A clinical study of diseases of the kidneys : including systematic chemical examination of urine, for clinical purposes : systematic microscopical examination of urinary sediments : systematic application of urinary analysis to diagnosis and prognosis : treatment

Preface

Harley has well said that the state of the urine is a key to the condition of the body. While some diseases may not affect the urine, morbid urine indicates disease. Chemical and microscopical examination of the urine enables the practitioner to determine the diagnosis in a large number of disorders and, oftentimes, to save the lives of patients.

The object of my work is to show the practical bearing of thorough examination of the urine on the diagnosis, prognosis, and treatment not only of diseases of the kidneys themselves, but of many other disorders. The relation of urinary analysis to diet I have endeavored to explain at considerable length It is by careful observation of the condition of the urine that we often differentiate among various therapeutic agents, mineral waters, and adjuvants of many kinds.

PREFACE.

I have devoted one hundred pages of this book to a consideration of the treatment of Bright's disease. The modern treatment of albuminuria consists in carefully observing many particulars. I have discussed with as much minuteness as possible circumstances of diet, air and exercise, care of the skin, place of residence, psychical influences, etc., etc., which, if observed in connection with proper remedial treatment, will often keep the patient with chronic Bright's disease alive for many years, in some cases, possibly, to the natural limit of life.

I have endeavored so far as possible to write the book for American patients and from an American standpoint as regards diet and mode of life. The influence of English writers on diet and hygiene has been too strongly felt in this country. We should accept with some reserve the dietetic regulations of those who are more familiar with the Hogarth type of eater and his needs, than with the sufferings of the American stomach in general or the Mississippi Valley liver in particular. Should any American novelist make his characters disport themselves out-of-doors during an Illinois

PREFACE.

winter, or in a New York blizzard, as do those of Dickens in the comparatively balmy English holiday week, he would be justly held up to ridicule. Yet many of our own medical writers do not hesitate to advise American "featherweights " to pursue that mode of living which our gigantic Saxon kinsmen in their English climate may find salutary.

In order to make the book useful for the general practitioner, I have inserted numerous tables by study of which diagnosis is made easier. A large number of clinical notes from the experience of well-known physicians will explain the action of various remedies which I have found useful. I have paid some attention to the details of management of cases during such emergencies and complications as arise in the course of Bright's disease.

I think it necessary in considering renal diseases to pay attention also to those of the entire urinary tract. The authors of many works on diseases of the kidneys ignore diseases of the kidney-pelvis, ureters, bladder, and urethra. But inasmuch as the kidney soon feels the effects of any hindrance to the flow of urine in the lower urinary tract, the practitioner

PREFACE.

should become familiar with those disorders on which the renal lesion may depend.

In quoting from the works of others, I have, as a rule, named my authority on the spot.

The drawings for the cuts of microscopical objects were made by Dr. J. A. Hemsteger of Chicago.

70 State Street, Chicago.

Chapter I. Chemical Examination Of Urine Fob Clinical Purposes

How to detect Albumin, Peptones, Bile, Sugar ; how to estimate the quantity of Albumin and Sugar ; how to examine a Urinary Sediment for Urates, Phosphates, Uric Acid, Blood, Pus, Calcium Oxalate, Mucus ; how to estimate the quantity of Urea, Chlorides, Phosphates, Urates, Sulphates, etc.; List of Eeagents and Chemical Apparatus required, with five illustrations. Apparatus used by the author Pages 5-42

Chapter II. Microscopical Examination Of Urine For Clinical Purposes

How to Select a Specimen of Urine for Examination ; how to collect a Urinary Sediment ; how to remove a Drop of the Sediment by means of a Pipette ; how to use the Microscope ; how to use Chemicals in Microscopical Work ; how to identify, with the Microscope, Uric Acid crystals, Blood, Pus, Mucus corpuscles, Calcium Oxalate crystals, Epithelial cells, Triple Phosphate crystals, Calcium Phosphate crystals, Bacteria, Tubercle Bacilli, Tube Casts of all sorts ; List of Reagents and Apparatus for Microscopical Work ; twelve illustrations. Apparatus used by author Pages 43-72

Chapter III. Systematic Application Of Urinary Analysis To Diagnosis

What to do when Albumin is found in the Urine ; how to differentiate between Functional and Organic Albuminuria : Classification of Renal Lesions ; six Tables, showing at a glance the Etiology, Symptoms, Condition of the urine in the various renal lesions, acute and chronic ; Albuminuria according to Lesion ; Acute Exudative Nephritis ; Acute Parenchymatous ; Acute Diffuse ; Chronic Parenchymatous Change ;

Contents

Puerperal Nephritis ; Parenchymatous Change in Diabetes Mellitus ; Chronic Diffuse Nephritis; Sclerosis; Gouty Kidney; Lardaceous Disease ; Acute and Chronic Hyperemia of the Urine in the various Renal Lesions, Acute and Chronic; how to tell whether Nephritis is Acute or Chronic ; two Tables, showing Symptoms of Acute Nephritis ; Table of Differential Diagnosis in Chronic Eenal Lesions, parenchymatous, diffuse, sclerotic, etc Pages 73-97

Chapter IV. The Prognosis In Diseases Of The Kidneys

The Prognosis in Functional Albuminuria ; the Prognosis in Organic Albuminuria. Favorable and unfavorable signs. The Prognosis in Chronic Nephritis; the Bearing of Tube-Casts on Prognosis ; Nephritis without Albuminuria ; Condition of the Heart ; Dr. Tyson's Conclusions for the Life Insurance Examiner ; Summary of Prognosis Pages 98-110

Chapter V. Therapeutics Of Bright's Disease

One Hundred Pages on the Treatment of Bright's Disease : how to cure Functional Albuminuria ; what Cases of Acute Nephritis are Curable, and how to bring about Recovery ; Indications for Use of Remedies ; Complete Hygienic Details : What the Patient should Eat, what he should Drink, and what he should Wear ; how to prevent Post- Scarlatinal Nephritis ; how to cure Post-Scarlatinal Nephritis; Table, giving Choice of Leading Remedies in Acute Nephritis ; Treatment of Emergencies, with Remarks on Use of Purgatives, Diuretics, and Diaphoretics ; Cerebral Symptoms and Heart Failure ; Treatment of the Anaemia of Acute Nephritis ; how to cure Sub-Acute Nephritis; Climatic Cure of Sub-Acute Nephritis; Diet, Hygiene, and Remedies in Sub-Acute Nephritis. Chronic Nephritis : Diet, Place of Residence, Care of Skin, Air and Exercise, Psychical Influences ; Food and Drinks in Chronic Nephritis ; Use of Mineral Waters ; Alcoholic Drinks ; the Milk Treatment, and just how to use it. Climatic Cure of Bright's Disease : Relative Advantages of Egypt, Cape Town, Southern California, New Mexico; Winter Resorts in Europe and America for the Nephritic Patient ; Summer Resorts in the United States, England, Switzerland, etc. The Value of Rest in the Treatment of Bright's Disease ; the Effect of Psychical Influences; Clothing and Baths for the Albuminuric ; Value of Fresh Air and Exercise ; Use of Oxygen Gas, Passive Exercise, etc. How to follow the Course of a Case by Examination of the Urine ; the Author's Method of Classifying Cases Clinically by ascertaining the Quality of the Urine.

CONTENTS.

Remedies in Chronic Nephritis ; Table, giving Choice of Leading Remedies in Chronic Renal Degeneration, dependent upon Hepatic Disorders ; what Mineral Waters to use ; Clinical Notes ; Remarks on Treatment of Dropsy ; Remedies in Chronic Diffuse Nephritis due to Syphilis, Gout, or Malaria ; the Treatment of Syphilitic Cases ; the Treatment of Gouty Cases: Remedies and Waters; the Treatment- of Malarial Cases ; Treatment of Anaemia ; Remedies in Sclerosis, both according to Cause and Symptomatically ; Treatment of Sclerosis prior to Cardiac Hypertrophy and subsequent to it ; Treatment during Stage of Heart Failure ; Signs of Death in Sclerosis ; Remedies in Lardaceous Disease ; Remedies in Acute Hyperaemia ; how to cure Acute Hyperemia of the Kidneys ; Causes of Chronic Hypersemia, with Treatment ; New Remedies used as Heart Stimulants.

The Heart in Renal Diseases. Apex Beat ; how to tell when the Heart is Hypertrophied and Dilated ; Weak Heart ; Cardiac Failure ; Mitral Diseases : Differential Diagnosis ; Atheroma ; High Arterial Tension ; Low Arterial Tension ; Treatment of Renal Disease with reference to the Heart. The Albuminurias of Pregnancy : How to tell whether a Pregnant Woman is in Danger of Uraemia ; Choice of Remedies in Puerperal Cases ; Clinical Notes : Treatment of Convulsions ; Induction of Labor. Complications of Renal Diseases: Treatment of Ascites, Apoplexy, Asthma, Bronchitis, Cardiac Lesions, Epistaxis, Erysipelas, Gangrene, Gastric Disorders, Headache, Hydrothorax, Hydropericardium, Jaundice, Nervous Derangements, (Edema, Palpitation of the Heart, Pericarditis, Peritoneal Effusion, Pleuritis, Pneumonia, Retinal Lesions, Septicaemia. Urmmia: Landois's Theory ; Role of the Liver ; Acute Uraemia ; Symptoms, Diagnosis, and Treatment ; Treatment of Uraemic Convulsions ; Uraemia during Pregnancy ; Chronic Uraemia more prevalent than generally known ; Treatment. Syphilis of the Kidney.

Summary : General Indications for the Use of Fifty Remedies in Bright' s disease, with sixty-five Clinical Notes from the Experience of noted Practitioners in this country and abroad, illustrating the effect of medicinal agents Pages 111-216

Chapter VI. Pyuria And Hematuria

Examination of the Urine in Diagnosis of Diseases of the Kidney- Pelvis, Bladder, etc.; how to tell where Pus in the Urine comes from ; how to tell where Blood in the Urine comes from ; Use of the Spectroscope ; Diagnosis by Instrumental Exploration ; Examination of the Saliva after Injection into the Bladder of Potassium Iodide Solution ; Ratio of Albumin to Haemoglobin. Newman's apparatus Pages 217-225

CONTENTS.

Chapter VII. Renal Tumors

Hydronephrosis ; Cystic Degeneration ; Hydatid. Cysts ; Table of Differential Diagnosis in cases of Renal Tumors ; Differential Diagnosis between Renal and Non-Renal Tumors ; Etiology, Diagnosis, Prognosis, and Treatment of Hydronephrosis, Cystic Degeneration, and Hydatid Cysts Pages 226-233

Chapter VIII. Suppurative Diseases Of The Kidneys, Renal Pelvis, And Ureters

Etiology, Pathology, Diagnosis, and Treatment of Suppurative Nephritis, Pyelo-Nephritis, Pyonephrosis, and Pyelitis ; Micro-organisms in the Urine, and Infective Processes ; Precautions in the Use of Instruments ; Administration of Boracic Acid ; Dietetic Rules ; Directions for Cupping of the Loins ; twenty Remedies of Value, Avith Clinical Notes ; Perinephritic Abscess: Causes, Diagnosis, Prognosis, and Treatment. . . .Pages 234-255

Chapter IX. Renal Calculus

Forty Pages on an Important Subject ; Frequency of Calculous Disorders in the West ; the Uric Acid Diathesis : Diagnosis ; what to do when Renal Calculus is suspected ; the Urine in Oxaluria and Phosphaturia ; how to tell in what Part of the Urinary Tract a Calculus is Lodged; Analyses of Urine in cases of Renal Calculus ; Treatment of Uricsemia (Uric Acid Diathesis) ; Details in regard to Food and Drinks ; what Food to Avoid ; what Mineral Waters to Drink ; Solvent Treatment of Calculus ; Remedies in Uricsemia ; Palliative Measures ; Oxaluria : Diagnosis, Diet, and Treatment ; Phosphaturia : Causes, Diagnosis, Treatment ; when there is Flatulent Dyspepsia.

Treatment of Renal Colic : Remedies, Manipulation, Baths, etc ; Treatment of the Hematuria of Renal Calculus ; when to Operate for Renal Calculus ; Nephro-Lithotomy and miscellaneous Surgical Measures ; Renal Colic in Children: how to detect Uricsemia in children Pages 256-296

Chapter X

CHRONIC RENAL TUBERCULOSIS. CARCINOMA, AND OTHER TUMORS. FLOATING KIDNEY.

How to Find Tubercle Bacilli in Urine ; the Urine in Genito-urinary Tuberculosis ; Symptoms of Genito-Urinary Tuberculosis ; Table of Differential Diagnosis in Tubercular Pyelitis,

CONTENTS^ XI

Calculous Pyelitis, and Renal Cancer ; Treatment of Renal Tuberculosis.

Cancer of the Kidney : How to Detect its Presence ; Symptoms and General Treatment. Other Tumors. Diagnosis and Treatment of Floating Kidney ; " Strangulation of the Kidney ; " General Treatment of Renal Hematuria Pages 'Z97-311

Chapter XI. Suppubative Diseases Of The Uketeks, Bladder, Prostate, And Urethra

Diagnosis of Ureteritis and Renal Tenesmus ; Differential Diagnosis between Renal Tenesmus and Renal Colic ; Prognosis and Treatment of Ureteritis , Cystitis : Diagnosis ; the Urine in Cystitis ; Extraordinary Progress in Diagnosis from use of the Cystoscope ; the Urine in new Growths of the Bladder, and in Stone in the Bladder ; Hemorrhage from the Bladder ; Prognosis in Cystitis ; Treatment of Cystitis. Diet and Hygiene, Mineral Waters, Remedies, and Clinical Notes ; Solutions used in washing out the Bladder. Cystitis in the Female : Diagnosis and Treatment ; how to use the Catheter ; how to wash out the Bladder ; Catheter Fever ; Treatment of Hemorrhage from the Bladder ; Suppuration in the Neck of the Bladder : Differential Diagnosis from Pyelitis ; Treatment. Fissure in the Neck of the Bladder in Females ; Hemorrhages from Neck of the Bladder and Prostate.

Prostatic Disorders : Hypertrophy ; Congestion : Chronic Prostatitis ; Prostatic Irritability ; Treatment. Urethritis : how to find the Gonococci ; " Clap-threads" in the Urine. Summary : How to Examine a Patient when Pus is found in the Urine, with hints for the diagnosis ' Pages 312-356

Chapter XII

OLIGURIA AND ANURIA. INCONTINENCE OF URINE. MOTOR-NEUROSES.

Oliguria and Anuria ; Diagnosis and Treatment ; Retention and Suppression ; Treatment. Incontinence of Urine : Causes ; what to do in cases of Urinary Incontinence ; Diet and Treatment, Medical and Surgical, of Incontinence. Motor-Neuroses of the Urinary System : Spasm of the External Sphincter ; Spasm of the Detrusors ; Treatment. Paresis of the Bladder : Diagnosis and Treatment . Enuresis : Treatment and Clinical Notes ; Examination of the Patient in Motor-Neuroses, with hints for the diagnosis. Pages 357-368

CONTENTS.

Chapter XIII. Diabetes Mellitus And Insipidus

How to Test for Sugar in the Urine ; Haines's Test ; Briicke's Test ; when to Test for Sugar ; Differential Diagnosis between Glycosuria and true Diabetes; Early Recognition of Diabetes; Diabetes Decipiens ; Analyses of Urine ; what to do in cases of Diabetes ; how to Estimate the Quantity of Sugar in the Urine ; Fehling's Solution, how made ; Relation of Uricsemia to Diabetes ; the Prognosis in Diabetes ; Unfavorable Signs ; the Urine in Diabetic Coma ; Early Recognition of Diabetic Coma ; how to Test the Urine in cases of Diabetic Coma.

The Cure of Diabetes Mellitus, when possible ; Systematic Method for the Cure; Bill-of-Fare in Diabetes; Drinks; Effect of Diet, Rest, and Exercise ; Baths , Residence ; Climates to be sought; Massage and Electricity ; Respirations; Care of the Mouth and Teeth ; Removal of drops of Urine ; Protection of the Skin ; Occupations; Accidents; Oxygen; Mineral Waters ; Remedies ; Clinical Notes ; Empirical Treatment ; Complications.

Diabetes Insipidus the two Forms ; Symptoms, Diet, and Treatment Pages 369-398

Chapter XIV. Miscellaneous

Disorders in which Peptone is found in the Urine ; Biuret Test ; Tests for the various Peptones ; the Urine in Diseases of the Liver : Jaundice, Acute Yellow Atrophy, Functional Disorders of the Liver, Carcinoma, Amyloid Disease, Cirrhosis, Hepatic Tumors ; the Urine in Pernicious Anaemia ; the Urine in Neurasthenia ; the Urine in Insanity and Epilepsy ; Ehrlich's Typhoid Fever Reaction : its use in Pneumonia, Phthisis, Puerperal Fever ; Aromatic Compounds in the Urine ; Indican in the Urine ; the Urine in Diseases of the Upper Air Passages: Uricsemia and Congestion of the Larynx and Pharynx ; Summary of the Urine in Cancer, especially Cancer of the Stomach . Tests for certain Poisons in the Urine : Iodoform, Carbolic Acid, Morphine Pages 399 to 410

Appendix. — Tables, showing at a glance how to tell what percentage of the normal average a given quantity of Urine, Urea, or Phosphoric Acid is Pages 411 to 416

Index Pages 417 to 431

CHAPTER I. Systematic Chemical Examination of Urine for Clinical Purposes

Before entering upon the study of urinary pathology it is necessary to become familiar with the physical characteristics of normal urine, its chemical constituents, and the microscopic appearance of the sediment. Attention should also be paid to the changes taking place in normal urine as it becomes old. It is often the case that patients will collect their urine and set it aside for a day or two before giving it to a physician for examination. It is always advisable to inquire into the age of a specimen of urine about to be examined, so as to waste no time on urine several days old.

For quantitative chemical analysis the urine of twenty-four hours is necessary. The best day for collecting is

DISEASES OF THE KIDNEYS.

Sunday. To collect the urine of twenty-four hours the patient should begin Sunday morning after breakfast. He should save the first urine voided after breakfast and all voided during the day, including that which is voided on going to bed at night, pour it all into a bottle and label "Day Urine." He should also save all the urine voided during the night and that which is voided on rising the next morning, pour into a second bottle and label "Night Urine." These two bottles contain the total urine for twenty-four hours.

The day urine should be two or three times as much in quantity as the night urine, provided the patient is in health. In addition to the urine of twenty-four hours, the patient should furnish for microscopical examination a sample of freshly voided urine passed after the twenty-four hours' urine has been collected. Moreover, in special cases where it is desirable to detect traces of albumin and of sugar, examinations of the urine should be made at different hours of the day.

A complete examination of urine, therefore, to be satisfactory, should include the following:

CHEMICAL EXAMINATION OF UEINE.

I. Quantitative chemical analysis of the twenty-four hours' urine, with also qualitative tests for abnormal constituents and estimation of the quantity of such as are found.

II. Microscopical examination of the sediment of the twenty- four hours' urine and of the sediment of a freshly voided sample of urine passed about noon.

III. Tests for albumin and sugar at different hours of the day. Test for albumin at whatever hour the patient is most fatigued, or after the most active exercise of the day. Test for sugar in the urine voided about three hours after the heartiest meal of the day. I have found sugar in urine voided between three and four o'clock in the afternoon when I could not find it at any other time.

It is not necessary for clinical purposes to make what chemists would call a thorough quantitative analysis, since the significance of many of the urinary solids is either unknown or of little importance. Estimation, approximately, of the total solids according to a method given in Table III should be made, and also quantitative estimates of urea, phosphoric acid and, in certain cases, uric acid; if albumin and sugar are found,

DISEASES OF THE KIDNEYS.

the quantity should be estimated. Indican should be tested for and the result compared with normal urine. I have arranged a series of tables which will be found in the Appendix, giving comparisons with normal averages, taking as standards the analyses of Yvon-Berlioz and Parkes, respectively. These tables will be found serviceable to those making numerous quantitative analyses, as comparison of the results of any analysis with normal averages can be made at once without the trouble of figuring.

In cases where it is impossible to obtain the total urine of twenty-four hours, microscopical examination of any freshly voided specimen may be made and chemical tests applied to urine voided on rising in the morning. Reliance should not, however, be placed on the results of a few tests of single specimens. Moreover, patients should be taught to furnish as much urine as possible for analysis. Many patients seem to feel that it is indelicate to supply the physician with a large quantity of urine, and give him but an ounce or two, or possibly but a few fluidrachms. Urinary examinations have been much more valuable in their teachings since the collection of

CHEMICAL EXAMINATION OF URINE.

twenty-four hours' urine has been insisted on. Patients are usually willing, and among the more intelligent classes even anxious to supply the full quantity for the twenty- four hours if they understand that it is wanted, and the suggestion be made that Sunday be taken for the day of collection.

TABLE I.

Constituents of Normal Urine.

Constituent. Average amount in 24. hours.

Water, . . 40 to 50 fluid ounces, or 1,200 to 1,500 C. c. Urea, . . 30S.6 to 617.2 grains, or 20 to 40 grams

Urates,. . . 6.17 to 12.34 grains, or 0.4 to 0.8 gram Kreatinine, . . 7.7 to 20 grains, or 0.5 to 1.3 gram

Hippuric acid, . . 7.7 to 15.4 grains, or 0.5 to 1 gram

Chlorides,. . I54-3 to 246.8 grains, or 10 to 16 grams

Earthy phosphates, 1543 to 23.14 grains, or 1 to 1.5 gram Alkaline phosphates, 30.S6 to 61.72 grains, or 2 to 4 grams Sulphates, . . 46.29 to 61.72 grains, or 3 to 4 grams.

TABLE II.

Physical Characteristics of Normal Urine.

1. Quantity in 24 hours:

Average, 48 fluid ounces; 3 pints; 1500 Cubic centimetres- Possible normal range : Men, 30 to 60 fluid ounces ; Children, 17 to 50 fl. oz.; Women, 26 to 45 fl. oz.

2. Color:

Yellow to amber; after drinking, pale; on rising, dark amber. In young children, but little color.

DISEASES OF THE KIDNEYS.

Of the 24 hours' urine, 1015 to 1025; after a full meal, high as 1030; on rising, 1015 to 1025.

4. Solids :

55 to 75 grams, or 850 to 1 155 grains, in 24 hours.

5. Reaction :

Of the 24 hours' urine, slightly acid ; after drinking, neutral ; after full meal, neutral or slightly alkaline.

6. Odor:

Of the 24 hours' urine, faintly aromatic.

7. Transparency :

Usually clear when freshly voided; faintly visible cloud after standing a few hours ; sometimes partially opaque when first voided, but later clear, above, with flocculent mass beneath;* sometimes turbid on cooling.f

8. Consistence :

Perfectly fluid like water.

TABLE III.

How to Examine Urine as to Chemical and

Physical Characters.

Characteristk, Method of Examination.

1. Quantity in 24. hours:

Cause patient to collect all urine voided in 24 hours, beginning and ending with an empty bladder. Measure in Cubic centimetres or fluid ounces and compare results with Table II. 1. (Quantity).

2. Color:

Let ten or fifteen fluid ounces of the 24 hours' urine settle,

*A slight sediment of earthy phosphates, cleared by a few drops of nitric acid, can hardly be regarded as abnormal.

tCaused by deposition of urates, which clear on application of heat.

CHEMICAL EXAMINATION OF URINE.

and note color of the urine in the middle and upper parts of the glass; or filter, and note color of filtered urine. If colorless to straw yellow, it is pale; if yellow to amber, is normal; if reddish-yellow to brown, is highly colored. Note any unusual color, as green^ dirty-blue, blood-red, intense yellow, brown, or black.

Take the specific gravity of the 24 hours' sample with a good urinometer, standardized for a temperature of 770 F., and use a fluted glass jar;* read the figure on the scale from above the fluid.

4. Total amount of Solids :

Estimate the quantity of solids from the specific gravity : multiply the last two figures of the sp. gr. by Hawser's coefficient, 2.33, and the product will be approximately the number of grams of solid matters in every 1,000 C. c. of the urine; multiply this product by 15^ and the new product will be the number of grains in every 33.8 fluid ounces of urine. [Another and more rapid method is to measure the quantity of urine of 24 hours in fluid ounces and multiply the number found by the last two figures of the sp. gr. The product represents approximately the number of grains of solids in the whole urine of 24 hours]. Consult Table II., 4. ( Solids ).

5. Reaction :

The urine being: in a beaker or vessel with a wide mouth dip into it a piece of neutral litmus paper. Hold the paper in the urine until it is saturated ; if it turns red, the urine is said to be acid; if it turns blue, alkaline; if it does not change color, it is neutral. In case the neutral litmus paper cannot be obtained, the ordinary red and blue papers may be used. Dip into the urine a slip

*A long stemmed urinometer standardized at 60" and provided with a thermometer is also valuable.

DISEASES OF THE KIDNEYS.

of red litmus paper, and also, using the other hand, a slip of blue. Hold the papers in the urine until they are saturated ; if the blue paper is reddened, the urine is acid ; if neither is changed in color, it is neutral.

If the urine is found to be alkaline, allow the litmus paper used to dry, and notice whether the blue color remains, or whether the red has returned. If the blue color remains, the urine is alkaline from fixed alkali; if the red returns, the urine is alkaline from volatile alkali.

If a piece of bright blue litmus paper is very quickly turned a marked red in freshly voided urine, there is hyper-acidity of the urine.

Odor :

Notice whether the odor be (i) normal (faintly aromatic), (2) strongly urinous, as in that of fevers, or (3) fetid and ammoniacal, as in stale urine.

Transparency :

Notice whether the urine deposits a sediment on standing. If the sediment is plainly visible, the urine is abnormal except perhaps in cases of females, and possibly when the deposit consists of earthy phosphates or urates. (See Table II., 7, foot note.)

A slight turbidity or "mucus cloud," barely perceptible, is noticed in all normal urine on standing for a short time; after the urine has been voided for some hours, a turbidity may normally be present.

The urine of children four or five days old is somewhat turbid.

The turbidity seen in urine is due to the presence of substances, which the water of the urine cannot dissolve or keep dissolved, and which, after long standing, form what is known as a sediment, that is, " something which settles to the bottom."

Urine which is transparent is not necessarily normal.

CHEMICAL EXAMINATION OF URINE.

Urine which is very turbid when freshly voided is abnormal.

Consistency : Observe whether the urine is (a) perfectly fluid like water, readily flowing through a tube of very small diameter and dropping easily from it, in which case its consistence is normal ; or, whether (b) it is thick, " ropy," and viscid ; or, (c) creamy, forming a jelly-like mass after being voided.

Notice whether the froth on the surface of the urine is (a) temporary, in which case it is normal, or (<5) permanent.

I. Notes on Manipulation.

1. Quantity: To collect the urine of young children place a clean sponge over the genitals and fasten the diaper over it.

To measure the urine of 24 hours, use a 64 fluidounce graduated jar, or two smaller ones. To convert fluid ounces into Cubic centimetres multiply by 29i.

2. Color: To determine the color of turbid urine, have recourse to filtration.

In order to filter urine there is need of a funnel, filter paper, and a receiving vessel of some kind, such as a salt-mouthed bottle or a beaker. A filter-ring and stand are also very useful.

Funnels for this purpose are of glass, and those three or four inches in diameter across the top are of convenient size.

IO DISEASES OF THE KIDNEYS.

Filter paper is unsized paper, and the best is called Swedish, and may be bought already cut in circular form; filters seven and a half inches in diameter fit well into the funnels above described. In order to fold a filter so as to fit it into a funnel, first fold it in two, then turn the right half over on the left. In this way a funnel shape is given to the paper. Now fit it into the funnel and it is ready for use. When the paper thus folded has been fitted into the funnel three "pockets" can be seen; the liquid may be poured into any one of these three " pockets " except the middle one. It is often well to wet the paper slightly so as to fit it better to the funnel, and, for quick filtrations where the filtered urine only is wanted the filter paper may be ribbed. At the bedside, use small filters one to two inches in diameter folded as above, and inserted without a funnel into a wide mouthed test-tube. Observe the color of the urine after it has come through the filter paper.

3. Specific Gravity: Be careful to note as to whether your urinometer is standardized for 60° F., or for 77°. Take the temperature of the urine, using a chemical thermometer, and warm or cool it to the temperature to which the urinometer is standardized. (Or consult Table of Corrections for temperature. See "Practitioner's Guide in Urinary Analysis.") Squibb's urinometer, recommended by Prof. Tyson, is standard-

CHEMICAL EXAMINATION OF URINE. I I ized at 77° F., and is free from many objections. A urinometer with a long stem and provided with a thermometer is also useful.

4. Solids : In taking the specific gravity with a view to estimation of urea or solids, the urine should first be boiled, filtered while hot, then cooled to standard temperature, 77° F., with a Squibb urinometer, or 60° F., if a common instrument is used.

5. Reaction: Litmus-paper may be procured in the form of little books, which should be kept protected from the air. Blue litmus can be turned red by exposing to action of acid fumes or by immersing in vinegar and water; in the latter case dry before using. Kemember that urine on standing may grow more acid, and finally may change to alkaline reaction.

II. Tests for Albumin, Peptone, Bile, Sugar.

In general, examine a specimen of the 24 hours' urine. In doubtful cases, examine the urine of each micturition during some one period of 24 hours; if albumin is sought for, cause the patient to take as vigorous exercise as is prudent before voiding urine for examination; women should take a cleansing injection before voiding urine for examination, especially if they are troubled with leucorrhoea,