globules, and various forms of dirt from unclean receptacles, find their way into urine, and give the beginner trouble in microscopical examinations. QUESTIONS. What are the characteristics of normal urine? Upon what factors does the specific gravity of urine depend ? What is the reaction of normal urine and upon what does it depend ? What are the various colors of urine in disease? Upon what factors doen the color depend ? Mention the constituents of normal urine. Under what conditions is a quantitative estimation of urea of value? What is uric acid ? In what condition is uric acid increased? In what decreased ? In what forms is the sulphur of the urine excreted ? Of what significance is indican ? Name the different phosphates of the urine. EXAMINATION OF THE URINE. 191 In what conditions are the chlorides diminished and increased? Of what significance is the frequent presence of calcium oxalate crystals in freshly voided urine ? Mention the pathological substances found in the urine. In what conditions is albumin found in the urine ? Of what significance is the presence of acetone, diacetic acid, and /3- oxybutyric acid ? In what diseases are diazo substances found in the urine ? Under what conditions are blood and pus found in the urine? What are casts? Of what significance are they? What are cylindroids, and what is their significance ? Mention the various cells found in urine. Name the pathological bacteria found in urine. In what conditions are lymph and fat found in the urine ? CHAPTER XIII. EXAMINATION OF THE URINE. It is self-evident that it is impossible for the physician to make complete urinary examinations according to text-book directions. Not only that, but it would be a great waste of time in the majority of cases, so far as useful, accurate clini- cal knowledge is concerned. This statement applies espe- cially to the quantitative analyses of the various solids, such as urea, uric acid, chlorides, sulphates, phosphates, etc. In the vast majority of cases such time-consuming analyses have thrown very little practical light on the diagnosis and treat- ment of cases which could not have been more easily and satisfactorily gained by other methods of examination. On the other hand, too much emphasis can not be laid upon the necessity of a routine examination for the chief abnormal constituents in every important case. As an example of a very sensible and useful guide in urine examination the following scheme, used by Professor Dock in his clinic, is appended. In it the essential methods for clinical diagnosis are considered. They may be modified in private practice as the physician sees fit. 192 EXAMINATION OF THE URINE. Scheme for Recording Urinary Examinations. — A com- plete examination of a fresh sample, catheterized if neces- sary, should be made as soon as possible after the patient is seen ; also of the first twenty-four hours' urine. In this examination note the following points : Physical and Chemical Examination. — Name, Date, Quantity, Specific gravity, Reaction, Color, Odor, General Appearance (clear or turbid ; floating particles, clap-threads). Albumin. — Boiling and nitric acid ; ferrocyanide and acetic acid, Heller test if in doubt. Test for other albuminous bodies if indicated. Sugar. — Fehling. If positive, make fermentation test. Acetone. — Diacetic acid, /3-oxy butyric acid. Bile. — Foam, Gmelin's test. Indican. — Amount. Microscopical Examination. — Centrifuge a specimen for sedi- ment ; note amount and appearance. Record the following : Crystals. — Kind and amount. Cads. — Full description. Blood-corpuscles. — Condition. Leukocytes. — Kind. Pus, spermatozoa, epithelium, bacteria, protozoa, fat-glob- ules or crystals. Test for such other substances as may be suspected or indicated. In all cases of pyuria stain for tubercle bacilli and gono- cocci. In all cases of fever and neiv growths make the diazo test. In diabetes keep careful note of acetone, diacetic acid, and /9-oxybutyric acid. In albuminuria examine day and night urine separately. If the first examination is negative, note daily the quan- tity, specific gravity, and reaction, and make a careful exam- ination at once if any alteration is noted. Make a careful examination once a week, anyway. If the first examination is positive, repeat daily the com- plete examinations, with full notes, especially of any varia- tion. EXAMINATION OF THE URINE. 193 Determination of Total Solids. — (1) Specific Gravity Method. — From the specific gravity the total amount of solid material in the urine can be calculated with sufficient accuracy for all practical purposes. Assuming the volume to be constant, the increase or decrease in the specific gravity depends entirely upon the increase or decrease in solids excreted ; the substances which will cause these variations are, of course, those which are given off in fairly large amounts — that is, the urea, and chlorides, sulphates, and phosphates ; and in pathological urine, sugar and albumin. An increase in uric acid, for instance, can not be great enough to affect the specific gravity noticeably. It has been found by experiment that if the last two figures of the specific gravity at 15° C. — that is, the figures in the second and third decimal places — be multiplied by 2.33 (Trapp's or Haeser's coefficient), the product will represent approximately the amount of solid matter in 1 litre of urine. If this figure is multiplied by the number of litres in the twenty-four hours' urine, the total amount of solid matter excreted in twenty-four hours is obtained. Example : 24 hours, urine = 2000 c.c. Sp. gr., =1.020. 20 X 2.33 == 46.6. 46.6 X 2 == 93.2 grammes. Results by this method agree very closely with those obtained by the long and tedious chemical methods. This method can not be used with diabetic urine. It is evident that such a procedure as this would not give a correct result unless the total twenty-four hours' urine were collected, measured, and the specific gravity taken, since the urine varies greatly in its composition at different times dur- ing the day. In the morning, upon rising, it has a high specific gravity, while after meals or after drinking much liquid the gravity will be very low. Absurd results will be obtained from the estimation of solids based upon separate portions. (2) By Evaporation and Weighing. — 5 c.c. of urine, accu- rately measured, are placed in a watch-glass containing a little 13— C. D. 194 EXAMINATION OF THE URINE. dry sand (sand and crystal having been previously weighed) : this is placed over a dish containing concentrated sulphu- ric acid, and under the receiver of an air-pump which has been made perfectly air-tight with vaselin. The receiver is exhausted ; at the end of twenty-four hours it is exhausted again, and the urine allowed to remain another twenty-four hours ; at the end of this time the crystal is weighed, the difference between the two weights obtained indicating the amount of solids in 5 c.c. of urine, from which the percent- age and total amount are readily calculated. Urea. — The quantitative estimation of urea is based upon the decomposition of urea into carbon dioxide and nitrogen by means of sodium hypobromite : CON 2 H 4 + 3NaOBr = 3NaBr + C0 2 + 2H 2 4- 2N. The carbon dioxide formed is absorbed by an excess of the sodium hydrate added to the hypobromite solution, while the nitrogen is set free and can be measured. Doremus Ureometer (Fig. 56). — A small amount of urine is poured into the smaller tube B y while the stopcock (7 is closed. This is then opened for a moment to allow its lumen to become filled, then closed. Tube A is now washed out with water and filled with solution of caustic soda. By means of a curved 1 c.c. nipple pipette add 1 c.c. of bromine, and a sufficient amount of water to fill the bend of the tube. (By this means a fresh solution of sodium hypobromite is formed.) Now allow 1 c.c. of urine (less if concentrated) to flow into the longer tube and mix with the hypobromite solu- tion, when brisk effervescence occurs, and the nitrogen rises to the top of the tube. After a short time the volume of gas present is read from the scale. The degrees marked upon the tube show the number of grammes or grains of urea contained in the amount of urine employed. This being 1 c.c, the total amount of urea is obtained by simply multiplying the reading of the instru- ment by the volume of the urine in cubic centimetres. This method gives fairly accurate results provided proper care is exercised. About a quarter of an hour should be EXAMINATION OF THE URINE. 195 allowed for the gas to collect ; after that time the gas which still continues to be given off will not affect the reading much. Since gas expands with rise in temperature, the instrument should not be held in the hand or placed in a warm place. Uric Acid. — Qualitative Test. — Murexid. — A small portion of the sediment or of suspected particles is treated with a few drops of nitric acid in a porcelain dish ; this is then carefully evaporated to dryness, best on a water-bath ; a yellowish spot remains if uric acid or xanthin is present. On ex- posing this spot to the vapor of ammonia it will assume a purplish color. This is due to the formation of ammo- nium purpurate (murexid). If it is now moistened with a drop of potassium hydrox- ide, it will become violet if due to uric acid. For the quantitative esti- mation of uric acid, the reader is referred to the larger text- books. The Folin modifica- tion of the Hopkins' method is recommended as being the simplest and the most practi- cable. Chlorides . — Qualitative Test. — Remove albumin from a few c.c. of urine (see p. 198). Acidify with several drops of nitric acid, and add a few drops of a 1 : 20 solution of silver nitrate. In the presence of chlo- rides a white precipitate of insoluble silver chloride forms (AgNO s + NaCl = AgCl + NaNO s ). A general idea of the Doremus ureometer. 196 EXAMINATION OF THE URINE. quantity present may also be gained, a heavy caseous precipi- tate pointing to a large amount. For accurate quantitative tests, which the clinician will find of little value, the reader is referred to the larger text- books. Sulphates. — (1) Preformed Sulphates. — Test — Strongly acidify a few cubic centimetres of urine with acetic acid and treat with a few drops of barium chloride. A cloud or white precipitate of barium sulphate forms and indicates their presence. Conjugate sulphates give no precipitate, it being necessary first to split these into their component parts ; this is done by boiling with a mineral acid. (2) Conjugate Sulphates. — Filter the precipitate obtained above, after allowing it to stand for some time in order to have complete precipitation of the simple sulphates ; add several drops of hydrochloric acid and boil for some minutes, with the addition of a few drops more of barium chloride if necessary. Any precipitate or cloudiness now is caused by conjugate sulphates. It is well to test the filtrate with a little barium chloride before adding the hydrochloric acid, in order to be sure the simple sulphates were all removed. For quantitative analysis consult the larger text-books. The method used is exactly the same as the foregoing quali- tative test, carried out in a quantitative manner. For clinical purposes the indican test is taken as an index of the quantity of conjugate sulphates present. Phosphates. — Qualitative Test. — Ferric chloride precipi- tates phosphoric acid as ferric phosphate, which is insoluble in acetic acid. Acidify a few cubic centimetres of urine with a few drops of acetic acid, then add a few drops of 10 per cent, ferric chloride solution. A yellowish -white precipitate occurs in the presence of phosphates. Test for Earthy and Alkaline Phosphates. — Bender 10 c.c. of urine alkaline with ammonia ; a flocculent precipitate is due to the earthy phosphates. After precipitating the earthy phosphates as above, filter, acidify the filtrate with acetic acid, and test with ferric chloride as described above. For quantitative analysis, see larger text-books. EXAMINATION OF THE URINE. 197 Under certain conditions the earthy phosphates are pre- cipitated from the urine on heating, and may at first sight be mistaken for albumin. On the addition of a drop of nitric acid they are dissolved and the urine clears. The xanthin bases, hippuric acid, creatinin, oxalic acid, benzoic acid, leucin, and tyrosin are of practically no clini- cal importance, so methods for their detection and estimation are intentionally omitted. Tests for Albumin. — The urine should be perfectly clear in order to test for small amounts of albumin. Turbidity from phosphates can be removed by adding a few drops of nitric acid; from urates by heating. If the turbidity is due to the presence of bacteria or very fine particles, it can not be removed by ordinary filtration through filter-paper, which serves the purpose in most cases. Under these circumstances the addition of insoluble substances, like chalk, magnesia, etc., to precipitate the phosphates may clarify the urine, which may then be filtered. The use of the Chamberland filter will completely clarify the urine. Tests for albumin are far too numerous ; they vary much in delicacy, some being too delicate for practical purposes, others not delicate enough. Only a few of those which are most useful will be mentioned. Heat and Nitric Acid. — If more than a trace of albumin is present, this is an extremely useful test, both qualitatively and quantitatively. A test-tube partially filled with perfectly clear urine is heated to boiling over a flame. A cloudiness may result, due to albumin or earthy phosphates. A little nitric acid is then added ; if the cloudiness is due to the phosphates, the urine immediately becomes perfectly clear, while if due to albumin it remains or may even be increased. It is necessary to bear in mind the fact that earthy phos- phates are liable to be precipitated by heat, this being due to a change in the conditions. Also that very slight amounts of albumin may not be precipitated by heat alone, but the addition of nitric acid will cause all of it to be thrown out of solution in the form of very fine or coarse floccules. It may 198 EXAMINATION OF THE URINE. be difficult to notice any change on simple observation ; but by holding a tube of the urine beside the tested portion, and observing against a dark background for comparison, even an extremely faint turbidity will be easily seen ; after stand- ing for a few moments these floccules collect into larger ones and settle. Such comparison tests are often very helpful in other cases. It is necessary to have the amounts of acid and urine in proper proportion, since too little acid may fail to cause pre- cipitation, an acid albumin forming, and too much strong acid may redissolve the precipitate if the boiling be continued. Best results are obtained by adding about one-tenth to one- twentieth as much acid as there is urine. An idea of the amount of albumin may be obtained by observing the bulk of the precipitate ; and by always using the same amounts of urine and reagent, data will be given which are very useful for comparison. Acetic Acid and Heat. — Albumin may be precipitated by faintly acidifying the urine with acetic acid and heating. Unlike nitric acid, acetic acid must be used in very small amount, barely enough to acidify ; if more is used, an acid albumin forms which is not precipitated even by continued boiling. A single drop of glacial acetic acid may be too much. The addition of a cubic centimetre or so of a saturated solution of sodium chloride (common salt) will aid in the completeness of the reaction, and may be necessary with dilute urines. This is the best method for removing albumin preparatory to testing for sugar. If a large amount of albumin is present, it will coagulate and form a solid mass in the test-tube. The character of the precipitate should be carefully noted after the addition of nitric acid. According to Dock, the presence of coarse gran- ules indicates primary kidney disease, while that of fine granules indicates some cause outside of the kidneys, such as heart disease. Heller's Ring Test. — If properly applied, this is a very satisfactory and delicate test. The ordinary method of over- EXAMINATION OF THE URINE. 199 laying nitric acid with urine poured from a bottle is ex- tremely unsatisfactory, as the fluids are usually mixed. The following are excellent modifications of this method : Boston's Pipette Method. — A piece of glass tubing about eight or ten inches long and p IG 57 about one-fourth to one-fifth inch in diameter is needed. With the index finger firmly pressed over the top of this tube, it is introduced into the urine, and by relaxing the pressure of the finger a small amount of urine is drawn up to the distance of about one inch. The tube is then placed under the tap and washed, and its outer surface is wiped dry, and introduced into a test- tube containing pure nitric acid, and the pressure of the finger again relaxed, allowing about as much acid to run in. Pressure is again applied, the tube removed and examined. There is a very sharp line of demarcation between the two liquids. If albumin is pre- sent, a distinct w r hite ring forms at the junction of the two liquids, increasing with the percentage of albumin pre- sent (Fig. 57). Boston's pipette method. The horismoscope, manufactured by Nelson, Baker & Co., of Detroit, is useful in making all ring tests, but is easily broken. In testing urine for albumin, fill the large tube of the instrument two-thirds full of clear urine. Then pour into the funnel tube 25 or 30 drops of nitric acid ; this will pass into the capillary tube and form a layer be- 200 EXAMINATION OF THE URINE. neath the urine. If albumin is present, a distinct white zone will presently appear at the point of contact, sharply defined against the black background, the amount of albumin being indicated by the density of the opaque ring. The tube should be free from air-bubbles before the addition of the acid. They can be driven out by merely tilting the instrument. A descriptive pamphlet accompanies the apparatus (Fig. 58). Simon's Modification of Heller's Test. — This is a highly use- Fig. 58. Horismoscope. ful qualitative test, and furnishes valuable quantitative sug- gestions. About 20 c.c. of urine are placed in a conical glass, and by means of a pipette a few cubic centimetres of nitric acid are carried to the bottom of the glass and allowed slowly to run out, by gradually lessening the pressure of the finger on the pipette. The last portion of acid should be retained in the pipette, since if allowed to dribble as the pipette is removed, it will cause more or less mixing (Fig. 59). EXAMINATION OF THE URINE. 201 Fig. 59. By carefully following these directions, the nitric acid forms a distinct layer beneath the urine. If albumin is pres- ent, a distinct white cloud will form as a ring at the junction of the two liquids. The extent and intensity of this ring vary w r ith the amount of albumin. The glass should be allowed to stand for some time, when a number of important points may be brought out. The same quantities of urine and reagent should always be used in each test, in order to draw satisfactory compari- sons. Uric acid in excess is in- dicated by the appearance, within five to ten minutes, of a distinct ring in the clear urine a little above the zone of contact, similar in appear- ance to the albumin ring. If this ring does not appear in five to ten minutes, uric acid is probably present in dimin- ished amount or the urine is quite dilute. The size of the ring indicates the extent of in- crease of the uric acid. In a urine containing more than 25 grammes of urea to the litre, an appearance like hoar frost will be noted on the sides of the vessel, due to the formation of urea nitrate. With 50 grammes and over per litre a dense mass of urea nitrate separates out. Biliary urine treated in this way, if the nitric acid con- tains a little nitrous acid, shows the typical color-play of bilirubin. Indican is shown by the appearance of a ring which is more or less violet blue, &nd situated above that referable to Nitric acid test. (Simon.) Wr-n \ir-U I 202 EXAMINATION OF THE URINE. the normal urinary pigment. It varies from a light blue to a deep indigo-blue, depending upon the amount present. Potassium Ferrocyanide Test for Albumin.— This test is sufficiently delicate for all clinical purposes. To a few cubic centimetres of clear urine in a test-tube several drops of acetic acid are added, then a few drops of a 10 per cent. Fig 60 solution of potassium ferrocyanide are allowed to fall into the mixture ; if even a trace of albumin is present a distinct cloudiness ensues, and if present in large amount a flaky precipitate. It is best seen by comparing the tube, as the ferrocyanide is being dropped in, with another tube containing clear urine. If the urine is very concentrated, it should be diluted with distilled water. Occasionally the addition of acetic acid alone pro- duces a cloud ; this may be due to urates or urinary mucin (nucleoalbumin). If this happens, the urine should be refiltered, diluted with water, and then the ferrocyanide added. Quantitative Estimation of Albumin. — 1. As mentioned under the heat and nitric acid test, the bulk of the precipitated albumin, ^ J, J, etc., will give an approximation of the quantity. 2. Esbach's Method (Fig. 60). — A special, grad- uated test-tube, called the albuminimeter, and Es- bach's reagents are required. The tube is filled to the U mark with the filtered urine, and then with albumin- the reagent to the point R. The tube is closed with a rubber stopper, inverted twelve times, and set aside for twenty-four hours. At the end of this time serum-albumin, serum-globulin, the albumoses, uric acid, and creatinin will have settled down and the amount per thou- sand, in grammes, can be read off from the scale. The reac- tion of the urine should be acid, a few drops of acetic acid being added if necessary, and the specific gravity should not exceed 1.006 or 1.008. If higher, a definite amount of dis- tilled water may be added and the proper calculations made. Tests for Albumoses. — (1) Biuret Test. — Render the cold EXAMINATION OF THE URINE. 203 filtrate alkaline with a solution of sodium hydrate ; a pink or rose color develops on the addition of a very dilute solu- tion of copper sulphate, added drop by drop. (2) To a test-tube partially filled with cold filtered urine, add a few cubic centimetres of nitric acid. If a cloud appears, which disappears on w T arming and reappears on cooling, it indicates the presence of albumose. (3) Strongly acidify the urine with acetic acid and add an equal volume of a saturated solution of common salt. A precipitate occurring which dissolves on heating and reap- pears on cooling indicates albumose. To remove albumin, which is usually present with albumose, filter the liquid while hot. The albumoses are in solution in the hot filtrate and reappear on cooling. The separate recognition of serum-globulin, peptone, etc., is of no special clinical value. Globulin responds to the albumin tests exactly as albumin does ; is associated with it, and has the same significance. Peptone w r ill give the biuret test just as albumose will. Albumin and globulin will also give this test, though heat is required, and the color is deeper, more of a violet. Tests for Carbohydrates. — Albumin if present should be removed. Glucose Qualitative Tests. — 1. Fehling's Test.— Equal parts of the copper sulphate and the alkaline tartrate solu- tions are placed in a test-tube, diluted with 3 or 4 vol- umes of water, and boiled. The urine is then added, a little at first, and more if necessary ; not more than an equal vol- ume should be used. Sugar produces a precipitate of yellow hydroxide of copper or red cuprous oxide. The solution should not be boiled after the addition of the urine, only warmed for a moment. It must be kept in mind that other substances present in the urine may reduce cupric oxide, such as uric acid and creatinin, also though rarely milk-sugar, pyrocatechin, hydrochinon, and bile-pigment. Following the ingestion of some medicines reducing sub- stances also appear. These may be disregarded if care is taken not to boil after the addition of the urine, since the 204 EXAMINATION OF THE URINE. precipitation of cuprous oxide in the presence of sugar takes place before the boiling-point is reached. Sometimes a slight reduction of Fehling's solution is caused by the uric acid ; the cuprous oxide is, however, held in solution by creatinin, and instead of a red precipitate there is a reddish or brownish solution. 2. Haines's Test. — Haines's test is the best of the copper tests. Formula.— Take pure copper sulphate, 30 grains ; distilled water, \ ounce ; make a perfect solution and add pure glycerin, \ ounce; mix thoroughly and add 5 ounces of liquor potassse. Test — Take about 1 drachm of the solution and gently boil it in an ordinary test-tube. Next add from 6 to 8 drops — not more — of the suspected urine, and again gently boil. If sugar be present, a copious yellow or yellowish-red pre- cipitate is thrown down. This test solution is stable and can be kept indefinitely. 3. Phenylhydrazin Test. — This is an extremely delicate test, perhaps five or six times more so than Fehling's, if made as follows : Place in a test-tube about 0.5 gramme each of phenylhydrazin hydrochloride and sodium acetate (about as much as can be placed on a 5-cent piece), fill tube one- third to one-half full of urine, and heat over a flame till the solution is clear. Remove from the flame for a moment, then bring to a boil again, and repeat three times, removing the tube from the flame between times. Set aside to cool, being careful not to disturb the formation of crystals by shaking. (With sugar phenylhydrazin forms an insoluble crystalline compound, phenylglucosazon.) Examine in about fifteen minutes. With a pipette transfer some of the crys- tals to a slide, cover with a cover-glass, and examine under the microscope. If present, these crystals appear as delicate bright-yellow needles arranged in bundles and sheaves. To illustrate the delicacy of this test, a 4 per cent, sugar urine was diluted 120 times, and gave the test. The same urine diluted 20 times failed to give the Fehling test. Quantitative Sugar Tests. — (1) Fermentation Test. — EXAMINATION OF TEE VRINE. 205 With yeast, sugar undergoes fermentation, with the forma- tion of alcohol and carbonic acid. The specific gravity of the urine is lowered by this process, and upon this fact is based the quantitative estimation. Two 6-ounce bottles are filled two-thirds with urine ; to one a fourth of a cake of fresh Fleischmann's yeast is added/ in small pieces. Noth- ing is added to the other. Both are corked to prevent con- tamination, a slit being cut in the cork of bottle No. 1 to allow the gas to escape. Great care must be taken not to contaminate No. 2. The bottles are set aside in a warm room for twenty-four hours ; at the end of this time No. 1 is tested for sugar with Fehling's solution ; if there is no reaction, the urine is filtered and the specific gravity very carefully taken. The specific gravity of No. 2 is also taken at the same time, and the specific gravity of No. 1 subtracted from it. The figure obtained is multiplied by Robert's factor, 0.230, the product resulting representing the percentage of sugar. Example. — Specific gravity before fermentation, 1040 Specific gravity after fermentation, 1020 ~20 20 X 0.230 = 4.60 per cent. For a very accurate estimation of the specific gravity, Lohnstein's urinometer should be used, reading to the fourth place. The saccharimeter of Einhorn or Lohnstein may be em- ployed. Either is extremely handy and fairly accurate. The percentage of sugar corresponding to the displacement of urine by gas can be read oif the instrument directly. The objection to the fermentation test is that it requires a wait of twenty-four hours or longer for its completion (Fig. 61). (2) Purdy's Modification of the Pavy Method. — This is by all means the most practical method of estimating the per- centage of sugar. The quantitative estimation of sugar by the Fehling method is so time-consuming and the end-reac- tion so uncertain that in the hands of most physicians it is extremely unsatisfactory. 206 EXAMINATION OF THE URINE. Fig. 61. H Einhorn's saccharimeter. (Simon.) To demonstrate the simplicity and accuracy of Purdy's method, a series of sugar estimations, by all three methods — i. e., Fehling, Purdy, and fermentation — was carried out in the clinical laboratory of the University of Michigan on a diabetic urine, by Dr. Cleaves, with the following results : July. Fehling. Purdy. Fermentation. Quantity. Per cent. Grammes Per cent. Grammes Per cent. Grammes c.c. 12 1.50 13.90 1.43 13.23 . , . , 925 13 1.40 14.97 1.30 13.32 1.38 14.83 1075 14 0.89 5.78 0.87 5.56 0.92 5.98 650 15 1.47 14.41 1.48 14.43 1.51 14.72 975 16 1.13 8.27 1.11 8.32 1.15 8.62 750 17 1.16 10.15 1.18 10.32 1.15 10.06 875 From the above figures it can be seen that the results with Purdy's method approach very closely those obtained by the EXAMINATION OF THE URINE. 207 Fehling and the fermentation methods. Purdy's method is based on the fact that a definite amount of sugar will cause the complete reduction of a definite amount of the reagent, the latter being of a certain prescribed strength. The cupric oxide is reduced to cuprous, and this, instead of being pre- cipitated as a red granular precipitate, is held in "solution by the ammonia of the reagent, giving at the end a perfectly clear, colorless liquid. The end-point is thus very easily de- termined. The reagent is of such strength that exactly 35 c.c. will be just reduced completely by 0.020 gramme of sugar. Technic of Purdy's Method. — Place 35 c.c. of the reagent in a flask of 150-200 c.c. capacity, add about 2 volumes of water, and bring the contents to the boiling-point. Run the urine from a burette into the boiling copper solution, drop by drop, until the blue color begins to fade ; then still more slowly, three to five seconds elapsing after each drop, until the blue color just completely disappears, and leaves the solution perfectly transparent and colorless. The number of cubic centimetres of urine required to decolorize the 35 c.c. of the re- agent contain exactly 20 milligrammes (0.02 gramme) of sugar. Example. — If it require 2 c.c. of urine to reduce 35 c.c. of the test-solution, there is present 1 per cent, of sugar ; if it require 4 c.c, there is present 0.5 per cent, of sugar. The total quantity of sugar excreted in twenty-four hours can easily be calculated. Suppose 2000 c.c. of urine are excreted, and 2 c.c. reduce the copper, 2 c.c. = 0.020. 2000 c.c. = 1000 X 0.020, or 20 grammes in twenty-four hours. Precautions for Purdy's Technic. — It will be noticed after the determination that upon standing for some time the contents of the flask slowly assume the blue color again. This is due to reoxidation, which is somewhat rapid, and should not be mistaken for imperfect reduction or defect in manipulation. The best results are obtained by first diluting the urine before the titration if the amount of sugar is large. The diluted urine should contain about 1 per cent, of sugar, and the calculation is made according to the dilution. Polariscopic Methods. — By means of the polariscope the percentage of sugar can be estimated ; and also the kind of 208 EXAMINATION OF THE URINE. sugar can be determined. For the use of the instrument the reader is referred to special books. Tests for Acetone in the Urine.— Legal's Test. — To a few cubic centimetres of urine in a test-tube add a crystal of sodium nitroprusside, render alkaline with sodium or potassium hy- droxide, and shake till it is dissolved. The dark-red color produced may be due to creatinin or to acetone. The addition of a few drops of acetic acid changes this to a wine-red color if acetone is present; if absent, the color changes to a yellow. This test may also be used for creatinin, the change from red to yellow on the addition of acetic acid being characteristic. Lieben's Test. — Phosphoric acid is added to the urine, about 1 gramme to the litre ; 500 to 1000 c.c. of this are distilled, only 10 to 15 c.c. being distilled over. To this add a few- drops of potassium or sodium hydroxide and enough of dilute LugoPs solution to give a yellowish color, then sodium hydroxide till the color just fades. If acetone is present, a yellow precipitate of iodoform appears, which is recognizable by its odor on heating, and by the form of the crystals, very small six-sided plates or stars. Diacetic or Acetoacetic Acid in the Urine. — Gerhardt's Test. — A few cubic centimetres of urine are treated with a strong solution of ferric chloride, added drop by drop. If a precipitate of phosphates occurs, this is filtered off and more iron added to the filtrate. A wine-red color indicates the presence of diacetic acid. A second portion of the urine is boiled and similarly treated. If the reaction occurs after the urine has been boiled, it is not due to diacetic acid. If in the second urine no reaction is obtained, a third por- tion is acidulated with sulphuric acid and extracted with ether. The ethereal extract when treated with ferric chloride solution gives a wine-red color, which disappears on standing for twenty-four to forty-eight hours, if diacetic acid is pres- ent, especially if acetone is abundant. Salicylates in the urine give a similar reaction on the addi- tion of ferric chloride, but the color is permanent, while that due to diacetic acid gradually fades. Diacetic acid is readily changed to acetone by heating, or even by standing. EXAMINATION OF THE URINE. 209 ft-oxybutyric Acid. — If after fermentation of the sugar the urine rotates the plane of polarized light to the left, /^-oxy- butyria acid is present. Such rotation, before fermentation, may be caused by lsevulose. Tests for Bile in the Urine. — Bilirubin is the only bile- pigment met with in fresh urine. It is never found in nor- mal urine, so is an infallible sign of disease. Foam Test. — This is a very satisfactory method of demon- strating the presence of bile. A few cubic centimetres of urine in a test-tube are shaken vigorously ; if bile is present, the foam takes on a greenish or greenish-yellow T iridescence, and is quite permanent. Morphological elements, casts, etc., are stained by the bilirubin, and appear yellow under the microscope. Gmelin's Test. — Make a ring-test just as in making the Heller test for albumin, using concentrated nitric acid which contains some nitrous acid fumes. If bilirubin is present a band of colored rings appears just above the point of contact of the two liquids, exhibiting the colors of the rainbow. The green is the most characteristic and important, especially when taken in conjunction with the pink. These colors are caused by the oxidation of bilirubin through a series of products ; the green is due to biliverdin, and represents the first product, it is therefore nearest the oxidizing agent. The nitric acid can be prepared by simply allowing it to stand exposed to sunlight until it becomes colored yellow. Rosenbach's Modification of Gmelin's Test. — Filter the urine through thick filter-paper ; unfold the filter and place a drop or so of concentrated nitric acid, which contains some nitrous, upon its inner surface. If bilirubin is present, the typical rings are produced, the green being the most typical and important. Iodine Test. — Pour 1 c.c. of tincture of iodine, diluted with 8 parts of alcohol, on the surface of the urine in a test-tube. A green ring at the point of contact of the two liquids shows the presence of bile. Tests for Indican in the Urine. — Jaffa's Test. — Bliss has modified this test by using the official solution of ferric 14— c. D. 210 EXAMINATION OF THE URINE chloride, instead of the solution of calcium hypochlorite, which spoils very quickly. To a few cubic centimetres of urine in a test-tube add an equal volume of concentrated hydrochloric acid, 2 or 3 drops of ferric chloride or hypochlorite solu- tion, and 3 or 4 c.c. of chloroform. Shake thoroughly but not vigorously, and set aside. Indoxyl is set free, and is oxidized to indigo-blue, which is taken up by the chloro- form ; this settles to the bottom of the tube. The intensity of the blue color depends on the amount of indican pres- ent. Albumin does not interfere with the reaction. Bile- pigments interfere with the reaction, and must be removed by careful addition of a solution of lead subacetate. Potas- sium iodide, because of the liberation of iodine, colors the chloroform more or less violet. It is well to have marked test-tubes, and to use the same amounts of urine and reagents each time, and thus become familiar with the comparative colors in different urines. This test can be made quantitative by comparing with a set of tubes of a chloroform solution of indigo-blue of known strengths ; the volumes of solution must, of course, be the same in all. Diazo Reaction of Ehrlich. — For method of preparing the reagent (see page 186). To 5 c.c. of sulphanilic acid solu- tion add 2 drops of sodium nitrite solution ; this gives a mixture of about 40 : 1. To this mixture add an equal vol- ume of urine, and mix carefully by reversing the test-tube several times. Now add about 2 c.c. of ammonia, letting it run down the side of the test-tube. At the point of contact of the ammonia and the mixture rings of various tints form, ranging from light yellow, through dark yellow, orange and brown, to eosin or garnet, depending upon the urine. The formation of a red ring is an indispensable part of the true Ehrlich diazo reaction. It is also essential that, on shaking, the foam takes on a pink color. This color varies consider- ably in intensity, depending on the strength of the reaction, from the palest rose to the deepest pink, but must not be any other color, such as salmon, orange, etc. The foam is also persistent. EXAMINATION OF THE URINE. 211 Tests for Blood in the Urine. — The color of the urine suggests its presence, and may vary from " smoky " when little blood is present, to red or brown. The sediment may be reddish if the corpuscles settle. The hsemin crystal and guaiacum tests may be applied (see page 21). The presence of red blood-corpuscles under the microscope is pathogno- monic. Albumin, white cells, and haemoglobin can always be demonstrated in the presence of blood. For recognition of red cells (see page 31). In alkaline urine the corpuscles disintegrate rapidly, and may not be demonstrable after ammoniacal fermentation has begun. Fat in the Urine is most readily detected by the micro- scope (see page 190). If necessary, the specimen may be treated with Sudan III. This solution has an affinity for fat only, staining it red, and leaving everything else unstained. Specimens must not be treated with alcohol or ether, since the fat would be dissolved out. A drop of the solution is allowed to run under the cover-glass preparation ; under the microscope the neutral fat-particles are seen to take on a red color. Fat may be removed from urine by shaking with ether, removing the ethereal layer after it has risen, and evaporat- ing. The fat may then be subjected to chemical tests. Pancreatic Urine Test. — The diagnosis of diseases of the pancreas has assumed such importance in medicine and surgery of late years, and it is such a difficult field of diag- nosis, that a trustworthy urinary test would be welcomed with open arms. Cam midge, working in conjunction with Mayo Robson, has introduced the following test : Sufficient work has not as yet been done w T ith the reaction to prove its value in pancreatic diagnosis. However, it is to be hoped that it will prove to be all that its author claims for it. Pancreatic Reaction. — Cammidge describes the procedure in which he calls reaction "A" as follows : The specimen of urine to be examined is filtered, and 10 c.c. of the filtrate are poured into a small flask. One cubic centimetre of strong hydrochloric acid is added and, a funnel having been placed in the neck to act as a condenser, the flask 212 EXAMINATION OF THE URINE. is placed on a sand bath and gently boiled for ten minutes after the first sign of ebullition is detected. A mixture of 5 c.c. of the filtered urine and 5 c.c. of distilled water is then poured into the flask, which is afterward cooled in running water. The excess of acid is now neutralized by slowly adding 4 grammes of lead carbonate and, after standing for a few minutes to allow of the completion of the reaction, the urine is filtered through a moistened filter-paper and the flask is washed out with 5 c.c. of distilled water on to the filter. To the clear filtrate are now added 2 grammes of powdered sodium acetate and 0.75 gramme of phenylhydrazin hydrochlorate, and the mixture is boiled for from three to four minutes on the sand bath. The hot fluid is then poured into a test-tube and allowed to cool undisturbed. After the lapse of a period, vary- ing with the severity of the case from one to twenty-four hours, a more or less abundant flocculent yellow deposit is found at the bottom of the tube, and this when examined under the microscope with a ^-inch objective is seen to consist of sheaves and rosettes of golden-yellow crystals. As the pres- ence of sugar in the urine would obviously vitiate the results thus obtained, it is necessary before proceeding to the test to make sure that the untreated urine does not give a reac- tion with phenylhydrazin. This may roughly be done with Fehling's solution, or some similar test, but it is better to carry out a control experiment with phenylhydrazin hydrochlorate and sodium acetate in the manner I have just described, omit- ting the preliminary boiling with hydrochloric acid. Should the control experiment reveal even a trace of sugar, it must be removed by fermentation, with subsequent boiling to expel the alcohol formed, before the investigation is proceeded with. The presence of albumin in the urine is also liable to cause trouble, and it is best got rid of either by treatment with ammonium sulphate or by acidifying with acetic acid, heating and filtering. The results obtained by this method were found not to be absolutely trustworthy, although a useful aid in diagnosis, since a positive reaction was also obtained in patients suffering from certain other diseases where active tissue-change was taking place, such as cancer, adenitis, pneumonia, etc. EXAMINATION OF THE URINE. 213 For a long time the positive reaction given by these non-pan- creatic cases diminished the practical usefulness of the test, but eventually a means by which the cases of pancreatitis might be distinguished was devised, and we now believe that, by combining the results of the two, it is possible in the large majority of cases to make a trustworthy diagnosis from the examination of the urine alone. The differentiating test depends on the fact that the formation of the crystals described in reaction " A" is interfered with in inflammation of the pancreas by a preliminary treatment of the urine with perchloride of mercury, while such treatment does not affect the appearance of crystals in cases of cancer of the pancreas and the other conditions which give rise to a positive reaction. The procedure, which I shall refer to as the u B" reaction, is as follows : Twenty cubic centimetres of the filtered urine are thoroughly mixed with half its bulk of a saturated solution of perchloride of mercury. After standing for a few minutes it is carefully filtered, and to 10 c.c. of the filtrate 1 c.c. of strong hydrochloric acid is added. The mixture is then boiled for ten minutes on a sand bath and subsequently diluted with 5 c.c. of filtrate from the mixed urine and perchloride of mercury solution and 10 c.c. of distilled water. After cooling it is neutralized with 4 grammes of lead carbonate and the suc- ceeding stages of the operation are carried out as in reac- tion " A." Experiments were then set on foot to still further differ- entiate the forms of disease, and a careful observation of the crystals isolated from the urines of various types of pan- creatic disease showed that while there is a general resem- blance, certain variations occurred and the differing rate of solubility of crystals in dilute sulphuric acid was remarked and found to be of still greater value. If the crystals obtained in reaction "A". are observed under the microscope while a 1 : 3 dilution of sulphuric acid is being irrigated under the cover-glass, they will be seen to turn brown when the acid reaches them and dissolve. In acute pancreatitis the interval that elapses between the first appearance of the brown color and complete solution varies from a few seconds to one-half or 214 EXAMINATION OF THE URINE. three-quarters of a minute. In chronic pancreatitis it extends from half to one and a half or, rarely, to two minutes, while in malignant disease the crystals do not completely disappear until three to six minutes. The practical results of the examination of the urine he summarizes as follows : 1 . If no crystals are found by either the " A" or "B" method the pancreas is not at fault, and some other explanation of the symptoms ought to be sought. 2. If crystals are obtained by the "A" method, but not by the "B" reaction, active inflam- mation of the pancreas is present, and surgical interference is generally indicated, (a) The crystals obtained by the " A" method will in acute inflammation dissolve in 33 per cent, sulphuric acid in about half a minute, (b) In chronic inflam- mation the crystals obtained by the "A" method will take one or two minutes to disappear. 3. If crystals are found in prep- arations made by both the "A" and the U B" methods there may be (a) malignant disease of the pancreas, when the crys- tals will, as a rule, take from three to five minutes to dissolve, and operation is inadvisable ; (6) a damaged pancreas, due to past pancreatitis, when the crystals will dissolve in from one to two minutes ; (c) some disease not connected with the pan- creas, when the crystals dissolve in about one minute. In the latter, two (6) and (c), the urgency of the symptoms and the condition of the patient must decide the need for an exploratory incision, but there is generally not much difficulty in referring the case to one or other of the groups when the clinical history is considered in conjunction w r ith the result of the examination of the urine. QUESTIONS. Give scheme for urinary examinations. What is Trapp's method for the determination of total solids ? Describe a quick method for the quantitative determination of urea. What is the murexid test for uric acid ? Describe a qualitative test for chlorides. What is meant by conjugate sulphates f Describe a qualitative test for phosphates. Describe the Boston pipette method of testing for albumin. Describe Simon's modification of Heller's test. Describe the potassium ferrocyanide test for albumin. URINARY SEDIMENTS, 215 Describe the volume method of quantitatively estimating albumin. Describe Esbach's method. Mention several tests for albumose. What is Fehling's test for sugar? Haines' test ? Describe Purdy's method of quantitatively estimating sugar. Describe Legal's test. Lieben's test. Describe Gerhardt's test. How are salicylates in the urine distinguished from diacetic acid in the urine ? Describe Gmelin's test. Also the foam test for bile. Describe Jafle's test for indican. Describe the diazo-reaction of Ehrlich. Of what value is cryoscopy in urinalysis? CHAPTER XIV. UEINAEY SEDIMENTS. Macroscopical Examination. — Normal urine on standing for some time gradually deposits a faint white cloud occupy- ing the lower part of the vessel, and made up of mucus, a few epithelial cells and mucous corpuscles. A dense sedi- ment of amorphous urates is common, especially in cold weather, and varies in color from almost white to pink or brown; this is the so-called "brick-dust" deposit; it disap- pears on warming the urine or on the addition of caustic alkali. Uric acid is often deposited from very acid, highly colored urines, in the form of small grains looking like red pepper; it can be demonstrated by the murexid test or its solubility in caustic alkali. A voluminous white sediment usu- ally means earthy phosphates, though it may have ammonium urate, triple phosphate, or pus with it, or it may be pure pus. This, however, is usually shiny or sticky, while the phosphate sediment is light and fluffy ; such urines are usually alkaline. A yellowish-white sediment may consist of pus ; if the urine is acid, it is separated into small freely moving par- ticles ; but if alkaline, it consists of a viscid, stringy, cohe- rent mass. 216 URINARY SEDIMENTS. A chocolate-brown sediment usually indicates the presence of blood in the urine ; clots of blood may come from the kidney, ureter, bladder, or urethra, and may at times resem- ble worms. Microscopical Examination. — The microscopical exami- nation of urinary sediments is a very important part of urine analysis, and very frequently throws much light on both diagnosis and prognosis. The freshly passed urine is sedimented by means of the centrifuge or by standing for several hours in a conical vessel, covered to keep out dust. The first method is preferable, as it requires only two or three minutes; if the latter method be used, certain changes may take place in the urine during the long wait, modifying the sediment, and thus incorrect conclusions may be drawn regarding it. In the freshly passed urine small floating particles or mucous threads, technically termed " floaters," may be seen. These may be fished out by means of a glass tube and exam- ined separately. Special attention should be given to these mucous threads, the so-called " clap-threads," and to the minute opaque cheesy bits; the former should be stained and examined for gonococci, the latter for tubercle bacilli. These particles can be obtained by the following method : With the index-finger pressed firmly over the top, a pipette or glass tube is brought near the particles, pressure is then slightly relaxed and the particles drawn up into the tube ; pressure is increased again, the tube withdrawn and held for a moment to allow settling, and then they are deposited on a slide or cover-slip ; excess of urine is removed with a strip of filter-paper. The specimen is then dried, stained, and exam- ined. After the urine is sedimented specimens are trans- ferred to a slide in exactly the same way as just described for floating particles, and examined with the microscope. The specimens should not be covered with a cover-slip, and a low power should be used ; furthermore, the light should be fairly well shut off. When in doubt as to the recognition of certain of the smaller elements, as blood-corpuscles, etc., or when desiring to study their finer structure, a cover-slip V BINARY SEDIMENTS. Fig. 62. 217 Extraneous matters found in urine : a, cotton-fibres ; 6, flax-fibres ; c, hairs ; d, air- bubbles; e, oil-globules; /, wheat-starch : g, potato-starch ; /*, rice-starch granules; i, i, i, vegetable tissue ; k, muscular tissue ; I, feathers. should be applied and a higher power used. For the recog- nition of bacteria it may be necessary to prepare the speci- men, dry, fix, and stain it, as with sputum. Specimens of sediment must always be examined while 218 URINARY SEDIMENTS. still wet, since as the water evaporates all the solid constitu- ents of the urine will be left in crystalline or amorphous form covering everything else. For this reason it is well to prepare one at a time ; and if the examination is to be pro- longed, hanging-drop preparations, as made in bacteriological examinations, will be found very convenient. (See under Widal Reaction.) On the other hand, too much fluid will be liable to run off the slide on to the stage of the instru- ment. Excess of urine can easily be removed with a strip of filter-paper. It is frequently desirable to treat a specimen of sediment with a reagent and notice the effect under the microscope. The common way of adding the reagent to the edge of the cover-slip and allowing it to flow under will usually result unsatisfactorily ; some of the reagent is almost certain to get on top of the slip, and may get on the objective. A much better plan is to place a small drop of the concentrated sedi- ment and a drop of the reagent side by side on the slide, allow them to run together, and cover if necessary. Such a preparation is much neater and there is no danger of injur- ing the microscope. Classification of Urinary Sediments. — Chemical, or Unorganized < A ^ s , me * 1 Amorphous. r Formed elements, as blood-cor- puscles ; pus-cells ; epithe- lium ; casts ; cylindroids ; A , ^ , spermatozoa. Anatomical, or Organized < -r> r ., • i i . i i .Parasites, animal and vegetable. Foreign bodies ; fragments of tissue ; clap-threads ; blood- clots, etc. Chemical Sediments. — These, as a rule, are of little diag- nostic or prognostic value. Most of the substances entering into their formation occur in solution in normal urine ; but as a result of changes from normal conditions to abnormal, or in some cases to slightly different but still normal condi- tions, they are rendered insoluble, and so appear as a seai- URINARY SEDIMENTS. 219 ment. Such changes, which may at times be considered as pathological, and at other times as simply due to alteration in diet, habits, etc., are hyperacidity of the urine ; decrease in acidity or even change to alkaline ; increase in the amount of a normal constituent above the usual amount ; decrease in the volume of the urine, rendering it more concentrated, and thus relatively increasing the amounts of the substances in solution ; the occurrence of certain substances as a result of eating certain articles of food ; development of ammonia. This last is always pathological if occurring before the urine is passed, and is always to be expected in urine which is kept for some time. Some of the substances found in chemical sediments always occur in crystalline form ; some always are amorphous ; a few may take either form, but usually the crystalline. A few are rare, and need practically no consideration ; these are cystin, xanthin, cholesterin, leucin, and ty rosin. These always occur as crystals when found in the sediment ; but they may remain in solution. The first three are of interest, since they have been found in calculi. If there is reason to suspect their presence, the reader should consult large books for methods of identification and tests. The commonly occurring sediments are composed of uric acid and urates ; the various phosphates ; oxalate and car- bonate of lime. Sulphate of lime and hippuric acid are rare, their solubility precluding their deposition except in very concentrated urine. Fat or oil in the form of globules, or crystals, of fatty acids and soaps, are not common except as accidental constituents. Certain coloring-matters, such as hsematoidin, bilirubin, indigo, etc., are also very rare, though indigo is frequently seen in the sediment of old decomposed urines. If the following facts be borne in mind, the identification of a sediment will not be a difficult matter. A sediment is composed only of such substances as are insoluble in the urine under the existing conditions of concentration, reaction, etc. ; none of the substances is absolutely insoluble, though some are practically so ; a sediment therefore represents the excess 220 UEINA R Y SEDIMENTS. over the amount that can be held dissolved. Whenever, by any change in the conditions or by any combination of cir- cumstances, an insoluble compound can form, the tendency will be for it to form ; the equilibrium existing between the substances in the solution is thus destroyed and the reaction will continue until equilibrium is again restored. Certain new chemical compounds may thus be formed. Substances which crystallize will always take a certain definite form when possible ; but various causes may inter- fere, and instead of well-developed, perfect crystals, there will be more or less imperfect forms, or even an amorphous deposit ; often the crystals will show the tendency toward the normal form. When crystals are being deposited slowly they will grow; triple phosphate, for instance, will appear as very small well-formed crystals at first, but if examined a few days later, after th§ ammoniacal fermentation has progressed further, the crystals will be much larger, and may even be large enough to be recognized with the naked eye. The influences which modify crystal formation are especially the rate and the presence of other substances. As a rule, the slower the formation, the more perfect the form ; and the rate may be retarded by slow cooling, slow evaporation, etc. Triple phosphate may be used again as an illustration : if ammonia is produced in the urine by bacteria, and thus slowly, the triple phosphate will appear in almost perfect form ; if, however, ammonia be added to the urine directly, the triple phosphate is formed at once and precipitated ; no time is given for the characteristic form to be taken, and fern-leaf-shaped or star-shaped crystals will be seen. Ammo- nium urate, if made by adding ammonia to a solution of uric acid, nothing else being present, will consist of needles; but as found in a urinary sediment, it is almost always in the form of small more or less highly colored, balls ; the other constituents of the urine prevent it from taking the needle- shape ; the small spicules so frequently seen show the ten- dency toward needles ; and sometimes a burr-like mass of crystals can be observed. Some substances on being deposited from urine, or from URINARY SEDIMENTS. 221 other solutions also, will enclose and drag down suspended particles or coloring-matter ; for example, uric acid deposited from urine is almost invariably colored, the more deeply the more intense the color of the urine ; on the other hand, friple phosphate and calcium oxalate are never colored, but are bright and shining. A familiar illustration of an analogous process is the clarification of water by means of alum, the bulky, voluminous precipitate of aluminum hydrate, in set- tling, acting as a drag-net, will carry down suspended parti- cles, bacteria, etc. This process may be used in clarifying urine which will not filter clear. Fig. 63. Uric-acid crystals of various shapes. Uric Acid. — Uric acid itself has a very slight solubility ; it forms two kinds of salts, acid and normal. Sodium acid urate, C-H 8 NaN 4 3 , maybe taken as the type of the former ; and C 5 H 2 Na 2 N 4 3 the latter. The constituents of normal urine increase the solubility of these difficultly soluble forms, holding them as the normal urates, which are easily soluble, and they do not therefore appear as sediment in fresh urine. The acid salts also have very slight solubility. It is as normal salts that uric acid exists in urine ; by a change in the conditions, excess in the amount, the degree of acidity, lower- ing of the temperature, etc., there is a change to the more 222 URINARY SEDIMENTS. insoluble form, either the acid urate or uric acid, and the appearance of a sediment. This frequently occurs in cold weather as a result of simple cooling. Uric acid crystals are almost always colored either a deep yellow or brownish red. or even brown, rarely a pale yellow. The rhombic prism is the essential form of the crystal, but it may present all sorts of modifications of this form, star-shaped and fan-shaped clusters. Colored crystals occurring in acid urine are in all probability uric acid. Urates. — As explained above, urates are very frequently deposited as a result of cooling of the urine ; an interchange Fig. 64. Fig. 65. Sodium urate : a, a, from a gouty con- cretion ; b, b, artificially prepared by add- ing liquor sodse to the amorphous urate deposit. (Roberts.) Ammonium urate spontaneously deposited: a, spheres and globular masses ; b, dumb-bells, crosses, rosettes, (Roberts.) takes place between the normal urate and the acid phosphate, with formation of the acid urate and alkaline or secondary phosphate. The acid urate is thus precipitated. The same reaction may go farther and form uric acid. The urates are chiefly those of sodium and potassium, sometimes also of calcium and magnesium ; they are spoken of as the amor- phous, or acid, or mixed urates, or brick-dust deposit. Ammonium urate, as stated, will appear only when there is ammonia. The urates rarely appear in crystalline form, though sometimes small needles are found. The usual form is a rather dense, sandy deposit, cream-colored, yellow, pink UMINARY SEDIMENTS. 223 or rose-colored, or even brown, depending upon the color of the urine. Under the microscope small sandy particles are seen, usually yellowish or brownish, with now and then a crystal of uric acid. If there should be any doubt, the fol- lowing very simple characteristic tests can be applied : (a) A drop of caustic soda or potash added to the sedi- ment on the slide will cause it to dissolve immediately, (b) A drop of hydrochloric acid added to the sediment will in two or three minutes produce numerous very small colorless Fig. 66. Ammonium urate. (Musser.) crystals of uric acid, (c) Simply warming some of the urine in a test-tube will cause a solution of the deposit and clear- ing-up of the urine (Figs. 64 and 65). Calcium Oxalate. — Calcium oxalate is usually found in acid urine, frequently associated with uric acid or urates ; but occasionally in alkaline urine, and at times associated with triple phosphate. It is almost always in the form of small colorless shining octahedra, the so-called envelope crystals ; these have the appearance of small squares with lines con- 224 URINARY SEDIMENTS. necting the corners and crossing at the middle. It rarely occurs as small dumb-bells, ovals, or amorphous (Fig. 67). Fig. 67. Calcium oxalate crystals. The solubility in hydrochloric acid and insolubility in acetic acid or caustic alkali may aid in identifying it. Fig. 68. Various forms of triple phosphates. (Finlayson.) Phosphates. — Whenever the urine becomes alkaline from any cause, the phosphates of calcium and magnesium, Ca 3 (P0 4 ) 2 and Mg 3 (P0 4 ) 2 , may be expected ; if ammonia is URINARY SEDIMENTS. 225 present, ammonium magnesium phosphate, NH 4 MgP0 4 , or triple phosphate will also appear. In urine which is very faintly acid these may be found, as explained, or rarely the acid phosphate of calcium, CaHP0 4 . The first named, earthy or amorphous phosphates, occur as a very voluminous, colorless, fluffy deposit, hardly visible under the microscope. Triple phosphate occurs almost invariably as the so-called " coffin-lid " crystals, colorless prisms ; rarely as fern-leaf- shaped or in stars of leaf-shaped crystals, and these only when ammonia has been added to the urine or has developed very rapidly (Fig. 68). The acid phosphate of calcium forms colorless wedge-shaped crystals, often in bundles (Fig. 69). Fig. 69. Monocalcium phosphate crystals. The reaction of the urine and the solubility of the deposit in acids will distinguish phosphates from anything else. Calcium Carbonate. — This is frequently found in amrno- ■ niacal urine in the form of very small colorless granules or dumb-bells. The effervescence with a drop of acid will identify it (Fig. 70). Cystin. — This is a very rare urinary deposit. It occurs most often in small six-sided plates with a " mother-of-pearl " appearance, or in the form of four-sided square prisms (Fig. 71). 15— C. D. 226 URINARY SEDIMENTS. Xanthin. — This is found very infrequently, and occurs in the form of small fusiform crystals. Leucin and Tyrosin. — These are very rare, being found Fig 70. 8 d ^ Calcium carbonate crystals. Fig. 71. Vl & >^ O a, Crystals of xanthin (Salkowski; b, crystals of cystin (Robin). only in severe diseases of the liver. Leucin occurs in mulberry-like masses. Tyrosin appears as very fine needles arranged in the form of sheafs. Both are insoluble in alco- Fig. 72. Tyrosin crystals. (Charles.) hol or ether, readily soluble in acids, alkalies, or warm water (Figs. 72 and 73) Organized Sediment. — Red blood-corpuscles can usually be recognized under the microscope with the low power. URINARY SEDIMENTS. 227 If there is any doubt, the specimen should be covered with a cover-slip and a high dry power used. In freshly passed urine they usually show a light-yellow color and the typical biconcave appearance. If they have become shrunken, cre- nated, or the haemoglobin has become dissolved out, they may be recognized with difficulty. Only rarely are chemieal tests required. If a hemorrhage has occurred within the urinary tract, blood-clots may be found ; these may be moulded into more or less definite-shaped masses if formed within the tubules Fig. 73. Crystals of leucin (different forms) : (Crystals of kreatinin-zinc chloride resem- ble the leucin crystals depicted at a.) The crystals figured to the right consist of comparatively impure leucin. (Charles.) (blood-casts) or in the ureters ; but they are usually simply masses of clotted blood, especially if formed in the bladder. Leukocytes and Pus-cells. — A few leukocytes may be pres- ent in normal urine. An excess of leukocytes ov pus always indicates disease in some part of the urinary tract, except in the female, when the cells may be numerous as a result of contamination with vaginal discharge. In such cases they are associated with a corresponding increase in the vaginal epithelium. A catheterized specimen of urine should then be examined. The appearance of pus-corpuscles depends on the reaction of the urine. In acid and neutral urines they are usually well preserved ; but in alkaline urine they swell up, become 228 UMNAHY SEDIMENTS. opaque, and the nucleus is recognized with difficulty, except after the addition of acetic acid. In pyogenic conditions the leukocytes are all polynuclear. The presence of a good many mononuclear leukocytes makes the presence of genito-urinary tuberculosis extremely suspicious. Pus can be most easily demonstrated by pouring off the greater part of the urine and adding a small piece of caustic soda or potash, when a viscid, sticky, slimy mass is formed. Epithelial cells occur in small numbers in the sediments of normal urine. An increased number of cells indicates an inflammatory condition in some part of the urinary tract. Unfortunately it is impossible to be absolutely certain as to which part of the urinary tract certain cells come from, since the cells from the bladder, ureters, and the pelvis of the kidneys are practically alike. Hence definite conclusions can very seldom be drawn from the microscopical examina- tion alone. Cells are of three kinds : (1) Round cells ; (2) Conical and caudate cells ; (3) Squamous, or pavement cells. Round cells are a trifle larger than leukocytes and have a more distinct nucleus. They may be confused with pus-cells, but in the latter it requires the addition of acetic acid to bring out the nucleus, which is furthermore polynuclear. In fatty degeneration of the kidney, fat can be demonstrated in these cells by means of Sudan III. Conical and caudate cells have their origin in the superfi- cial layers of the pelvis of the kidneys and the neck of the bladder ; the latter have the longer processes. Squamous or flat cells may come from the ureters, the bladder, the vulva and vagina of the female, and the prepuce of the male. They are large polygonal cells with a distinct nucleus and slightly granular protoplasm (Fig. 74). Tube-casts. — There are three main classes : (1) Hyaline and waxy casts. These are clear, almost URINARY SEDIMENTS. 229 transparent, homogeneous bodies ; they may be narrow or broad. There are also composite casts, chiefly hyaline, but more or less covered with granules and organized elements. (2) Those consisting of organized elements embedded in a hyaline matrix ; blood-casts, leukocyte casts, epithelial casts, bacterial casts. (3) Those consisting of the debris of organized bodies ; granular casts, fatty casts. Fig. 74. Cellular elements from the urine: 1, squamous epithelium ; 2, red blood-corpus- cles ; 3, polynuclear leukocytes; 4, transitional cells ; 5, epithelium from the kid- neys; 6, epithelium from the bladder; 7, Micrococcus urese ; 8, yeast-fungi. (Musser.) The inexperienced worker best recognizes and studies casts by comparing his microscopical preparation with good cuts. Casts usually indicate nephritis, acute or chronic ; but may be found in cases of renal calculi, icterus, diabetes, and some- times in secondary congestion of the kidney, and in fevers. Hyaline casts are clear, translucent cylinders, which are easily overlooked on account of their slight refraction of light. Their borders are clearly marked and their ends may 230 URINARY SEDIMENTS. be rounded or have a broken-off appearance ; they are seldom long, and are either straight or slightly curved. In diameter they vary from that of a white blood-cell (narrow) to five or six times this diameter (broad). It is seldom that they do not show some granulation. It is essential to have most of the light shut off when searching for these casts. Waxy casts are somewhat similar to hyaline, but have a Fig. 75. Hyaline casts from a case of acute nephritis : 1, plain hyaline cast; 2 granular deposit on hyaline cast ; 3, cellular deposit (blood and epithelium). (Musser.) light-yellow color, refract the light better, and are usually larger and seem more cylindrical. They have a waxy appearance (Fig. 75). Blood-casts consist most often of hyaline casts whose sur- face is covered with blood-cells, or of masses of blood-corpus- cles pressed into cylindrical shape. The same is true of epithelial and leukocyte casts (Fig. 76). Granular casts have as their basis the hyaline cast ; this is covered with fine or coarse granules, few or many, or URINARY SEDIMENTS. 231 is granular from a disintegration of the cast itself. The granules may be so coarse and numerous as to give the cast a dark appearance. Enormous numbers of coarse dark granular casts have, according to Dock, a grave prognostic indication. Fatty casts are simply hyaline or granular casts on which are deposited minute oil drops, or sometimes crystals of fat. Cylindroids resemble hyaline casts, except in shape and Fig. 76. a, Fatty casts ; b and c, blood-casts ; d, free fatty molecules. (Roberts.) size. They are much larger, and usually taper from a thick end to a slender wavy or twisted point, or they may show several constrictions in their course. They may have a striated or ribbed appearance (Fig. 77). They have practi- cally no pathological significance. False casts have been described. They consist of urinary crystals or amorphous salts moulded into cylindrical forms. Spermatozoa are easily recognized by their tadpole ap- pearance (Fig. 78), 232 URINARY SEDIMENTS. Fig. 77. a and b, cylindroids from the urine in congested kidney, (v. Jaksch.) Parasites — Vegetable and Animal. — Vegetable. — The bacteria of most importance in urinary examination are the gonococcus, the tubercle bacillus, and the colon bacillus and typhoid bacillus. URINARY SEDIMENTS. 233 Clap-threads may be fished out of freshly passed urine or the urine may be centrifugated, and spreads made of the sediment, dried in the air, and fixed in a flame. These are now stained with methylene-blue solution or by Gram's method or with neutral red or Kresylechtviolett. Tubercle Bacillus. — Any opaque particles are fished out of the suspected urine, or it is centrifugated and spreads made, dried, and fixed as above. The specimen is then double-stained with carbol-fuchsin and methylene-blue, as in sputum examination. Tubercle bacilli in the urine are often Fig. 78. Human semen : a, spermatozoa ; b, cylindrical epithelium ; c, bodies enclosing' lecithin-granules ; d, squamous epithelium from the urethra ; d', testicle-cells ; e, amyloid corpuscles ; /, spermatic crystals ; g, hyaline globules, (v. Jaksch.) arranged in thick masses, having an S-shaped form. It may be difficult to demonstrate the germs by staining methods. The urine is then sedimented, and 1 or 2 c.c. of the sediment injected into the peritoneal cavity of a guinea-pig. In the course of six weeks the pig should develop tuberculosis if the urine contains tubercle bacilli. The pig is posted, and tubercles found in the various organs of the abdomen and perhaps chest. Smegma Bacillus. — This is important because it resembles the tubercle bacillus very closely in its morphology and stain- ing characteristics. It is found on the external genitals of 234 URINARY SEDIMENTS. both sexes, and at times in the urethra. It may find its wav into the urine and faeces, and thus be mistaken for the tuber- cle bacillus. It does not cause disease ; hence animal inocula- tion is a certain means of differentiating the two germs. They can also be differentiated by Pappenheim's method of differentiating Bacillus tuberculosis from the smegma bacillus. The specimen is stained with carbol-fuchsin solution : then after draining off the excess of stain, it is dipped from three to five times into Pappenheim's solution (1 part of corallin (rosolic acid) in 100 parts of absolute alcohol, to which methylene-blue is added to saturation. This mixture is treated further with 20 parts of glycerin). The specimens are washed in water, dried between filter-paper, and mounted . in Canada balsam. The tubercle bacilli are stained red, and all other germs, including smegma bacilli, are stained blue. A simpler method of differentiation is to stain with carbol- fuchsin, decolorize in 33 per cent, nitric acid, then wash in 95 per cent, alcohol for thirty seconds, and counterstain with methylene-blue. Smegma bacilli hold the red color in the presence of acids, but not in the presence of alcohol. Gonococci. — (1) Stain by Gram's method (see page 19), then counterstain with dilute carbol-fuchsin 1 : 8, without heat, or with saturated aqueous solution of Bismarck-brown with heat to the steaming-point, Wash in water and mount. Diplococci within leukocytes, which have been decolorized by Gram's stain, and have taken the counterstain of red or brown, are to be considered as gonococci. (2) Neutral Red Stain. — This is an excellent stain. In a dilution of about 1 : 15,000 it shows a selective action for gono- cocci, staining them a red color, while other organisms, with the exception of the Diplococcus urethra communis, which takes a somewhat lighter red, remain unstained. Morse gives the following directions : 1. Make a stock 1 per cent, aqueous solution of neutral red. 2. To a beaker of distilled water add sufficient of this stock solution to give a sherry-wine color (about 1 : 15,000). 3. Float fixed spread, specimen side down, upon this solu- tion for about five minutes. URINARY SEDIMENTS. 235 4. Wash quickly in distilled water and dry with filter- paper. (3) Methylene-blue. — With this stain the diplococci within the leukocytes are usually considered as gonococci. The stain is easily applied, but is not specific, as all cocci in the preparation take the same blue stain. Gram and Neutral Red Stain for Gonococci (Morse) : 10 c.c. water ; 2 c.c. anilin oil ; shake ; filter clear. Add 1 c.c. alcohol and 1 c.c. saturated gentian-violet solution. Fig. 79. A gonorrhoea! thread. (Simon.) 1. Stain in this cold for two minutes. 2. Leave in Gram's (I in KI) solution for three minutes. 3. Wash in alcohol till decolorized. 4. Wash in water. 5. Float in neutral red solution 1 : 5000 about five minutes. 6. Dip once in distilled water and dry with filter-paper. As is well known, certain bacteria are stained by Gram's stain, while others are not (see Gram's stain). The Diplococ- cus urethrse communis resembles the gonococcus very closely in its morphology ; it is a little larger and longer. The average observer is likely to mistake it for the gonococcus. It is stained by the Gram method, while the gonococcus is not. The above stain will differentiate these two organisms. Bacteriuria is the name given to a condition in which 236 URINARY SEDIMENTS. micro-organisms are present in considerable numbers in urine at the time of voiding. These can be demonstrated by preparing the sediment, fixing, and staining with methylene- blue. The bacteria of the infectious diseases can sometimes be demonstrated by appropriate methods of culture and staining. The trichomonas is rarely found in the urine. Sarcines, yeasts, and moulds are rarely found. Animal parasites are rarely found, and then chiefly in resi- dents of the tropics. Among them are the echinococcus, Filaria sanguinis hominis, Bilharzia hsematobia, Distoma haematobium, Stron- gylus gigas. Calculi. — Examination of the freshly passed urine may throw considerable light upon the nature of the calculus. Small crystalline masses, gravel, or deposits of uric acid or calcium oxalate may be seen. If the urine is distinctly acid at the time the gravel was passed or the attack of renal colic occurred, it is almost certain that the calculus is either uric acid or calcium oxalate; in a large percentage of the cases the former, especially if directly on cooling the urine precipi- tates crystals of uric acid. If the fresh urine shows con- tinually the presence of crystals of calcium oxalate, it is most likely a calcium oxalate calculus. In alkaline urines the calculus is usually of the mixed phosphate variety, or has a nucleus composed of uric acid or calcium oxalate and coated with phosphates. Accidental Substances. — Extraneous matter found in the urine may consist of fibres of various kinds, such as cotton, linen, or woollen ; starch-granules or oil drops, or particles of dust. These may appear in the urine as a result of con- tamination with towels, clothing, toilet preparations, dust, etc. CRYOSCOPY. Molecular Concentration of the Urine. — The method of determining the freezing-point of the urine is the same as that for the blood. URINARY SEDIMENTS, 237 Lenhartz gives the following statement of the value of eryoscopy in the examination of urine : " In defective renal function and consequent retention in the blood of substances which should be excreted in the urine, a diminution of the molecules in the urine must occur in the same ratio. In other words, in disturbed renal function the freezing-point of the urine (J) rises above the normal. "It has been shown that in healthy kidneys this varies be- tween 0.87° and 2.42° C, according to the conditions of metab- olism. In order to obtain an approximate idea of the actual amount of molecules excreted, the daily amount of urine must, of course, be considered. In order to obtain standard values, the product of A and the amount of urine = V (valence number) has been calculated. The figures given by different authorities vary between 766 and 3770. While, the practical value of the molecular determination of the urine in internal medicine is limited (because the limits of the normal value, which among other things are decidedly influenced by solid and liquid foods, are very variable) the researches of Kummel and Rumpel have shown that eryoscopy is of the greatest advantage in the diagnosis of unilateral renal affections. For this purpose it is necessary to collect the urine of both kidneys separately by ureteral catheterism. The urine of each kidney is then examined in regard to its freezing-point and also its urea and sodium chloride content. If A of one kidney shows a normal value, while A of the other kidney is under 0.87° C, this indicates an affection of the latter." The foregoing remarks indicate that the value of eryoscopy is extremely limited, as the members of the profession who are thoroughly familiar with ureteral catheterism in the male, and the technique of eryoscopy will always be very few and confined to the larger medical centres. QUESTIONS. What points are to be noted in the naked-eye examination of urine ? Describe the correct method of making a microscopical examination of urine. Classify urinary sediments. What substances are most commonly found in chemical sediments? 238 VRIKARY SEDIMENTS. What substances are rarely found ? Mention the important points in the law of crystalizatiou. Describe the various forms of uric acid crystals. Describe the various forms of urates. Mention several simple tests for the detection of urates. Describe the common form of calcium oxalate crystals. Describe the various forms of phosphates. Describe calcium carbonate, cystin, xanthin, leucin, and tyrosin crystals. Describe the red blood-corpuscles in varying conditions of the urine. Give several methods for recognizing pus in the urine. Of what significance is an excess of mononuclear leukocytes in the urine? Name the different areas of the urinary tract in which similar cells are fuund. Mention the chief classes of tube casts. In what conditions are tube casts found, and what is their significance ? Describe cylindroids. False casts. Describe the various methods of demonstrating tubercle bacilli in the urine. Describe a differential stain for the gonococcus. What is meant by bacteriuria ? Of what value is sediment examination in determining the nature of calculi ? Mention accidental substances found in urinary sediments. INDEX. ACETIC acid and heat-test for albu- min, 198 Acetone, 186 tests for, 208 Achlorhydria, 129 Acid, combined hydrochloric, 117 free hydrochloric, tests for, 116 lactic, 116, 117 organic, 116, 117 Actinomycosis, 159 Albumin in urine, 184, 185 quantitative estimation of, 202 tests for, 197-203 varieties of, 184, 185 Albuminuria, mixed, 185 Albumose, 185 tests for, 202, 203 Alexins, 99 Alizarin solution, 105 Amoeba coli, 137, 138 Anchylostoma duodenale, 144 Aniline water, 19 Animal inoculation, 164 Apepsia, 129 Appendicitis, 100 Articular fluid, 167 Ascaris lumbricoides, 143 BABCOCK fat tester, 169 Bacillus pneumoniae of Fried- lander, 158 Bacteremia, 93 Bacteriological clinical examinations, 163 Bacteriuria, 189, 235, 236 Barium chloride solution, 172 Basophilia, punctate, 61 Bile, tests for, 209 Biuret reaction, 202 Blood, 21-104 agglutinins of, 30 alkalinity of, 68 bacteriology of, 72 Blood, chemical analysis of, 30, 31 clinical examination of, 34, 35 coagulation of, 30, 69 color of, 29 index of, 41 counter, Turck's, 45 counting fluids, 25, 26 red corpuscles of, 42, 43, 44 white corpuscles of, 45, 46, 47 cryoscopy of, 70, 71 diseases of, 72-93 ansemia, aplastic, 75 primary pernicious, 72, 73, 74 secondary, 76 pernicious, 74, 75 chlorosis, 76 differential diagnosis in, 79, 80 Hodgkin's disease, 79 iodophilia, 80 leukaemia, 77, 78, 79 splenomegaly, 79 dust, 32 fibrin network, 33 fixing spreads of, 50, 51 fresh drop examination of, 35, 36 guaiacum test for, 21 haBmin test for, 21 hsemoglobin, 30 estimation of, 36-40 method of securing, 35 physiology of, 31 pigment granules, 30 pipettes, cleaning of, 23-25 plates, 32, 53 reaction, 29 abnormal forms of red corpuscles of, 31, 52, 55, 61 serum, 30 specific gravity of, 31, 41, 42 spreads or films, making, 48-50 staining with Wright's stain, 51-54 with Ehrlich's tricolor mixture, 54-56 239 240 INDEX, £U ood staining with eosin and hsemo- toxylon, 56, 57 stains, 26-28 stickers, 23 total volume of, 29, 69 white corpuscles of, 31 work, technique of, 23-25 Boas sieve, 132 test-breakfast, 109 Boston's test for albumin, 199 Bothriocephalus latus, 141, 142 p-oxybutyric acid, 186, 209 CALCIUM oxalate, 223 Calculi, urinary, 189, 236 Cammidge's pancreatic test, 211-214 Carbol fuchsin, 19 Casts in urine, 187 Centigrade and Fahrenheit conver- sion, 23 Cercomonas intestinalis, 138 Cerebrospinal fluid, examination of, 166 Cestodes, 138, 139 Charcot-Leyden crystals in faeces, 135 in sputum, 162 Chlorides in urine, 182. 195 Chyluria, 190 Clap threads, 188 Color index, 41 Congo-red test, 116 Cream gauge, 169 Cryoscopy, 70, 71, 236, 237 Crystallization, laws of, 219, 220 Crystals in faeces, 135 in urine, 189 Culture media, 163 Curschmann's spirals, 153 Cylindroids, 188 DARE'S haemoglobinometer, 40, 41 Decinormal sodium hydrate solu- tion, 105 Degeneration of red blood-cells, endo- globular, 60 granular, 61 Delah* eld's hsematoxylon, 27 Diabetic coma, 186 Diacetic acid, 186, 208 Diazo reaction of Ehrlich, 186, 210 solutions, 171 Dimethylamido-azobenzol solution, 105 Diphtheria bacillus, 164 Diplococcus intracellulars meningiti- dis, 165 pneumoniae, 158 Distoma pulmonale, 161 Doremus ureometer, 194 Dumdum fever, 92 Durham's heematocytometer, 48 ECHINDCOCCUS cysts, 160 Ehrlich's dahlia solution, 28 diazo reaction, 171, 186, 210 tricolor mixture, 27 Elastic tissue in sputum, 155 Endocarditis, malignant, 93 Eosin, 27 Eosinophilia, 103, 104 Erythrocytes, 31 (see Red blood-cor- puscles). Esbach's albuminimeter, 202 reagent, 171 Ethereal extracts, 20 Euchlorhydria, 129 Eupepsia, 129 Ewald and Boas test-breakfast, 108 Exudates, 167 FAECES, 130-147 amount of, 130 bacteria in, 135-137 bacteriological examination of, 136 blood in, 133 color of, 130, 131 consistence of, 130, 131 crystals in, 135 fat in, 133 macroscopical examination of, 131, 132 method of obtaining specimen of, 133, 134 microscopical examination of, 133, 135 mucus in, 132 odor of, 130 parasites in, 137-146 pus in, 133 Fat, detection of, 20 estimation of, 168, 169 in urine, tests for, 211 Fehling's solution, 171 test, 203 Fermentation test for sugar, 201 Ferric chloride solution, 172 Ferrocyanide of potassium solution, 172 Feser's lactoscope, 168 Fibrinous casts, 152 Ficker's typhoid diagnosticum, 66 Filariasis, 90 INDEX. 241 Fleischl's hsemoglobinometer, 36 Foam test for bile, 209 Fungi in urine, 189 GABBETT'S stain, 157 Gall-stones, 132 Gastric analysis, 104-129 apparatus required for, 104-106 reagents required for, 105 short method of, 120 Topfer's method of, 117-120 juice, analysis of, 108, 116 Gentian violet, 19 Gerhardt's test for diacetic aoid, 208 Glassware, cleaning of, 18 Gmelin's test for bile, 209 Gonococci, methods of staining, 234 235 Gower's fluid, 26 Gram's stain, 19 Gunzburg's reagent, 105 test, 116 HEMATOCRIT, Daland's, 68 Hematuria, 187 Hsemocytometer, Oliver's, 68 Haemoglobin, 36-41 estimation of, with Dare's hsemo- globinometer, 41 with Fleischl's hsemoglobinom- eter, 36-39 with Miescher's hsemoglobinom- eter, 39, 40 with Oliver's hemoglobin oineter, 40,41 with Tallqvist's scale, 36 Haeser's coefficient, 193 Haine's sugar test, 204 Hammerschlag's method of estimat- ing pepsin, 124 Hayem's fluid, 26 Heart-failure cells, 162 Heat and nitric acid test for albumin , 197 Pleller's ring test, 198 Helminthiasis, 103 Holt's cream gauge, 169 Horismoscope, 199 Hyperchlorhydria, 129 Hyperpepsia, 129 Hypobromite solution, 172 Hypochlorhydria, 129 Hypopepsia, 129 TNDICAN, 181, 209, 210 1 Indol, 130, 180 16— C. P. Influenza bacillus, 158 Iodine test for bile, 209 for starch, 20 Iodophilia, 28, 57 JAFFE'S test for indican, 209, 210 Jaundice, 186 Jenner's stain, 53, 54 Jolle's ferrometer, 40 KARYOKINESIS, 62 Kelling's test for lactic acid, 116 Klebs-Loffler bacillus, 164 LABORATORY supplies, 17, 18 Lactic acid, 116, 117 Kelling's test for, 116 Strauss' test for, 117 Uflelmann's test for, 116 Lactodensimeter of Quevenne, 169 Lactoscope of Feser, 168 Lactose in urine, 186 Legal' s test for acetone, 208 Leishman-Donovan parasite, 92 Leptothrix buccalis, 159 Leukocytes, 31, 57, 58, 59 degeneration of, 62, 63 differential counting of, 59 diluting fluid for counting of, 26 table of, 47 varieties of, 52-60 eosinophile, 52, 56, 59 large mononuclear, 52, 55 lymphocyte, 52, 55 mast cell, 52, 56, 59 melaniferous, 90 myelocyte, 53, 58, 59, 60 normal percentage of each variety in the adult, 96 polynuclear, 52 transitional, 55 Leukocytosis, 96-104 chemotactic theory of, 98, 99 in appendicitis, 100 inflammatory and infectious, 100 in malignant disease, 102 of digestion, 97 of pregnancy, 97 pathological, 98 post-hemorrhagic, 99 therapeutical and experimental, 102 varieties of physiological, 97, 98 Leukopenia, 93, 94, 95 in tuberculosis, 94 in typhoid fever, 95 242 INDEX. Leukopenic phase, 99 Lieben's test for acetone, 208 Loffler's methylene-blue, 19 Lohnstein's urinometer, 175 Lugol's solution, 19, 172 Lumbar puncture, 166 Lymphatic leukaemia, 102, 103 Lymphocytosis, 102 MALAEIA, 80-90 leukocytes, melaniferous, in, 90 melansemia in, 90 parasites of, 53, 80-90 sestivo-autumnal, 89 crescentic bodies, 89 double tertian, 88 flagellation in, 88 fragmentation in, 87 presegmenting bodies, 87 quartan, 88 ring forms, 87 signet ring, 89 spheroidal bodies, 87 staining the malarial parasite, 81, 86 tertian, 86-88 Megaloblast, 61 Megalocyte, 61 Methylene-blue, 19, 27 Metrocyte, 62 Mett method of determining peptic digestion, 121-123 Microblast, 61 Microcyte, 61 Miescher's haernoglobinorneter, 39 Milk, average cows', 168 human, 168 examination of, 168, 169 specific gravity of, 169 Mucous colitis, stools in, 132 threads in urine, 188 Mucus in faeces, 132 Murexid test for uric acid, 195 NEMATODES, 142, 143 Neusser's basophilia, 63 Neutral red stain for gonococci, 234, 235 Nocht-Romanowsky stain, 28 Normoblast, 61 Nucleo-albumin, 185 OIDIUM albicans, 160 Oliver's hsemoglobinometer, 40 Oppler-Boas bacillus, 115 Oxalic acid and oxalates, 183 Oxyuris vermicularis, 143 PANCREATIC diseases, urine test for, 211-214 Pappenheim's stain, 234 Parasites in blood, 80-93 in fseces, 135-146 in sputum, 159-161 in urine, 189 Peptic digestion tests, 121-125 Peptone, 185 Pertussis, lymphocytosis in, 103 Phagocytosis, 99 Phenol, 180 Phenolphthalein solution, 105 Phenylhydrazin test, 204 Phosphates, 181, 182 Plasmodium malaria, 53, 80-90 Plate cultures, 163 Poikilocytosis, 60 Polari scope, 207 Potassium ferrocyanide test for albu- min, 202 hydrate solution, 172 Proteids, tests for, 124, 125 Protozoa, 137, 138 Purdy's solution, 171 sugar test, 205, 206, 207 Purulent affections, blood in, 80 Pyroplasma hominis, 92 Q UEVENNE'S lactodeusimeter, 169 RED blood-corpuscles, abnormal forms of, 61, 62 Relapsing fever, 90 Rennet, tests for, 124 Riegel test-dinner, 109 Rocky Mountain tick, 92 Rosenbach's test for bile, 209 SACCHARIMETER of Einhorn or Lohnstein, 205 Sarcinae, 115 Serum globulin, 184, 185 Silver nitrate solution, 172 Simon's modification of Heller's test, 200, 201 Skatol, 130 Sleeping sickness, 91 Smegma bacillus, differential stain of, 233 Sodium hydrate solution, 173 INDEX. 243 Spermatozoa, 188 Spirochseta Oberrneieri, 90 Spotted fever, 92 Sputum, 147-163 amoeba coli in, 100 animal parasites in, 160 apparatus for examination of, 147 cheesy particles in, 152 color of, 150 consistence of, 150 crystals in, 162 epithelial cells in, 161 examination of, 149 leukocytes in, 161 macroscopical examination of, 150 method of obtaining, 148 microscopical examination of, 154 odor of, 150 red blood-cells in, 161 slide, author's, 149 spreading of, 149 staining of, 156 stains and reagents for examination of, 147 trichomonades in, 160 varieties of, 152 crudum, 152 globosum, 152 mucoid, 152 mucopurulent, 152 mucoserous, 152 nummular, 152 purulent, 152 sanguineous, 152 sanguinomucopurulent, 152 serosanguineous, 152 serous, 152 vegetable parasites in, 156 Squibb' s urinometer, 175 Stains, 19, 20 analine water gentian -violet, 19 carbol fuchsin, 19 dahlia solution of Ehrlich, 28 eosin, 27 and methylene-blue, 27 Gram's, 19 hsematoxylon, Delaneld's, 27, 56 Hewes' after-stain, 54 iodophilia mixture, 28, 80 Jenner's, 53, 54 Loffler's methylene-blue, 19 Leish man's, 53, 54 Lugol's solution, 19 neutral red, 234 Nocht-Romanowsky, 28 Stains, Pappenheim's, 234 Sudan III., 20 thionin, 86 tricolor mixture of Ehrlich, 27, 54 Wright's, 26, 81 Starch, iodide test for, 20 iodine test for, 20 Stomach, 104-129 absorptive power of, 128 contents, examination of, 114-120 motor power of, 127, 128 size, shape, and position of, 128, 129 Stomach-tube, contra-indications to the use of, 110 method of use, 111-113 Strauss' test for lactic acid, 117 Streak method of bacteriological ex- amination, 164 Streptococci and staphylococci in spu- tum, 159 Streptothricosis, 159 Sudan III., 20, 172 Sugar in the urine, 85 tests for, 202-208 Sulphates, 180 tests for, 196 TAENIA saginata, 139 solium, 141 Tallqvist's haemoglobin scale, 36 Test-meals, 108-110 Thrush, 160 {see Oidium albicans). Toisson's fluid, 25 Topfer's method of gastric analysis, 117 Transudates, 167 Trapp's coefficient, 193 Trichina, 146 Trichomonas intestinalis, 138 Triple phosphate, 182 Trypanosomiasis, 91 Tubercle bacillus, 156 in fseces, 136, 137 in sputum, 156 in urine, 233 methods of staining, 156, 157 Tiirck's blood-counter, 45 Typhoid fever, 93 UFFELMANN'S test, 116 Uncinaria duodenalis, 114 {see Anchylostoma duodenale). Uncinariasis, examination of fseces in, 146 Urate of ammonium, 22£ 244 INDEX. Urate of sodium, 222 Urates, 222 Urea, 177, 178 estimation of, 194 Uric acid, 179, 195 crystals, 221 Urinalysis, value of, 173 Urinary sediments, 215-236 calcium carbonate, 225 oxalate, 223, 224 casts, 228-231 blood, 230 fatty, 231 false, 231 granular, 230 hyaline, 229 waxy, 230 chemical, 218 classification of, 218 cylindroids, 231 cystin, 225 epithelial cells, 228 leucin, 226 leukocytes, 227 macroscopical examination of, 215 microscopical examination of, 216- 218 organized, 226-236 phosphates, 224, 225 pus-cells, 227 triple phosphates, 224 ty rosin, 226 urates, 222 uric acid, 221 xanthin, 226 Urine, 170-238 accidental substances in, 236 acetone in, 186 albumins in, 184, 185 amount of, 174 apparatus used in examination of, 170, 171 bacteria in, 189 bile in, 186 blood in, 187, 211 /3-oxybutyric acid in, 186 calculi in, 189 carbohydrates in, 185 casts in, 187 characteristics of normal, 173-176 chlorides in, 182 clap threads in, 188 color of, 175, 176 Urine, constituents of normal, 176-183 cryoscopy of, 236, 237 crystals in, 189 cylindroids in, 188 diacetic acid in, 186 epithelium in, 188 examination of, 191 fat in, 190 foreign matter in, 190 freezing-point of, 236, 237 fungi in, 189 haemoglobin, 185 leukocytes in, 187 lymph in, 190 mucous threads in, 188 odor of, 176 oxalic acid in, 182, 183 parasites in, 189, 232-236 pathological substances in, l^oH'l phosphates in, 181, 182 pus in, 187 reaction of, 175 reagents used in examination of, 171, 172 scheme for recording examinations of, 192 specific gravity of, 174, 175 spermatozoa in, 188 sulphates in, 180, 181 tissue debris in, 188 total nitrogen in, 180 solids, determination of, 198, I'M turbidity of, 173, 176 worms in, 190 VEGETARIANS, stools of, 131 WELSH'S capsule stain. 158 Weights and measures, tablt of, 22 Widal reaction. 64-67 Worms. 138, 135) in urine, 190 Wright's method of counting leuko- cytes, 47. 18 stain, 26 VAXTHIX bodies, 179 yEAST-CELLS, L15 MAY 11 1905 «£A mi ra» jAM @B» 5ra j**h§Sk w*B swlssl w$& $3*0*31 LIBRARY OF CONGRESS 007 681 835 6 Nh III!! ■ 1 Bin w ■■ \\m\ illlllllll ■I